Paediatric asthma hospital utilization varies by demographic factors and area socio-economic status.

OBJECTIVES: Associations of emergency department (ED) visits and hospital admissions for asthma in children with demographics and area socio-economic status (SES) were examined to evaluate long-term trends and identify vulnerable populations. STUDY DESIGN: Retrospective population-based trend and cross-sectional analyses. METHODS: Asthma hospital admissions (2000-2007) and ED visits (2005-2007) for children aged 0-14 years living in Orange County, California were linked with zip-code-level SES data (2000 US Census). Annual population estimates were obtained to calculate age-specific admissions and ED visit rates. Average annual percentage changes (AAPC) were calculated with joinpoint analyses. The risks of ED visits and hospital admissions were estimated from SES indicators with negative binomial regression. RESULTS: Rates of asthma hospital admissions and ED visits were highest among children aged 0-4 years, males and African Americans, and lowest among Asian/Pacific Islanders. African Americans and Hispanics/Latinos were more likely to be uninsured. Asthma admissions decreased significantly for all age groups over the study period. The greatest declines per 100,000 were among children aged 0-4 years (AAPC: -15.3%, 95% confidence interval -17.0% to -13.4%). Rates of hospital admissions and ED visits were significantly higher in low-SES groups. Hospital admission rates were 30-60% higher and ED visits were 80-90% higher in zip codes in the lowest tertile of median household income compared with the highest tertile of median household income. CONCLUSIONS: Paediatric asthma hospitalizations and ED visit rates are declining in Orange County. However, certain groups are disproportionately affected, including those living in areas with low SES. This information will help in targeting intervention strategies to children at highest risk for severe asthma episodes.

Organic compound characterization and source apportionment of indoor and outdoor quasi-ultrafine particulate matter in retirement homes of the Los Angeles Basin.

UNLABELLED: Quasi-ultrafine (quasi-UF) particulate matter (PM(0.25)) and its components were measured in indoor and outdoor environments at four retirement communities in Los Angeles Basin, California, as part of the Cardiovascular Health and Air Pollution Study (CHAPS). The present paper focuses on the characterization of the sources, organic constituents and indoor and outdoor relationships of quasi-UF PM. The average indoor/outdoor ratios of most of the measured polycyclic aromatic hydrocarbons (PAHs), hopanes, and steranes were close to or slightly lower than 1, and the corresponding indoor-outdoor correlation coefficients (R) were always positive and, for the most part, moderately strong (median R was 0.60 for PAHs and 0.74 for hopanes and steranes). This may reflect the possible impact of outdoor sources on indoor PAHs, hopanes, and steranes. Conversely, indoor n-alkanes and n-alkanoic acids were likely to be influenced by indoor sources. A chemical mass balance model was applied to both indoor and outdoor speciated chemical measurements of quasi-UF PM. Among all apportioned sources of both indoor and outdoor particles, vehicular emissions was the one contributing the most to the PM(0.25) mass concentration measured at all sites (24-47% on average). PRACTICAL IMPLICATIONS: Although people (particularly the elderly retirees of our study) generally spend most of their time indoors, a major portion of the PM(0.25) particles they are exposed to comes from outdoor mobile sources. This is important because, an earlier investigation, also conducted within the Cardiovascular Health and Air Pollution Study (CHAPS), showed that indoor-infiltrated particles from mobile sources are more strongly correlated with adverse health effects observed in the elderly subjects living in the studied retirement communities compared with other particles found indoors (Delfino et al., 2008).

Obesity, waist size and prevalence of current asthma in the California Teachers Study cohort.

BACKGROUND: Obesity is a risk factor for asthma, particularly in women, but few cohort studies have evaluated abdominal obesity which reflects metabolic differences in visceral fat known to influence systemic inflammation. A study was undertaken to examine the relationship between the prevalence of asthma and measures of abdominal obesity and adult weight gain in addition to body mass index (BMI) in a large cohort of female teachers. METHODS: Prevalence odds ratios (ORs) for current asthma were calculated using multivariable linear modelling, adjusting for age, smoking and race/ethnicity. RESULTS: Of the 88 304 women in the analyses, 13% (n = 11,500) were obese (BMI > or = 30 kg/m(2)) at baseline; 1334 were extremely obese (BMI > or = 40 kg/m(2)). Compared with those of normal weight, the adjusted OR for adult-onset asthma increased from 1.40 (95% confidence interval (CI) 1.31 to 1.49) for overweight women to 3.30 (95% CI 2.85 to 3.82) for extremely obese women. Large waist circumference (>88 cm) was associated with increased asthma prevalence, even among women with a normal BMI (OR 1.37, 95% CI 1.18 to 1.59). Among obese women the OR for asthma was greater in those who were also abdominally obese than in women whose waist was < or = 88 cm (2.36 vs 1.57). Obese and overweight women were at greater risk of severe asthma episodes, measured by urgent medical visits and hospital admissions. CONCLUSIONS: This study confirms the association between excess weight and asthma severity and prevalence, and showed that a large waist was associated with increased asthma prevalence even among women considered to have normal body weight.

Repeated respiratory hospital encounters among children with asthma and residential proximity to traffic.

OBJECTIVE: The prevalence of adverse respiratory outcomes among children has been frequently associated with measurements of traffic-related exposures, and other data suggest asthma severity is worsened with residence near heavy traffic. We examined the association between neighbourhood traffic burden and repeated acute respiratory illnesses that required emergency department visits and/or hospitalisation for children with a primary or secondary diagnosis of asthma (89% acute bronchitis or pneumonia). METHODS: This is a hospital-based longitudinal study of a southern California urban catchment area around two adjacent children's hospitals. Subjects' home addresses were geocoded and linked to nearby traffic data. Recurrent event proportional hazard analysis was used to estimate the hazard of repeated hospital encounters. RESULTS: We found living within 300 metres of arterial roads or freeways increased risk of repeated hospital encounters in 3297 children age 18 years or less. At highest risk were children in the top quintile of traffic density (HR = 1.21; 95% CL 0.99 to 1.49) and those who had 750 metres or more of arterial road and freeway length within 300 metres of their residence (HR = 1.18; 95% CL 0.99 to 1.41). Associations between repeated hospital encounters and residence near heavy traffic were stronger in females than males and in children without insurance or who required government sponsored insurance than children with private insurance. The gender disparity was most notable among infants (age 0) and children ages 6-18 years. CONCLUSIONS: Results suggest exposure to traffic-related air pollution increases asthma severity as indicated by hospital utilisation. The finding in infants suggests this is an especially vulnerable population, although the validity of asthma diagnosis at this age is unknown. Females and children who do not have private insurance may also be more vulnerable to air pollution from traffic.

The relationship of respiratory and cardiovascular hospital admissions to the southern California wildfires of 2003.

OBJECTIVE: There is limited information on the public health impact of wildfires. The relationship of cardiorespiratory hospital admissions (n = 40 856) to wildfire-related particulate matter (PM(2.5)) during catastrophic wildfires in southern California in October 2003 was evaluated. METHODS: Zip code level PM(2.5) concentrations were estimated using spatial interpolations from measured PM(2.5), light extinction, meteorological conditions, and smoke information from MODIS satellite images at 250 m resolution. Generalised estimating equations for Poisson data were used to assess the relationship between daily admissions and PM(2.5), adjusted for weather, fungal spores (associated with asthma), weekend, zip code-level population and sociodemographics. RESULTS: Associations of 2-day average PM(2.5) with respiratory admissions were stronger during than before or after the fires. Average increases of 70 microg/m(3) PM(2.5) during heavy smoke conditions compared with PM(2.5) in the pre-wildfire period were associated with 34% increases in asthma admissions. The strongest wildfire-related PM(2.5) associations were for people ages 65-99 years (10.1% increase per 10 microg/m(3) PM(2.5), 95% CI 3.0% to 17.8%) and ages 0-4 years (8.3%, 95% CI 2.2% to 14.9%) followed by ages 20-64 years (4.1%, 95% CI -0.5% to 9.0%). There were no PM(2.5)-asthma associations in children ages 5-18 years, although their admission rates significantly increased after the fires. Per 10 microg/m(3) wildfire-related PM(2.5), acute bronchitis admissions across all ages increased by 9.6% (95% CI 1.8% to 17.9%), chronic obstructive pulmonary disease admissions for ages 20-64 years by 6.9% (95% CI 0.9% to 13.1%), and pneumonia admissions for ages 5-18 years by 6.4% (95% CI -1.0% to 14.2%). Acute bronchitis and pneumonia admissions also increased after the fires. There was limited evidence of a small impact of wildfire-related PM(2.5) on cardiovascular admissions. CONCLUSIONS: Wildfire-related PM(2.5) led to increased respiratory hospital admissions, especially asthma, suggesting that better preventive measures are required to reduce morbidity among vulnerable populations.

Breast cancer, passive and active cigarette smoking and N-acetyltransferase 2 genotype.

The relationship of breast cancer to cigarette smoking is inconsistent in the literature, possibly due in part to heterogeneity in carcinogen metabolism. N-acetyltransferase 2 (NAT2) enzyme activity is believed to play a role in the activation of tobacco smoke carcinogens. We examined the effect of NAT2 genetic polymorphisms on risk of breast cancer from active and passive smoking. Women were recruited from those who had suspicious breast masses detected clinically and/or mammographically. Questionnaire data were collected prior to biopsy diagnosis to blind subjects and interviewers. Histopathology showed 113 cases with mammary carcinoma (30 carcinoma in situ) and 278 controls with benign breast disease. NAT2 genotype was determined using allele-specific polymerase chain reaction amplification to detect slow acetylator mutations. Effects of passive and active tobacco smoke and of NAT2 genotype on breast cancer risk were examined with logistic regression controlling for known risk factors. Models first included all controls, and subsequently 107 with no or low risk (normal breast or no hyperplasia), and finally 148 with high risk (hyperplasia, atypical hyperplasia, complex fibroadenomas). Referents had no active or passive smoke exposure. We found no association between breast cancer risk and NAT2, smoking status (never, former, current), smoking duration, or cigarettes per day. There were no effects of passive exposure among never-smokers. Models were unchanged across control groups. There were no statistical interactions between tobacco smoke exposure and NAT2. The results were similar when restricting the analysis to invasive cancers. These findings do not support the hypothesis that NAT2 is a risk factor for breast cancer or that it alters susceptibility to tobacco smoke.

Symptoms in pediatric asthmatics and air pollution: differences in effects by symptom severity, anti-inflammatory medication use and particulate averaging time.

Experimental research in humans and animals points to the importance of adverse respiratory effects from short-term particle exposures and to the importance of proinflammatory effects of air pollutants, particularly O(subscript)3. However, particle averaging time has not been subjected to direct scientific evaluation, and there is a lack of epidemiological research examining both this issue and whether modification of air pollutant effects occurs with differences in asthma severity and anti-inflammatory medication use. The present study examined the relationship of adverse asthma symptoms (bothersome or interfered with daily activities or sleep) to O(3) and particles (less than or equal to)10 micrometer (PM10) in a Southern California community in the air inversion zone (1200-2100 ft) with high O(3) and low PM (R = 0.3). A panel of 25 asthmatics 9-17 years of age were followed daily, August through October 1995 (n = 1,759 person-days excluding one subject without symptoms). Exposures included stationary outdoor hourly PM10 (highest 24-hr mean, 54 microgram/m(3), versus median of 1-hr maximums, 56 microgram/m(3) and O(3) (mean of 1-hr maximums, 90 ppb, 5 days (greater than or equal to)120 ppb). Longitudinal regression analyses utilized the generalized estimating equations (GEE) model controlling for autocorrelation, day of week, outdoor fungi, and weather. Asthma symptoms were significantly associated with both outdoor O(3) and PM(10) in single pollutant- and co-regressions, with 1-hr and 8-hr maximum PM(10) having larger effects than the 24-hr mean. Subgroup analyses showed effects of current day PM(10) maximums were strongest in 10 more frequently symptomatic (MS) children: the odds ratios (ORs) for adverse symptoms from 90th percentile increases were 2.24 [95% confidence interval (CI), 1.46-3.46] for 1-hr PM10 (47 microgram/m(3); 1.82 (CI, 1.18-2.81) for 8-hr PM10 (36 microgram/m(3); and 1.50 (CI, 0.80-2.80) for 24-hr PM10 (25 microgram/m(3). Subgroup analyses also showed the effect of current day O(subscript)3 was strongest in 14 less frequently symptomatic (LS) children: the ORs were 2.15 (CI, 1.04-4.44) for 1-hr O(3) (58 ppb) and 1.92 (CI, 0.97-3.80) for 8-hr O(3) (46 ppb). Effects of 24-hr PM10 were seen in both groups, particularly with 5-day moving averages (ORs were 1.95 for MS and 4. 03 for LS; p(less than or equal to)0.05). The largest effects were in 7 LS children not on anti-inflammatory medications [5-day, 8-hr PM10, 9.66 (CI, 2.80-33.21); current day, 1-hr O(3), 4.14 (CI, 1.71-11.85)]. Results suggest that examination of short-term particle excursions, medication use, and symptom severity in longitudinal studies of asthma yields sensitive measures of adverse respiratory effects of air pollution.

The effect of outdoor fungal spore concentrations on daily asthma severity.

The relationship between day-to-day changes in asthma severity and combined exposures to community air pollutants and aeroallergens remains to be clearly defined. We examined the effects of outdoor air pollutants, fungi, and pollen on asthma. Twenty-two asthmatics ages 9-46 years were followed for 8 weeks (9 May-3 July 1994) in a semirural Southern California community around the air inversion base elevation (1,200 ft). Daily diary responses included asthma symptom severity (6 levels), morning and evening peak expiratory flow rates (PEFR), and as-needed beta-agonist inhaler use. Exposures included 24-hr outdoor concentrations of fungi, pollen, and particulate matter with a diameter < 10 microns (PM10; maximum = 51 micrograms/m3) and 12-hour day-time personal ozone (O3) measurements (90th percentile = 38 ppb). Random effects longitudinal regression models controlled for autocorrelation and weather. Higher temperatures were strongly protective, probably due to air conditioning use and diminished indoor allergens during hot, dry periods. Controlling for weather, total fungal spore concentrations were associated with all outcomes: per minimum to 90th percentile increase of nearly 4,000 spores/m3, asthma symptom scores increased 0.36 (95% CI, 0.16-0.56), inhaler use increased 0.33 puffs (95% CI, -0.02-0.69), and evening PEFR decreased 12.1 l/min (95% CI, -1.8-22.3). These associations were greatly enhanced by examining certain fungal types (e.g., Alternaria, basidiospores, and hyphal fragments) and stratifying on 16 asthmatics allergic to tested deuteromycete fungi. There were no significant associations to low levels of pollen or O3, but inhaler use was associated with PM10 (0.15 inhaler puffs/10 micrograms/m3; p < 0.02). These findings suggest that exposure to fungal spores can adversely effect the daily respiratory status of some asthmatics.

Demographic differences in prostate cancer incidence and stage: an examination of population diversity in California.

INTRODUCTION: Geographic and racial/ethnic variability in prostate cancer incidence rates and stage distribution may be partly attributed to differences in screening and early detection. METHODS: Using California Cancer Registry data we aimed to characterize variability in prostate cancer rates statewide and to examine differences in the stage at diagnosis of prostate cancer by racial/ethnic group statewide and by census tract per capita income in San Diego County. We calculated annual average (1988-1991) age-adjusted incidence rates per 100,000 (AAIR) of prostate cancer for 49,880 men over age 34 years. Racial/ethnic groups were compared using incidence rate ratios (IRR) (AAIR localized plus regional stages divided by AAIR distant stage). RESULTS: Statewide, Caucasians showed a higher IRR [6.16, 95% confidence interval (CI), 6.00-6.30] than did African Americans (2.34, 95% CI, 1.89-2.89), Hispanics (3.84, 95% CI, 3.63-4.05), or Asian/others (3.61, 95% CI, 1.80-7.22). Within San Diego County, Caucasians living in higher per capita income census tracts (> or = 65th percentile) had a significantly higher IRR (8.80, 95% CI 7.84-9.89) than did lower-income tracts (5.68, 95% CI, 5.13-6.30). CONCLUSION: Findings from the present and similar studies suggest that outcomes research is needed to determine the impact of these demographic differences on prostate cancer mortality and quality of life. This is particularly important given the current controversy regarding the treatment of clinically localized prostate cancers, increasingly found through early detection, which often involve difficult choices between aggressive therapies including prostatectomy or watchful waiting.

Cancer risk among Scandinavian immigrants in the US and Scandinavian residents compared with US whites, 1973-89.

Studies of migrants can generate hypotheses on the aetiology of cancer. Such studies are most informative when cancer incidence data are available both in the source and host country. We compared the incidence rate ratio of cancers (stomach, lung, female breast, colorectal and prostate) in Scandinavian immigrants to the US to US-born whites, using data from the SEER registry, 1973-89. Odds ratios (OR) for cancer sites in relation to birthplace were estimated using logistic regression. We also compared rate ratios (RR) for Scandinavian and US residents, using Poisson regression. Compared with US whites, most Scandinavian migrant groups had elevated OR for stomach cancer (1.58 to 3.92), and lower OR for lung cancer (0.38 to 0.88). Similarly, compared with US whites, residents of most Scandinavian countries had elevated RR for stomach cancer (1.47 to 3.33) and lower RR for lung cancer (0.27 to 0.97). Therefore, risk factors for lung and stomach cancers, such as smoking habits and Helicobacter pylori infection, respectively, may have been retained upon migration. Risks for breast, colorectal and prostate cancer among immigrants approached risks in the US (contrasting Scandinavian risks) suggesting assimilation of environmental and/or lifestyle factors.

Smoking and moods in adolescents with depressive and aggressive dispositions: evidence from surveys and electronic diaries.

Surveys and electronic diaries were used to examine depressive and extemalizing dispositions as they relate to smoking and moods in 170 early adolescents. Negative moods were prevalent, with anger and anxiety reported on 26%-60% and sadness on 16%-40% of occasions. The risk of smoking, urges to smoke, and alcohol intake were elevated in teens with aggressive and depressive dispositions, as were diary reports of feeling hassled, angry, and sad. Girls high in depression and aggression also reported more anxiety, stress, and fatigue and less happiness and well-being than did their peers. For boys, depression seemed to dampen the elevated smoking risks associated with externalizing behaviors. Discussion focuses on gender differences in personality-smoking linkages, adolescent negative affectivity, the unique contributions of survey and diary methods, and the promise of targeted preventive interventions such as affect regulation training.

Evaluation of a real-time passive personal particle monitor in fixed site residential indoor and ambient measurements.

Recent experimental findings in animals and humans indicate adverse respiratory effects from short-term exposures to particulate air pollutants, especially in sensitive subpopulations such as asthmatics. The relationship between air pollution and asthma has mainly been determined using particulate matter (PM) measurements from central sites. Validated tools are needed to assess exposures most relevant to health effects. Recently, a personal passive particulate sampler (personal Data-RAM, pDR, MIE Inc., Bedford, MA) has become available for studying personal exposures to PM with time resolution at 1 min. The pDR measures light scatter from PM in the 0.1-10 microM range, the significant range for health effects. In order to assess the ability of the pDR in predicting gravimetric mass, pDRs were collocated with PM2.5 and PM10 Harvard Impactors (HI) inside and outside nine homes of asthmatic children and at an outdoor central Air Pollution Control District site. Results are presented of comparisons between the HI samplers and the pDR in various modes of operation: passive, active, and active with a heated inlet. When used outdoors at fixed sites the pDR readings exhibit interference from high relative humidity (RH) unless operated with a method for drying inlet air such as a heater, or if readings at times of high RH are adjusted. The pDR correlates more highly with the HI PM2.5 than with the HI PM10 (r2 = 0.66 vs. 0.13 for outdoors, r2 = 0.42 vs. 0.20 for indoors). The pDR appears to be a useful tool for an epidemiologic study that aims to examine the relationship between health outcomes and personal exposure to peaks in PM.

Reliability of hospital data for population-based studies of air pollution.

The use of hospital databases for research into the respiratory effects of air pollution has been questioned. In an attempt to address that issue, reabstracts of 1,279 discharge records from 14 Montreal hospitals were compared with the universal health insurance database of Quebec. Agreement levels on discharge diagnoses were 94.9% for asthma; 75.5% for all other respiratory diagnoses combined, including upper airway infections, pneumonia, and coronary obstructive pulmonary disease (COPD) (90% after ignoring disagreements between closely related respiratory diagnoses); and 93.1% for a nonrespiratory comparison group. Factors associated with misclassification included use of nonurgent admissions; delays in hospital admission from emergency rooms; and differences in levels of diagnostic agreement between hospitals, age groups, and outcome groups. These should be taken into account in air pollution epidemiologic research in which databases of the kind commonly maintained in North American health care systems are used.

Efficient determination of vehicle emission factors by fuel use category using on-road measurements: downward trends on Los Angeles freight corridor I-710.

To evaluate the success of vehicle emissions regulations, trends in both fleet-wide average emissions as well as high-emitter emissions are needed, but it is challenging to capture the full spread of vehicle emission factors (EFs) with chassis dynamometer or tunnel studies, and remote sensing studies cannot evaluate particulate compounds. We developed an alternative method that links real-time on-road pollutant measurements from a mobile platform with real-time traffic data, and allows efficient calculation of both the average and the spread of EFs for light-duty gasoline-powered vehicles (LDG) and heavy-duty diesel-powered vehicles (HDD). This is the first study in California to report EFs under a full range of real-world driving conditions on multiple freeways. Fleet average LDG EFs were in agreement with most recent studies and an order of magnitude lower than observed HDD EFs. HDD EFs reflected the relatively rapid decreases in diesel emissions that have recently occurred in Los Angeles/California, and on I-710, a primary route used for goods movement and a focus of additional truck fleet turnover incentives, HDD EFs were often lower than on other freeways. When freeway emission rates (ER) were quantified as the product of EF and vehicle miles traveled (VMT) per time per mile of freeway, despite a twoto three-fold difference in HDD fractions between freeways, ERs were found to be generally similar in magnitude. Higher LDG VMT on low HDD fraction freeways largely offset the difference. Therefore, the conventional assumption that free ways with the highest HDD fractions are significantly worse sources of total emissions in Los Angeles may no longer be true.

Gender-related differences in the distribution of thoracic versus abdominal malignant mesothelioma.

The relationship between malignant mesothelioma (MM) and asbestos is well established, but the determinants of host factor susceptibility of MM are not. This study probes susceptibility issues by examining gender-related differences in the distribution of 417 thoracic and 42 abdominal cases of MM from 1988-1989 California Cancer Registry databases. The age-adjusted incidence rate ratio (IRR) for male/female thoracic MM was 6.9 (95% confidence interval [CI]; 5.0-9.6) consistent with greater occupational exposure among men. However, the IRR for male/female abdominal MM was 1.5 (95% CI: 0.6-3.6). Also, average age of onset for thoracic MM was greater than for abdominal MM. Thus, some abdominal MMs may be due to nonoccupational asbestos exposure, occurring over a lifetime, interacting with host factor susceptibility. This study gives impetus to research regarding the importance of host factors and nonoccupational asbestos exposure in the etiology of malignant mesothelioma.

The relationship of urgent hospital admissions for respiratory illnesses to photochemical air pollution levels in Montreal.

The relationship between the number of daily urgent hospital admissions for respiratory illnesses (31 hospitals) and ambient air pollution in Montreal, Canada, was investigated for warm periods between 1984 and 1988. Air pollutants included 1-hr and 8-hr maximum ozone, estimated particulate matter < or = 10 microns in aerometric diameter (PM10), and estimated sulfate (SO4(2-) fraction of PM10. Regression analyses controlled for seasonal and day-of-week trends, autocorrelation, temperature, and relative humidity. For July and August periods, there was a statistically significant (P < 0.01) univariate relationship of all respiratory admissions to 8-hr maximum ozone, which became nonsignificant when coregressed with temperature. Levels of ozone which never exceeded the U.S. National Ambient Air Quality Standard (NAAQS) of 120 ppb and high intercorrelations between ozone, particulates, and temperature may explain this finding. Asthma admissions in the May-October periods increased by 2.7% over mean levels for each 12 micrograms/m3 increase in PM10 levels 3 days prior to the admission day (95% confidence interval, 0.7 to 4.8%). In the July and August periods, hospital admissions for respiratory illnesses excluding asthma were 9.6% higher (95% confidence interval, 0.5 to 18.7%) when estimated SO4(2-) had exceeded 8.1 micrograms/m3 4 days prior to the admission day compared to days when SO4(2-) was at or below this level. There were no significant (P < 0.05) associations of a reference group of nonrespiratory admissions to air pollution after controlling for weather. The above results were found despite levels of PM10 which never exceeded the NAAQS of 150 micrograms/m3. The associations found are relevant to public health, since hospital admissions are expected to be accompanied by considerably more frequent occurrences of less serious outcomes. The present findings suggest that particulate air pollution during photochemically active periods is related to respiratory morbidity in Montreal.

Temporal analysis of the relationship of smoking behavior and urges to mood states in men versus women.

Epidemiological investigations of mood and smoking have relied largely on retrospective self-reports, with little research on real-time associations. We examined the relationship of mood states to contemporaneous smoking urges and to subsequent smoking and also assessed the effects of smoking on subsequent mood. For 2 days, 25 female and 35 male smokers aged 18-42 made three prompted diary entries per hour plus pre- and post-smoking entries (6882 entries). Data were analyzed with generalized estimating equations. We found significant positive associations between smoking urge and anger, anxiety, and alertness in women and men; fatigue in men only; sadness more strongly in men than women; and happiness in women only. Decreased alertness and increased anxiety predicted subsequent smoking in men only. Smoking was followed by decreased anger levels in men and women and decreased sadness in men only. In men with lower overall anger episodes, increased anger was associated with subsequent increased smoking. These findings suggest that smoking is related to negative affect and energy level, more clearly in men, and has palliative effects on sadness in men and on anger in men and women. These data demonstrate that ambulatory research can reveal targets for early intervention and smoking cessation.

Positive predictive value for presumptive diagnoses of skin cancer and compliance with follow-up among patients attending a community screening program.

BACKGROUND: There is an ongoing need for evaluating the effectiveness of skin cancer screening programs and barriers to obtaining definitive diagnoses and treatments among screen-positive patients. METHODS: We studied 132 patients who were given presumptive diagnoses of skin cancer while attending a free skin cancer screening program during May 1994 in San Diego, California (464 screened). We assessed compliance with recommendations to see a physician for definitive diagnostic workup. Logistic regression models included potential determinants of compliance: age, gender, health insurance, educational level, anatomic site, number of suspicious skin lesions, personal and family history of skin cancer, propensity to sunburn, and history of recent change in moles. The positive predictive value (PPV) of skin cancer diagnoses was defined conservatively as a range by inclusion then exclusion of patients not biopsied. RESULTS: Follow-up information was obtained for 115 patients, and 88 (77%) of these reported obtaining a definitive workup. The final regression model controlling for age showed that patients without a family history of skin cancer were less compliant than those with a history [OR for noncompliance 3.29, 95% confidence interval (CI) 1.10-9.83], and patients with only one presumptive skin cancer lesion were less compliant than those with additional cancer lesions (OR 5.31, 95% CI 1.07-26.43). Older patients were more compliant than younger. Among 82 patients under 65 years of age, the above factors were important only among men. Also, noncompliance was significantly higher among younger men without versus with health insurance (OR 5.14, 95% CI 1.23-20.68). Two melanomas, 1 squamous cell carcinoma, and 23 basal cell carcinomas were histopathologically confirmed. The PPV for melanoma was 6-15%, for squamous cell carcinoma 4-12%, and for basal cell carcinoma 32-85%. CONCLUSIONS: This study confirms the ability of skin cancer screening programs to successfully identify individuals with cutaneous malignancies. The significant association of noncompliance to seek recommended follow-up care with lack of health insurance for men too young to participate in Medicare suggests that approaches to definitive workup for uninsured patients be developed alongside free screening programs.

The risk of invasive cervical cancer among Hispanics: evidence for targeted preventive interventions.

BACKGROUND: Mass screening for cervical cancer has considerably reduced invasive cancer rates; however, Hispanic Americans have not fully benefited. This study examined the relationship of demographic, socioeconomic, and acculturation factors to diagnostic stage prior to preventive interventions in a large Hispanic community (San Diego, CA, 1988-1991). METHODS: Age-adjusted incidence rates (IR) were estimated for three subareas: Hispanic community targeted with interventions, comparison Hispanic community, and remainder of county. Incident cases of cervical cancer in the California Cancer Registry were used to calculate incidence rate ratios (IRR) of in situ to invasive stage cancer and estimate differences in early detection between Hispanics and white non-Hispanics. Multiple logistic regression was used to examine the relationship of cancer stage to census-linked income, education, poverty status, foreign birth, and language spoken. RESULTS: The in situ cervical cancer IR is significantly lower for Hispanics than for white non-Hispanics in all three regions (P < 0.05). The overall IRR is 3.65 (95% CI 3.19, 4.18) for white non-Hispanics compared with 1.09 (95% CI 0.86, 1.38) for Hispanics. Hispanics in census tracts in the highest versus remaining quartiles for percentage of language-isolated households are at greater risk for invasive stage (OR = 2.10, 95% CI 1.27, 3. 40). White non-Hispanic women residing in census tracts in the highest versus lowest quartile of adults with less than 12 years education are at greater risk for invasive stage (OR = 2.10, 95% CI 1.31, 3.38). CONCLUSIONS: Results show efforts aimed at cervical cancer early detection for Hispanic women are needed and well targeted. White non-Hispanic women in low-education communities are also at risk. Population-based methods in this study can focus efforts in communities needing preventive interventions.

Monitoring of 1-min personal particulate matter exposures in relation to voice-recorded time-activity data.

Recent studies on the association between exposures to airborne particulate matter (PM) and disease have identified short-term peaks in PM exposures as posing especial health threats. Lightweight personal instruments are needed to characterize short-term exposures to PM and to identify the most important sources of high PM excursions. In this study, we measured exposure to fine PM using a small personal nephelometer (pDR; MIE, Inc) to investigate the utility of this instrument in identifying activities and microenvironments most associated with high PM exposures and the magnitude and duration of peaks in PM exposures. Ten adult volunteers wore a pDR recording PM concentrations at 1-min time intervals for 1 week each. PM concentrations were measured by the pDR in units of microg/m(3) based on light scatter. The use of a time-stamped voice recorder enabled activity and location to be continuously documented in real time. In addition, a small, inexpensive light intensity logger was affixed to the pDR to evaluate the potential of this instrument to assist in verifying wearer- recorded data. For each person, patterns of PM exposure were remarkably consistent over daily activities and showed large excursions associated with specific indoor and outdoor microenvironments and activities, such as cooking. When the magnitude and duration of excursions in PM were analyzed, we found that high PM levels occurred in relatively few of the minutes measured but comprised a substantial fraction of the total exposure to PM. Fifteen-minute averaged PM levels were found to be as much as 10 times the daily average. When the data were analyzed with a generalized estimating equation model to account for effects of autocorrelation and clustering, PM exposure was significantly higher during subject-reported events including barbeque, yard work, being near pets or construction activities, cooking, and environmental tobacco smoke exposure, as compared with periods with no pollution events. When light intensity data were explored to determine whether these loggers could be of potential use in establishing or verifying indoor vs outdoor location for future PM studies, we found that personal light intensity measurements differed among indoor, outdoor, and in-car environments (P<0.001). Overlap between measured values implies that light intensity cannot be used to absolutely predict location; however, a sudden increase or decrease in light intensity was highly associated with participant report of location change between indoors and outdoors. This study demonstrates the utility of the pDR in identifying patterns of personal exposures to particulate matter and especially in registering the magnitude and duration of excursions in PM in relation to location and activity.