Disparities in Cancer Stage Outcomes by Catchment Areas for a Comprehensive Cancer Center.

Importance: The National Cancer Institute comprehensive cancer centers (CCCs) lack spatial and temporal evaluation of their self-designated catchment areas. Objective: To identify disparities in cancer stage at diagnosis within and outside a CCC's catchment area across a 10-year period using spatial and statistical analyses. Design, Setting, and Participants: This cross-sectional, population-based study conducted between 2010 and 2019 utilized cancer registry data for the Johns Hopkins Sidney Kimmel CCC (SKCCC). Eligible participants included patients with cancer in the contiguous US who received treatment for cancer, a diagnosis of cancer, or both at SKCCC. Patients were geocoded to zip code tabulation areas (ZCTAs). Individual-level variables included sociodemographic characteristics, smoking and alcohol use, treatment type, cancer site, and insurance type. Data analysis was performed between March and July 2023. Exposures: Distance between SKCCC and ZCTAs were computed to generate a catchment area of the closest 75% of patients and outer zones in 5% increments for comparison. Main Outcomes and Measures: The primary outcome was cancer stage at diagnosis, defined as early-stage, late-stage, or unknown stage. Multinomial logistic regression was used to determine associations of catchment area with stage at diagnosis. Results: This study had a total of 94 007 participants (46 009 male [48.94%] and 47 998 female [51.06%]; 30 195 aged 22-45 years [32.12%]; 4209 Asian [4.48%]; 2408 Hispanic [2.56%]; 16 004 non-Hispanic Black [17.02%]; 69 052 non-Hispanic White [73.45%]; and 2334 with other or unknown race or ethnicity [2.48%]), including 47 245 patients (50.26%) who received a diagnosis of early-stage cancer, 19 491 (20.73%) who received a diagnosis of late-stage cancer , and 27 271 (29.01%) with unknown stage. Living outside the main catchment area was associated with higher odds of late-stage cancers for those who received only a diagnosis (odds ratio [OR], 1.50; 95% CI, 1.10-2.05) or only treatment (OR, 1.44; 95% CI, 1.28-1.61) at SKCCC. Non-Hispanic Black patients (OR, 1.16; 95% CI, 1.10-1.23) and those with Medicaid (OR, 1.65; 95% CI, 1.46-1.86) and no insurance at time of treatment (OR, 2.12; 95% CI, 1.79-2.51) also had higher odds of receiving a late-stage cancer diagnosis. Conclusions and Relevance: In this cross-sectional study of CCC data from 2010 to 2019, patients residing outside the main catchment area, non-Hispanic Black patients, and patients with Medicaid or no insurance had higher odds of late-stage diagnoses. These findings suggest that disadvantaged populations and those living outside of the main catchment area of a CCC may face barriers to screening and treatment. Care-sharing agreements among CCCs could address these issues.

Low-Dose Radiation Associated Mortality Risks of Site-Specific Solid Tumors in U.S. Shipyard Workers.

BACKGROUND: U.S. nuclear capable shipyard workers have increased potential for occupational radiation exposure. OBJECTIVE: to examine solid tumor mortality risks at low doses. METHOD: 437,937 workers working from 1957 to 2004 at eight U.S. shipyards were studied. RESULTS: Radiation workers with a median life-time dose at 0.82 mSv had a significantly lower solid tumor mortality risk [Relative risk (RR): 0.96, 95% confidence interval (CI): 0.94-0.98] than non-radiation workers. Among 153,930 radiation workers., the RRs of solid tumors increased with increasing dose categories without statistical significance. The dose category >0- < 25 mSv had significantly lower RR (0.95, 95% CI: 0.91-0.99) vs. 0 dose and the Excess Relative Risk was 0.05/100 mSv (95% CI: 0.01-0.08). CONCLUSION: Solid tumor risk might increase with radiation dose, but not linearly at low doses. Actual mortality risk may be dependent on dose received.

A Novel Approach for Conducting a Catchment Area Analysis of Breast Cancer by Age and Stage for a Community Cancer Center.

BACKGROUND: The U.S. Preventive Services Task Force recently issued an updated draft recommendation statement to initiate breast cancer screening at age 40, reflecting well-documented disparities in breast cancer-related mortality that disproportionately impact younger Black women. This study applied a novel approach to identify hotspots of breast cancer diagnosed before age 50 and/or at an advanced stage to improve breast cancer detection within these communities. METHODS: Cancer registry data for 3,497 women with invasive breast cancer diagnosed or treated between 2012 and 2020 at the Helen F. Graham Cancer Center and Research Institute (HFGCCRI) and who resided in the HFGCCRI catchment area, defined as New Castle County, Delaware, were geocoded and analyzed with spatial intensity. Standardized incidence ratios stratified by age and race were calculated for each hotspot. RESULTS: Four hotspots were identified, two for breast cancer diagnosed before age 50, one for advanced breast cancer, and one for advanced breast cancer diagnosed before age 50. Younger Black women were overrepresented in these hotspots relative to the full-catchment area. CONCLUSIONS: The novel use of spatial methods to analyze a community cancer center catchment area identified geographic areas with higher rates of breast cancer with poor prognostic factors and evidence that these areas made an outsized contribution to racial disparities in breast cancer. IMPACT: Identifying and prioritizing hotspot breast cancer communities for community outreach and engagement activities designed to improve breast cancer detection have the potential to reduce the overall burden of breast cancer and narrow racial disparities in breast cancer.

Mapping Cumulative Risk in Delaware: Approach and Implications for Health Equity.

BACKGROUND: Addressing health equity requires attention to upstream determinants of health, including environmental and social factors that act in tandem to increase communities' exposure to and vulnerability to toxicants. Cumulative risk assessment, which evaluates combined risks from environmental and social factors, is a useful approach for estimating potential drivers of health disparities. We developed a cumulative risk score of multiple indices of environmental and social conditions and assessed block group-level differences in New Castle County, Delaware. METHODS: This cross-sectional study used choropleth maps to visualize the distribution of environmental, social, and cumulative risks and Moran's I statistics to assess spatial clustering of cumulative risk across the county and among individual block groups. RESULTS: Findings indicate that environmental risk rarely occurs without social risk and that environmental and social risks co-occur in distinct areas, resulting in large-scale clustering of cumulative risk. Areas of higher cumulative risk had more Black residents and people of lower socioeconomic status. CONCLUSIONS: Replicable measures of cumulative risk can show how environmental and social risks are inequitably distributed by race and socioeconomic status, as seen here in New Castle County. Such measures can support upstream approaches to reduce health disparities resulting from histories of environmental racism.

The Burden of Back and Neck Strains and Sprains in Professional Baseball Players.

STUDY DESIGN: A retrospective case series study. OBJECTIVE: To analyze the epidemiology of diagnoses of back and neck strains and sprains among Major League (MLB) and Minor League (MiLB) Baseball players. BACKGROUND: Baseball players perform unique sets of repetitive movements that may predispose to neck and back strains and sprains. Data are lacking concerning the epidemiology of these diagnoses in this population. MATERIALS AND METHODS: De-identified data on neck/back strains and sprains were collected from all MLB and MiLB teams from 2011 to 2016 using the MLB-commissioned Health and Injury Tracking System database. Diagnosis rates of conditions related to cervical, thoracic, and lumbar musculature and their impact on days missed due to injury, player participation, and season or career-ending status were assessed. Injury rates were reported as injuries per 1000 athlete exposures (AEs). RESULTS: There were 3447 cases of neck/back strains and sprains in professional baseball players from 2011 to 2016. Seven hundred twenty-one of these occurred in MLB versus 2726 in MiLB. Of injuries 136 were season-ending (26 in MLB, 110 in MiLB); 22 were career-ending (2 in MLB, 20 in MiLB). The total days missed were 39,118 (8838 from MLB and 30,280 from MiLB). Excluding season or career-ending injuries, the mean days missed were 11.8 (12.7 and 11.6 in MLB and MiLB, respectively). The median days missed were 4 (3 and 5 in MLB and MiLB, respectively). Combining MLB and MiLB, the pitcher injury rate was 1.893 per 1000 AEs versus 0.743 per 1000 Aes for other position players (P < 0.0001). CONCLUSION: There was a high incidence of neck/back strains and sprains in MLB and MiLB players, with nearly 40,000 aggregate days missed in our 6-year study period. The median days missed were lower than the mean days missed, indicating rightward outliers. Pitchers had over double the rates of injuries compared with other position players. LEVEL OF EVIDENCE: Level III.

Geographic Disparities in Potential Accessibility to Gynecologic Oncologists in the United States From 2001 to 2020.

OBJECTIVE: To use a spatial modeling approach to capture potential disparities of gynecologic oncologist accessibility in the United States at the county level between 2001 and 2020. METHODS: Physician registries identified the 2001-2020 gynecologic oncology workforce and were aggregated to each county. The at-risk cohort (women aged 18 years or older) was stratified by race and ethnicity and rurality demographics. We computed the distance from at-risk women to physicians. Relative access scores were computed by a spatial model for each contiguous county. Access scores were compared across urban or rural status and racial and ethnic groups. RESULTS: Between 2001 and 2020, the gynecologic oncologist workforce increased. By 2020, there were 1,178 active physicians and 98.3% practiced in urban areas (37.3% of all counties). Geographic disparities were identified, with 1.09 physicians per 100,000 women in urban areas compared with 0.1 physicians per 100,000 women in rural areas. In total, 2,862 counties (57.4 million at-risk women) lacked an active physician. Additionally, there was no increase in rural physicians, with only 1.7% practicing in rural areas in 2016-2020 relative to 2.2% in 2001-2005 ( P =.35). Women in racial and ethnic minority populations, such as American Indian or Alaska Native and Hispanic women, exhibited the lowest level of access to physicians across all time periods. For example, 23.7% of American Indian or Alaska Native women did not have access to a physician within 100 miles between 2016 and 2020, which did not improve over time. Non-Hispanic Black women experienced an increase in relative accessibility, with a 26.2% increase by 2016-2020. However, Asian or Pacific Islander women exhibited significantly better access than non-Hispanic White, non-Hispanic Black, Hispanic, and American Indian or Alaska Native women across all time periods. CONCLUSION: Although the U.S. gynecologic oncologist workforce increased steadily over 20 years, this has not translated into evidence of improved access for many women from rural and underrepresented areas. However, health care utilization and cancer outcomes may not be influenced only by distance and availability. Policies and pipeline programs are needed to address these inequities in gynecologic cancer care.

Geographic variation in HCV treatment penetration among people who inject drugs in Baltimore, MD.

We evaluated geographic heterogeneity in hepatitis C virus (HCV) treatment penetration among people who inject drug (PWID) across Baltimore, MD since the advent of direct-acting antivirals (DAAs) using space-time clusters of HCV viraemia. Using data from a community-based cohort of PWID, the AIDS Linked to the IntraVenous Experience (ALIVE) study, we identified space-time clusters with higher-than-expected rates of HCV viraemia between 2015 and 2019 using scan statistics. We used Poisson regression to identify covariates associated with HCV viraemia and used the regression-fitted values to detect adjusted space-time clusters of HCV viraemia in Baltimore city. Overall, in the cohort, HCV viraemia fell from 77% in 2015 to 64%, 49%, 39% and 36% from 2016 to 2019. In Baltimore city, the percentage of census tracts where prevalence of HCV viraemia was ≥85% dropped from 57% to 34%, 25%, 22% and 10% from 2015 to 2019. We identified two clusters of higher-than-expected HCV viraemia in the unadjusted analysis that lasted from 2015 to 2017 in East and West Baltimore and one adjusted cluster of HCV viraemia in West Baltimore from 2015 to 2016. Neither differences in age, sex, race, HIV status, nor neighbourhood deprivation were able to explain the significant space-time clusters. However, residing in a cluster with higher-than-expected viraemia was associated with age, sex, educational attainment and higher levels of neighbourhood deprivation. Nearly 4 years after DAAs became available, HCV treatment has penetrated all PWID communities across Baltimore city. While nearly all census tracts experienced improvements, change was more gradual in areas with higher levels of poverty.

Epidemiology of Lumbar Spine Conditions in Professional Baseball Players.

STUDY DESIGN: A retrospective case series study. OBJECTIVE: To analyze the epidemiology and burden of diagnoses of lumbar spinal conditions affecting Major League Baseball (MLB) and Minor League Baseball players. SUMMARY OF BACKGROUND DATA: Lumbar spinal conditions are a common cause of low back pain in the general population and can be caused by participation in sports and athletics. Data concerning the epidemiology of these injuries in professional baseball players are limited. METHODS: We collected deidentified MLB and Minor League Baseball data concerning lumbar spine conditions (lumbar disk herniations, lumbar degenerative disease, or pars conditions) from 2011 to 2017 using the MLB-commissioned Health and Injury Tracking System database. Data concerning days missed because of injury, need for surgery, and player participation and career-ending status were assessed. Injury rates were reported as injuries per 1000 athlete exposures in concordance with prior studies. RESULTS: Over 2011-2017, 5948 days of play were missed because of 206 lumbar spine-related injuries, of which 60 (29.1%) were season ending. Twenty-seven (13.1%) of these injuries required surgery. The most common injury among both pitchers and position players were lumbar disk herniations (45, 44.1% and 41, 39.4%, respectively). More surgeries were performed for lumbar disk herniations and degenerative disk disease compared with pars conditions (74% and 18.5% vs. 3.7%). Injury rates for pitchers was significantly higher than those of other position players 0.111 per 1000 AEs versus 0.040 per 1000 AEs ( P <0.0001). Injuries requiring surgery did not vary significantly by league, age group, or player position. CONCLUSIONS: Lumbar spine-related injuries incurred substantial disability and days missed from play in professional baseball players. Lumbar disk herniations were the most common injury, and together with pars conditions led to higher rates of surgery compared with degenerative conditions. LEVEL OF EVIDENCE: III.

Neighborhood factors and triple negative breast cancer: The role of cumulative exposure to area-level risk factors.

BACKGROUND: Despite similar incidence rates among Black and White women, breast cancer mortality rates are 40% higher among Black women. More than half of the racial difference in breast cancer mortality can be attributed to triple negative breast cancer (TNBC), an aggressive subtype of invasive breast cancer that disproportionately affects Black women. Recent research has implicated neighborhood conditions in the etiology of TNBC. This study investigated the relationship between cumulative neighborhood-level exposures and TNBC risk. METHODS: This single-institution retrospective study was conducted on a cohort of 3316 breast cancer cases from New Castle County, Delaware (from 2012 to 2020), an area of the country with elevated TNBC rates. Cases were stratified into TNBC and "Non-TNBC" diagnosis and geocoded by residential address. Neighborhood exposures included census tract-level measures of unhealthy alcohol use, metabolic dysfunction, breastfeeding, and environmental hazards. An overall cumulative risk score was calculated based on tract-level exposures. RESULTS: Univariate analyses showed each tract-level exposure was associated with greater TNBC odds. In multivariate analyses that controlled for patient-level race and age, tract-level exposures were not associated with TNBC odds. However, in a second multivariate model that included patient-level variables and considered tract-level risk factors as a cumulative exposure risk score, each one unit increase in cumulative exposure was significantly associated with a 10% increase in TNBC odds. Higher cumulative exposure risk scores were found in census tracts with relatively high proportions of Black residents. CONCLUSIONS: Cumulative exposure to neighborhood-level risk factors that disproportionately affect Black communities was associated with greater TNBC risk.

Geospatial analysis of firearm injuries in an urban setting: Individual rather than community characteristics affect firearm injury risk.

BACKGROUND: The relationship between individual/socioeconomic characteristics and firearm injury risk in an urban center was evaluated. METHODS: A hospital registry was used to identify individuals in Baltimore City who experienced interpersonal firearm injury in 2019 (FA). Injuries that did not satisfy this criterion were used as a comparison group (NF). Socioeconomic characteristics were linked to home address at the block group level. Regression analysis was used to determine predictors of firearm injury. Clusters of high and low firearm relative to non-firearm injuries were identified. RESULTS: A total of 1293 individuals were included (FA = 277, NF = 1016). The FA group lived in communities with lower income (p = 0.005), higher poverty (p = 0.007), and more Black residents (p < 0.001). Individual level factors were stronger predictors of firearm injury than community factors on multivariate regression with Black race associated with 5x higher odds of firearm injury (p < 0.001). Firearm injury clustered in areas of low socioeconomic status. CONCLUSIONS: Individual versus community factors have a greater influence on firearm injury risk. Prevention efforts should target young, Black men in urban centers.

Agreement in extreme precipitation exposure assessment is modified by race and social vulnerability.

Epidemiologic investigations of extreme precipitation events (EPEs) often rely on observations from the nearest weather station to represent individuals' exposures, and due to structural factors that determine the siting of weather stations, levels of measurement error and misclassification bias may differ by race, class, and other measures of social vulnerability. Gridded climate datasets provide higher spatial resolution that may improve measurement error and misclassification bias. However, similarities in the ability to identify EPEs among these types of datasets have not been explored. In this study, we characterize the overall and temporal patterns of agreement among three commonly used meteorological data sources in their identification of EPEs in all census tracts and counties in the conterminous United States over the 1991-2020 U.S. Climate Normals period and evaluate the association between sociodemographic characteristics with agreement in EPE identification. Daily precipitation measurements from weather stations in the Global Historical Climatology Network (GHCN) and gridded precipitation estimates from the Parameter-elevation Relationships on Independent Slopes Model (PRISM) and the North American Land Data Assimilation System (NLDAS) were compared in their ability to identify EPEs defined as the top 1% of precipitation events or daily precipitation >1 inch. Agreement among these datasets is fair to moderate from 1991 to 2020. There are spatial and temporal differences in the levels of agreement between ground stations and gridded climate datasets in their detection of EPEs in the United States from 1991 to 2020. Spatial variation in agreement is most strongly related to a location's proximity to the nearest ground station, with areas furthest from a ground station demonstrating the lowest levels of agreement. These areas have lower socioeconomic status, a higher proportion of Native American population, and higher social vulnerability index scores. The addition of ground stations in these areas may increase agreement, and future studies intending to use these or similar data sources should be aware of the limitations, biases, and potential for differential misclassification of exposure to EPEs. Most importantly, vulnerable populations should be engaged to determine their priorities for enhanced surveillance of climate-based threats so that community-identified needs are met by any future improvements in data quality.

Reducing Exposure to Tobacco Retailers with Residential Zoning Policy: Insights from a Geospatial Analysis of Wilmington, Delaware.

Cigarette use remains the leading preventable cause of premature mortality in the US, with declines in smoking rates slowing in recent years. One promising target for improved tobacco control is the expanded regulation of tobacco retailers. Evaluations of such policy attempts have largely produced mixed results to date. The objective of this study was to the assess the potential of using a novel, residentially-focused zoning approach to produce a more targeted and equitable reduction in tobacco retailers in high-risk urban settings. We focused on Wilmington, Delaware, a city characterized by high poverty rates, a majority Black population, a disparate number of tobacco retailers, and an elevated smoking prevalence. Through the use of geospatial analyses, we observed disproportionately higher counts of convenience store tobacco retailers in medium- and high-density residential zones in Wilmington relative to the surrounding county. By linking electronic health record (EHR) data from a local health care system and US Census Bureau data, we further found that approximately 80% of Wilmington smokers and 60% of Wilmington youth lived in these residential zones. These findings highlight the potential to more equitably reduce tobacco retailer exposure through a residentially-focused zoning approach. Tobacco control policy and research implications are considered.

Low-Dose Radiation Risks of Lymphohematopoietic Cancer Mortality in U.S. Shipyard Workers.

The linear, non-threshold (LNT) hypothesis of cancer induction derived from studies of populations exposed to moderate-to-high acute radiation doses may not be indicative of cancer risks associated with lifetime radiation exposures less than 100 mSv. The objective of this study was to examine risks and dose-response patterns of lymphohematopoietic cancer (LHC) and its types associated with low radiation exposure while adjusting for possible confounding factors. A retrospective cohort of 437,937 U.S. nuclear shipyard workers (153,930 radiation and 284,007 non-radiation workers) was followed from 1957 to 2011, with 3,699 LHC deaths observed. The risk of LHC in radiation workers was initially compared to the risk in non-radiation workers. Time dependent accumulated radiation dose, lagged 2 years, was used in categorical and continuous dose analysis among radiation workers to examine the LHC risks and possible dose-response relationships based on Poisson regression models. These analyses controlled for sex, race, time dependent age, calendar time, socioeconomic status, solvent-related last job, and age at first hire. The median lifetime radiation dose for the radiation worker population was 0.82 mSv and the 95th percentile dose was 83.63 mSv. The study shows: 1. LHC mortality for radiation workers was significantly lower than non-radiation workers relative risk: 0.927; 95% confidence intervals (95% CI): 0.865, 0.992; P = 0.030]. Among LHC types, the risks for lymphoid leukemia and lymphomas in radiation workers were lower than the risk in non-radiation workers with statistical significance, while the risk for the rest of LHC types did not show any statistically significant difference. 2. In categorical dose analysis among radiation workers, sample size weighted linear trend of relative risk (RRs) for LHC and its types in five dose categories (>0-<25, 25-<50, 50-<100, 100-<200, and > = 200 mSv) vs. 0 mSv were not statistically significant, although there was an elevation of RR for chronic myeloid leukemia only in the 50-<100 mSv category (RR: 2.746; 95% CI: 1.002, 7.521; P = 0.049) vs. 0 mSv. 3. The Poisson regression analyses among radiation workers using the time dependent radiation dose as a continuous variable showed an excess relative risk (ERR) for LHC at 100 mSv of 0.094 (95% CI: -0.037, 0.225; P = 0.158) and leukemia less chronic lymphoid leukemia, of 0.178 (95% CI: -0.085, 0.440; P = 0.440) vs. 0 mSv. The ERRs and their linear trend for all other types were not statistically significant.

The association between vacant housing demolition and safety and health in Baltimore, MD.

We measured the association between vacant housing demolitions and changes in crime and emergency department (ED) visits in Baltimore, MD. We included 646 block groups in Baltimore, 224 of which experienced at least one demolition from 2012 to 2019. The exposure was the number of demolitions completed in a block group during the previous quarter. Crime (all, property, and violent) and ED visits (all, adults, children, and for specific causes) were examined as the change in the rate per 1000 people from the previous quarter to the current quarter and analyzed using multivariable mixed effects regression models. Demolitions were associated with a small decrease in total ED visits (difference = -0.068 per 1000 people from the previous quarter to the current quarter, 95% CI -0.119, -0.018) but no significant change in crime. For each demolition, the rate of total child ED visits was 0.452 lower compared to the previous quarter (95% CI -0.777, -0.127). Demolitions were associated with small decreases in adult injury-related ED visits in the short term.

Temporal and Spatial Differences between Symptomatic and Asymptomatic Malaria Infections in the Chittagong Hill Districts, Bangladesh.

Mapping asymptomatic malaria infections, which contribute to the transmission reservoir, is important for elimination programs. This analysis compared the spatiotemporal patterns of symptomatic and asymptomatic Plasmodium falciparum malaria infections in a cohort study of ∼25,000 people living in a rural hypoendemic area of about 179 km2 in a small area of the Chittagong Hill Districts of Bangladesh. Asymptomatic infections were identified by active surveillance; symptomatic clinical cases presented for care. Infections were identified by a positive rapid diagnostic test and/or microscopy. Fifty-three subjects with asymptomatic P. falciparum infection were compared with 572 subjects with symptomatic P. falciparum between mid-October 2009 and mid-October 2012 with regard to seasonality, household location, and extent of spatial clustering. We found increased spatial clustering of symptomatic compared with asymptomatic infections, and the areas of high intensity were only sometimes overlapping. Symptomatic cases had a distinct seasonality, unlike asymptomatic infections, which were detected year-round. In a comparison of 42 symptomatic Plasmodium vivax and 777 symptomatic P. falciparum cases from mid-October 2009 through mid-March 2015, we found substantial spatial overlap in areas with high infection rates, but the areas with the greatest concentration of infection differed. Detection of both symptomatic P. falciparum and symptomatic P. vivax infections was greater during the May-to-October high season, although a greater proportion of P. falciparum cases occurred during the high season compared with P. vivax. These findings reinforce that passive malaria surveillance and treatment of symptomatic cases will not eliminate the asymptomatic reservoirs that occur distinctly in time and space.

Aggregated spatial intensity as a method for estimating point-level exposures within area-level units: The case of tobacco retailer exposure in census tracts.

BACKGROUND: Aggregating point-level events to area-level units can produce misleading interpretations when displayed via choropleth maps. We developed the aggregated intensity method to share point-level location information across unit boundaries prior to aggregation. This method was applied to tobacco retailers among census tracts in New Castle County, DE. METHODS: Aggregated intensity uses kernel density estimation to generate spatially continuous expected counts of events per unit area, then aggregates these results to area-level units. We calculated a relative difference measure to compare aggregated intensity to observed counts. RESULTS: Aggregated intensity produces estimates of event exposure unconstrained by boundaries. The relative difference between aggregated intensity and counts is greater for units with many events proximal to their borders. The appropriateness of aggregated intensity depends on events' spatial influence and proximity to unit boundaries, as well as computational inputs. CONCLUSIONS: Aggregated intensity may facilitate more spatially realistic estimates of exposure to point-level events.

Racial disparities in triple negative breast cancer: toward a causal architecture approach.

BACKGROUND: Triple negative breast cancer (TNBC) is an aggressive subtype of invasive breast cancer that disproportionately affects Black women and contributes to racial disparities in breast cancer mortality. Prior research has suggested that neighborhood effects may contribute to this disparity beyond individual risk factors. METHODS: The sample included a cohort of 3316 breast cancer cases diagnosed between 2012 and 2020 in New Castle County, Delaware, a geographic region of the US with elevated rates of TNBC. Multilevel methods and geospatial mapping evaluated whether the race, income, and race/income versions of the neighborhood Index of Concentration at the Extremes (ICE) metric could efficiently identify census tracts (CT) with higher odds of TNBC relative to other forms of invasive breast cancer. Odds ratios (OR) and 95% confidence intervals (CI) were reported; p-values < 0.05 were significant. Additional analyses examined area-level differences in exposure to metabolic risk factors, including unhealthy alcohol use and obesity. RESULTS: The ICE-Race, -Income-, and Race/Income metrics were each associated with greater census tract odds of TNBC on a bivariate basis. However, only ICE-Race was significantly associated with higher odds of TNBC after adjustment for patient-level age and race (most disadvantaged CT: OR = 2.09; 95% CI 1.40-3.13), providing support for neighborhood effects. Higher counts of alcohol and fast-food retailers, and correspondingly higher rates of unhealthy alcohol use and obesity, were observed in CTs that were classified into the most disadvantaged ICE-Race quintile and had the highest odds of TNBC. CONCLUSION: The use of ICE can facilitate the monitoring of cancer inequities and advance the study of racial disparities in breast cancer.

Food Desert Status of Family Child Care Homes: Relationship to Young Children's Food Quality.

Family child care homes (FCCHs) are a favored child care choice for parents of young children in the U.S. Most FCCH providers purchase and prepare foods for the children in their care. Although FCCH providers can receive monetary support from the Child and Adult Care Food Program (CACFP), a federal subsidy program, to purchase nutritious foods, little is known about FCCH providers' access to nutritious foods, especially among FCCH providers serving children from communities that have been historically disinvested and predominantly Black. This study aims to describe the food desert status of FCCHs in Baltimore City, Maryland, and examine the relationship between food desert status and the quality of foods and beverages purchased and provided to children. A proportionate stratified random sample of 91 FCCH providers by CACFP participation status consented. Geographic information system mapping (GIS) was used to determine the food desert status of each participating FCCH. Participants reported on their access to food and beverages through telephone-based surveys. Nearly three-quarters (66/91) of FCCHs were located in a food desert. FCCH providers working and living in a food desert had lower mean sum scores M (SD) for the quality of beverages provided than FCCH providers outside a food desert (2.53 ± 0.81 vs. 2.92 ± 0.70, p = 0.036, respectively). Although the significant difference in scores for beverages provided is small, FCCH providers working in food deserts may need support in providing healthy beverages to the children in their care. More research is needed to understand food purchases among FCCH providers working in neighborhoods situated in food deserts.

The Most Common Type, Severity, and Expected Frequency of Injuries Vary by Defensive Position in Professional Baseball Players.

BACKGROUND: Location, frequency, and severity of in-game injuries by defensive position played have never been determined in professional baseball players. HYPOTHESIS: Catchers would have a higher frequency of hip and knee injuries; infielders and outfielders would have a higher frequency of general lower extremity injuries; and pitchers would have a higher frequency and severity of shoulder and elbow/forearm injuries. STUDY DESIGN: Descriptive epidemiology study. METHODS: The Major League Baseball Health and Injury Tracking System database was queried for all injuries in Major League Baseball and Minor League Baseball during the 2011-2019 seasons. Injuries were stratified by the following variables: athlete's level of play at the time of injury, anatomic region injured, whether the injury occurred during a game, and position played at the time of injury (infielder, outfielder, catcher, or pitcher). Number of days missed from competition immediately after an injury was used as a surrogate for injury severity: mild (0 days missed), moderate (1-5 days), and severe (>5 days). Observed versus expected injury ratios were calculated for each anatomic region based on position played, and ratios were adjusted by the number of players per position type during a standard inning of play. RESULTS: A total of 112,405 work-related injuries were reported, with the majority of injuries (86,520; 77%) occurring in Minor League Baseball athletes. Injuries to the leg, hand, shoulder, torso, and foot were the most common for athletes in both leagues, while hip/groin injuries were the least common. Catchers sustained the most in-game defensive head/neck injuries, while infielders and outfielders had the highest number of knee injuries. Starting and relief pitchers had the greatest total proportion of in-game defensive injuries across every other body region. Infielders and outfielders sustained injuries less frequently than expected across all body regions, while pitchers experienced more injuries than expected for all body parts. Catchers experienced more injuries than expected to the head/neck, hand, hip/groin, knee, and foot, and were more likely than other position players to sustain a knee injury that was categorized as severe based on time missed. CONCLUSION: The location, severity, and frequency of injuries vary by defensive position among professional baseball players.

Nested Spatial and Temporal Modeling of Environmental Conditions Associated With Genetic Markers of Vibrio parahaemolyticus in Washington State Pacific Oysters.

The Pacific Northwest (PNW) is one of the largest commercial harvesting areas for Pacific oysters (Crassostrea gigas) in the United States. Vibrio parahaemolyticus, a bacterium naturally present in estuarine waters accumulates in shellfish and is a major cause of seafood-borne illness. Growers, consumers, and public-health officials have raised concerns about rising vibriosis cases in the region. Vibrio parahaemolyticus genetic markers (tlh, tdh, and trh) were estimated using an most-probable-number (MPN)-PCR technique in Washington State Pacific oysters regularly sampled between May and October from 2005 to 2019 (N = 2,836); environmental conditions were also measured at each sampling event. Multilevel mixed-effects regression models were used to assess relationships between environmental measures and genetic markers as well as genetic marker ratios (trh:tlh, tdh:tlh, and tdh:trh), accounting for variation across space and time. Spatial and temporal dependence were also accounted for in the model structure. Model fit improved when including environmental measures from previous weeks (1-week lag for air temperature, 3-week lag for salinity). Positive associations were found between tlh and surface water temp, specifically between 15 and 26°C, and between trh and surface water temperature up to 26°C. tlh and trh were negatively associated with 3-week lagged salinity in the most saline waters (> 27 ppt). There was also a positive relationship between tissue temperature and tdh, but only above 20°C. The tdh:tlh ratio displayed analogous inverted non-linear relationships as tlh. The non-linear associations found between the genetic targets and environmental measures demonstrate the complex habitat suitability of V. parahaemolyticus. Additional associations with both spatial and temporal variables also suggest there are influential unmeasured environmental conditions that could further explain bacterium variability. Overall, these findings confirm previous ecological risk factors for vibriosis in Washington State, while also identifying new associations between lagged temporal effects and pathogenic markers of V. parahaemolyticus.