Calculating access to parks and other polygonal resources: A description of open-source methodologies.

Public health studies routinely use simplistic methods to calculate proximity-based "access" to greenspace, such as by measuring distances to the geographic centroids of parks or, less frequently, to the perimeter of the park area. Although computationally efficient, these approaches oversimplify exposure measurement because parks often have specific entrance points. In this tutorial paper, we describe how researchers can instead calculate more-accurate access measures using freely available open-source methods. Specifically, we demonstrate processes for calculating "service areas" representing street-network-based buffers of access to parks within set distances and mode of transportation (e.g., 1-km walk or 20-minute drive) using OpenRouteService and QGIS software. We also introduce an advanced method involving the identification of trailheads or parking lots with OpenStreetMap data and show how large parks particularly benefit from this approach. These methods can be used globally and are applicable to analyses of a wide range of studies investigating proximity access to resources.

Impacts of the choice of distance measurement method on estimates of access to point-based resources.

BACKGROUND/OBJECTIVE: Lack of access to resources such as medical facilities and grocery stores is related to poor health outcomes and inequities, particularly in an environmental justice framework. There can be substantial differences in quantifying "access" to such resources, depending on the geospatial method used to generate distance estimates. METHODS: We compared three methods for calculating distance to the nearest grocery store to illustrate differential access at the census block-group level in the Atlanta metropolitan area, including: Euclidean distance estimation, service areas incorporating roadways and other factors, and cost distance for every point on the map. RESULTS: We found notable differences in access across the three estimation techniques, implying a high potential for exposure misclassification by estimation method. There was a lack of nuanced exposure in the highest- and lowest-access areas using the Euclidean distance method. We found an Intraclass Correlation Coefficient (ICC) of 0.69 (0.65, 0.73), indicating moderate agreement between estimation methods. SIGNIFICANCE: As compared with Euclidean distance, service areas and cost distance may represent a more meaningful characterization of "access" to resources. Each method has tradeoffs in computational resources required versus potential improvement in exposure classification. Careful consideration of the method used for determining "access" will reduce subsequent misclassifications.

Machine learning-based placental clusters and their associations with adverse pregnancy outcomes.

BACKGROUND: Placental abnormalities have been described in clinical convenience samples, with predominately adverse outcomes. Few studies have described placental patterns in unselected samples. OBJECTIVE: We aimed to investigate associations between co-occurring placental features and adverse pregnancy outcomes in a prospective cohort of singletons. METHODS: Data were from the Safe Passage study (U.S. and South Africa, 2007-2015). Before 24 weeks' gestation, participants were randomly invited to donate placental tissue at delivery for blinded, standardised pathological examination. We used hierarchical clustering to construct statistically derived groups using 60 placental features. We estimated associations between the placental clusters and select adverse pregnancy outcomes, expressed as unadjusted and adjusted risk ratios (RRs) and robust 95% confidence intervals (CI). RESULTS: We selected a 7-cluster model. After collapsing 2 clusters to form the reference group, we labelled the resulting 6 analytic clusters according to the overarching category of their most predominant feature(s): severe maternal vascular malperfusion (n = 117), fetal vascular malperfusion (n = 222), other vascular malperfusion (n = 516), inflammation 1 (n = 269), inflammation 2 (n = 175), and normal (n = 706). Risks for all outcomes were elevated in the severe maternal vascular malperfusion cluster. For instance, in unadjusted analyses, this cluster had 12 times the risk of stillbirth (RR 12.07, 95% CI 4.20, 34.68) and an almost doubling in the risk of preterm delivery (RR 1.93, 95% CI 1.27, 2.93) compared with the normal cluster. Small infant size was more common among the abnormal clusters, with the highest unadjusted RRs observed in the fetal vascular malperfusion cluster (small for gestational age birth RR 2.99, 95% CI 2.24, 3.98, head circumference <10th percentile RR 2.86, 95% CI 1.60, 5.12). Upon adjustment for known risk factors, most RRs attenuated but remained >1. CONCLUSION: Our study adds to the growing body of epidemiologic research, finding adverse pregnancy outcomes may occur through etiologic mechanisms involving co-occurring placental abnormalities.

Cannabis and cocaine use, drinking outcomes, and quality of life in general hospital inpatients with alcohol use disorder.

Background: While associations between cannabis and cocaine use, and heavy drinking and quality of life (QOL), are well-established in the general population, it is unclear whether they are present in hospital inpatients with alcohol use disorder (AUD). The aim of the study was to assess associations between cannabis and cocaine use and two outcomes [heavy drinking days (HDDs) and QOL] among hospital inpatients with AUD. Methods: Hospitalized patients with AUD and at least one past-month HDD participated in this cross-sectional study. Cannabis and cocaine use were assessed using the Alcohol, Smoking, and Substance Involvement Screening Test. HDDs were assessed using the Timeline Followback. QOL was assessed by the WHOQOL-BREF instrument. Multivariable regression models assessed associations. Results: Of 248 participants, 225 (91%) had severe AUD. There were no statistically significant associations between: recent cannabis use and HDDs [Incidence Rate Ratio (IRR) = 0.95; 95% Confidence Interval (95% CI): 0.80, 1.14], cocaine use and HDDs [IRR = 0.88; 95% CI: 0.66, 1.18], or both cannabis and cocaine use and HDDs [IRR = 0.87; 95%CI: 0.70, 1.09], as compared to use of neither cannabis nor cocaine. Use of cannabis, cocaine, and both, were not associated with QOL [(odds ratio (OR) = 0.98; 95% CI:0.55, 1.74), (OR = 0.76; 95% CI:0.30, 1.93), (OR = 1.00; 95%CI: 0.49, 2.03), respectively]. Conclusions: Among hospital inpatients with AUD, there were no significant associations between cannabis and cocaine use, heavy drinking, or QOL. Our findings raise questions regarding how drug use affects AUD and whether similar results would be found among those with milder AUD and in prospective studies.

Accelerometer-Measured, Habitual Physical Activity and Circulating Brain-Derived Neurotrophic Factor: A Cross-Sectional Study.

BACKGROUND: One of the mechanisms suggested to link physical activity (PA) to favorable brain health is through stimulation of neural growth factors such as brain-derived neurotrophic factor (BDNF). Acute bouts of PA stimulate circulating BDNF levels. OBJECTIVE: In this investigation, we assessed whether habitual, accelerometer-measured PA levels were related to circulating BDNF levels in a middle-aged cohort. METHODS: In the Framingham Heart Study Third Generation cohort, 1,769 participants provided reliable accelerometry data and were not missing BDNF measurement or platelet counts. In a cross-sectional analysis, using multivariable regression, we related PA measures to serum BDNF levels, adjusting for age, sex, smoking status, platelet count, depression status, and accelerometer wear time. RESULTS: Our study participants (mean age 47±9 years, 50.8% women) spent an average of 22.3 mins/day in moderate-to-vigorous (MV)PA. Most PA variables (steps, MVPA, light activity, and sedentary time) were not related to BDNF levels (p > 0.05). We observed a non-linear trend, where 15-50 mins/week vigorous activity was associated with lower BDNF compared to those with 0 min vigorous activity (ß= -0.049±0.024, p = 0.05), but with no significant associations at lower or higher vigorous activity levels. In smokers, MVPA was also associated with lower BDNF levels (ß= -0.216±0.079, p = 0.01). CONCLUSION: Our study reveals that circulating BDNF is not chronically elevated in individuals with higher levels of habitual PA in middle-aged adults from the community and may even be chronically suppressed with higher PA in subgroups, including current smokers. These results do not contradict previous studies demonstrating that circulating BDNF rises acutely after PA.

Time to put it out - nurse-facilitated tobacco treatment in a comprehensive cancer center.

Few cancer patients receive guideline-concordant care for treatment of tobacco dependence. The purpose of this pilot trial was to obtain preliminary estimates of effectiveness of an evidence-based practice intervention on the delivery of tobacco treatment and cessation outcomes in cancer patients. We conducted a pragmatic implementation trial with a before-after design in 119 current or recently quit adult smokers with cancer who met with a clinician at a single National Cancer Institute designated comprehensive cancer center (CCC) (n = 61 pre-implementation, n = 58 post-implementation). We used a multi-component strategy based on the Chronic Care Model to implement National Comprehensive Cancer Network (NCCN) guidelines for smoking cessation. Smoking cessation counseling during the index visit was assessed by exit interview and patients were interviewed by phone to assess cessation outcomes at 3-month follow-up. Performance of cessation counseling and 7-day point prevalence abstinence (PPA) were compared across the pre- and post-implementation periods using log-logistic regression, accounting for clustering by nursing staff. More patients had received assistance in quitting at the index visit during the post-implementation period compared to the pre-implementation period (30 vs. 10%, p < .01). At 3-month follow-up, 38 and 14% of participants had discussed smoking cessation medication with a CCC healthcare professional and 57 and 27% of participants had used pharmacotherapy, respectively (p < .01 for both comparisons). Seven-day PPA at 3-month follow-up was similar in both periods, however (14 vs. 12%, respectively). A multi-component tobacco treatment intervention increased the proportion of smokers who received assistance in quitting smoking during usual cancer care but did not improve cessation outcomes.

Few patients with cancer receive help in quitting smoking. We conducted a pilot before-after trial to determine the effectiveness of an evidence-based practice intervention, including brief cessation counseling during the clinic visit and referral to an onsite tobacco treatment specialist, on the delivery of stop smoking services and cessation outcomes at a NCI-designated Comprehensive Cancer Center. During the post-implementation period, cancer patients who smoke were more likely to have received assistance in quitting in clinic and during 3-month follow-up. This change in process of care did not translate into improved short-term abstinence from tobacco, however. Greater and more sustained participation in tobacco treatment will be needed to improve cessation outcomes in this population.

Association of Prenatal Exposure to Maternal Drinking and Smoking With the Risk of Stillbirth.

Importance: Prenatal smoking is a known modifiable risk factor for stillbirth; however, the contribution of prenatal drinking or the combination of smoking and drinking is uncertain. Objective: To examine whether prenatal exposure to alcohol and tobacco cigarettes is associated with the risk of stillbirth. Design, Setting, and Participants: The Safe Passage Study was a longitudinal, prospective cohort study with data collection conducted between August 1, 2007, and January 31, 2015. Pregnant women from Cape Town, South Africa, and the Northern Plains region of the US were recruited and followed up throughout pregnancy. Data analysis was performed from November 1, 2018, to November 20, 2020. Exposure: Maternal consumption of alcohol and tobacco cigarettes in the prenatal period. Main Outcomes and Measures: The main outcomes were stillbirth, defined as fetal death at 20 or more weeks' gestation, and late stillbirth, defined as fetal death at 28 or more weeks' gestation. Self-reported alcohol and tobacco cigarette consumption was captured at the recruitment interview and up to 3 scheduled visits during pregnancy. Participants were followed up during pregnancy to obtain delivery outcome. Results: Of 11663 pregnancies (mean [SD] gestational age at enrollment, 18.6 [6.6] weeks) in 8506 women for whom the pregnancy outcome was known by 20 weeks' gestation or later and who did not terminate their pregnancies, there were 145 stillbirths (12.4 per 1000 pregnancies) and 82 late stillbirths (7.1 per 1000 pregnancies). A total of 59% of pregnancies were in women from South Africa, 59% were in multiracial women, 23% were in White women, 17% were in American Indian women, and 0.9% were in women of other races. A total of 8% were older than 35 years. In 51% of pregnancies, women reported no alcohol or tobacco cigarette exposure (risk of stillbirth, 4 per 1000 pregnancies). After the first trimester, 18% drank and smoked (risk of stillbirth, 15 per 1000 births), 9% drank only (risk of stillbirth, 10 per 1000 pregnancies), and 22% smoked only (risk of stillbirth, 8 per 1000 pregnancies). Compared with the reference group (pregnancies not prenatally exposed or without any exposure after the first trimester), the adjusted relative risk of late stillbirth was 2.78 (98.3% CI, 1.12-6.67) for pregnancies prenatally exposed to drinking and smoking, 2.22 (98.3% CI, 0.78-6.18) for pregnancies prenatally exposed to drinking only after the first trimester, and 1.60 (98.3% CI, 0.64-3.98) for pregnancies prenatally exposed to smoking only after the first trimester. The adjusted relative risk for all stillbirths was 1.75 (98.3% CI, 0.96-3.18) for dual exposure, 1.26 (98.3% CI, 0.58-2.74) for drinking only, and 1.27 (98.3% CI, 0.69-2.35) for smoking only compared with the reference group. Conclusions and Relevance: These results suggest that combined drinking and smoking after the first trimester of pregnancy, compared with no exposure or quitting before the end of the first trimester, may be associated with a significantly increased risk of late stillbirth.

Concurrent prenatal drinking and smoking increases risk for SIDS: Safe Passage Study report.

BACKGROUND: Sudden infant death syndrome (SIDS) is the leading cause of postneonatal mortality. Although the rate has plateaued, any unexpected death of an infant is a family tragedy thus finding causes and contributors to risk remains a major public health concern. The primary objective of this investigation was to determine patterns of drinking and smoking during pregnancy that increase risk of SIDS. METHODS: The Safe Passage Study was a prospective, multi-center, observational study with 10,088 women, 11,892 pregnancies, and 12,029 fetuses, followed to 1-year post delivery. Subjects were from two sites in Cape Town, South Africa and five United States sites, including two American Indian Reservations. Group-based trajectory modeling was utilized to categorize patterns of drinking and smoking exposure during pregnancy. FINDINGS: One-year outcome was ascertained in 94·2% infants, with 28 SIDS (2·43/1000) and 38 known causes of death (3·30/1000). The increase in relative risk for SIDS, adjusted for key demographic and clinical characteristics, was 11·79 (98·3% CI: 2·59-53·7, p < 0·001) in infants whose mothers reported both prenatal drinking and smoking beyond the first trimester, 3.95 (98·3% CI: 0·44-35·83, p = 0·14), for drinking only beyond the first trimester and 4·86 (95% CI: 0·97-24·27, p = 0·02) for smoking only beyond the first trimester as compared to those unexposed or reported quitting early in pregnancy. INTERPRETATION: Infants prenatally exposed to both alcohol and cigarettes continuing beyond the first trimester have a substantially higher risk for SIDS compared to those unexposed, exposed to alcohol or cigarettes alone, or when mother reported quitting early in pregnancy. Given that prenatal drinking and smoking are modifiable risk factors, these results address a major global public health problem. FUNDING: National Institute on Alcohol Abuse and Alcoholism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute on Deafness and Other Communication Disorders.

Accelerometer-determined physical activity and cognitive function in middle-aged and older adults from two generations of the Framingham Heart Study.

INTRODUCTION: Physical activity (PA) may play a role in maintenance of cognitive function in both middle and older ages and prevention of outcomes such as dementia and Alzheimer's disease. METHODS: Cross-sectional regression analyses were performed in Framingham Heart Study Third Generation (n = 1861) and Offspring (n = 909) cohort participants assessing the association of accelerometry-measured PA with cognitive function, adjusting for age, sex, accelerometer wear time, education, occupational status/PA, and smoking status. RESULTS: In each cohort, achieving just 10-21.4 min/day moderate-to-vigorous PA related to better executive function (P < .02); and just 10 min/day moderate-to-vigorous PA was associated with better verbal memory in middle-aged adults in the Third Generation cohort (P = .02). In older adults of the Offspring cohort, total PA (measured in steps/day) was associated with better executive function (P < .02). DISCUSSION: PA at levels lower than the current PA Guidelines (just 10 min/day moderate-to-vigorous PA and total PA including lower intensity PA) were associated with better cognitive function.

Register data in the evaluation and program planning of addiction treatment programs: using Sweden as an example.

Data from large-scale registers is often underutilized when evaluating addiction treatment programs. Since many programs collect register data regarding clients and interventions, there is a potential to make greater use of such records for program evaluation. The purpose of this article is to discuss the value of using large-scale registers in the evaluation and program planning of addiction treatment systems and programs. Sweden is used as an example of a country where register data is both available and is starting to be used in national evaluation and program planning efforts. The article focuses on possibilities, limitations and practicalities when using large-scale register data to conduct evaluations and program planning of addiction treatment programs. Main conclusions are that using register data for evaluation provides large amounts of data at low cost, limitations associated to the use of register data may be handled statistically, register data can answer important questions in planning of addiction treatment programs, and more accurate measures are needed to account for the diversity of client populations.

Clinical sensitivity and specificity of meconium fatty acid ethyl ester, ethyl glucuronide, and ethyl sulfate for detecting maternal drinking during pregnancy.

BACKGROUND: We investigated agreement between self-reported prenatal alcohol exposure (PAE) and objective meconium alcohol markers to determine the optimal meconium marker and threshold for identifying PAE. METHODS: Meconium fatty acid ethyl esters (FAEE), ethyl glucuronide (EtG), and ethyl sulfate (EtS) were quantified by LC-MS/MS in 0.1 g meconium from infants of Safe Passage Study participants. Detailed PAE information was collected from women with a validated timeline follow-back interview. Because meconium formation begins during weeks 12-20, maternal self-reported drinking at or beyond 19 weeks was our exposure variable. RESULTS: Of 107 women, 33 reported no alcohol consumption in pregnancy, 16 stopped drinking by week 19, and 58 drank beyond 19 weeks (including 45 third-trimester drinkers). There was moderate to substantial agreement between self-reported PAE at ≥19 weeks and meconium EtG ≥30 ng/g (κ = 0.57, 95% CI 0.41-0.73). This biomarker and associated cutoff was superior to a 7 FAEE sum ≥2 nmol/g and all other individual and combination marker cutoffs. With meconium EtG ≥30 ng/g as the gold standard condition and maternal self-report at ≥19 weeks' gestation as the test condition, 82% clinical sensitivity (95% CI 71.6-92.0) and 75% specificity (95% CI 63.2-86.8) were observed. A significant dose-concentration relationship between self-reported drinks per drinking day and meconium EtG ≥30 ng/g also was observed (all P < 0.01). CONCLUSIONS: Maternal alcohol consumption at ≥19 weeks was better represented by meconium EtG ≥30 ng/g than currently used FAEE cutoffs.

The safe passage study: design, methods, recruitment, and follow-up approach.

BACKGROUND: The Safe Passage Study is a large, prospective, multidisciplinary study designed to (1) investigate the association between prenatal alcohol exposure, sudden infant death syndrome (SIDS), and stillbirth, and (2) determine the biological basis of the spectrum of phenotypic outcomes from exposure, as modified by environmental and genetic factors that increase the risk of stillbirth, SIDS, and in surviving children, fetal alcohol spectrum disorders. METHODS: The results provided are based on an interim assessment of 6004 women enrolled, out of the 12,000 projected, from the Northern Plains, US, and Cape Town, South Africa, areas known to be of high risk for maternal drinking during pregnancy. Research objectives, study design, and descriptive statistics, including consent, recruitment, and retention information, are provided. RESULTS: Overall visit compliance is 87%, and includes prenatal, delivery/newborn, and postnatal contacts through 1 year post-delivery. Pregnancy outcome ascertainment is 98% prior to medical chart review; less than 2% of women withdraw. Consent for the use of DNA and placental tissue exceed 94%, and consent to participate in the autopsy portion of the study is 71%. CONCLUSIONS: The Safe Passage Study is the first multi-site study of SIDS and stillbirth to integrate prospectively collected exposure information with multidisciplinary biological information in the same maternal and fetal/infant dyad using a common protocol. Essential components of the study design and its success are close ties to the community and rigorous systems and processes to ensure compliance with the study protocol and procedures.

Interlaboratory comparison of fetal male DNA detection from common maternal plasma samples by real-time PCR.

BACKGROUND: Analysis of fetal DNA from maternal plasma by PCR offers great potential for noninvasive prenatal genetic diagnosis. To further evaluate this potential, we developed and validated a standard protocol to determine whether fetal DNA sequences could be reproducibly amplified and measured across multiple laboratories in a common set of specimens. METHODS: Each of five participating centers in a National Institute of Child Health and Human Development consortium collected 20 mL of peripheral blood from 20 pregnant women between 10 and 20 weeks of gestation. The plasma fraction was separated according to a common protocol, divided, and frozen in five aliquots. One aliquot was shipped to each participating laboratory, where DNA was extracted according to a standard protocol. All plasma samples (n = 100) were then analyzed blindly for the presence and quantity of total DNA (GAPDH) and male fetal DNA (SRY) by real-time PCR. Genomic DNA was isolated from female and male cells at one center, quantified, and shipped to the others to serve as calibrators for GAPDH and SRY, respectively. RESULTS: The amplification of known quantities of DNA was consistent among all centers. The mean quantity of male DNA amplified from maternal plasma when the fetus was male ranged from 51 to 228 genome equivalents (GE)/mL. Qualitative concordance was found overall among centers. The sensitivity of the assay for detection of male DNA when the fetus was male varied from 31% to 97% among centers. Specificity was more consistent (93-100%) with only four false-positive results obtained across the entire study. CONCLUSIONS: All centers were able to consistently amplify frozen and shipped DNA. The PCR procedure used here is reliable and reproducible. Centers that extracted and amplified more DNA per milliliter of maternal plasma had superior sensitivities of Y chromosome sequence detection. The specificity of the assay was more consistent among centers. A robust and thoroughly optimized protocol for the extraction of DNA from maternal plasma is needed to make testing of fetal DNA in maternal plasma a clinically relevant analytical tool.

Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project.

OBJECTIVE: To evaluate the effectiveness of training and institutionalizing teamwork behaviors, drawn from aviation crew resource management (CRM) programs, on emergency department (ED) staff organized into caregiver teams. STUDY SETTING: Nine teaching and community hospital EDs. STUDY DESIGN: A prospective multicenter evaluation using a quasi-experimental, untreated control group design with one pretest and two posttests of the Emergency Team Coordination Course (ETCC). The experimental group, comprised of 684 physicians, nurses, and technicians, received the ETCC and implemented formal teamwork structures and processes. Assessments occurred prior to training, and at intervals of four and eight months after training. Three outcome constructs were evaluated: team behavior, ED performance, and attitudes and opinions. Trained observers rated ED staff team behaviors and made observations of clinical errors, a measure of ED performance. Staff and patients in the EDs completed surveys measuring attitudes and opinions. DATA COLLECTION: Hospital EDs were the units of analysis for the seven outcome measures. Prior to aggregating data at the hospital level, scale properties of surveys and event-related observations were evaluated at the respondent or case level. PRINCIPAL FINDINGS: A statistically significant improvement in quality of team behaviors was shown between the experimental and control groups following training (p = .012). Subjective workload was not affected by the intervention (p = .668). The clinical error rate significantly decreased from 30.9 percent to 4.4 percent in the experimental group (p = .039). In the experimental group, the ED staffs' attitudes toward teamwork increased (p = .047) and staff assessments of institutional support showed a significant increase (p = .040). CONCLUSION: Our findings point to the effectiveness of formal teamwork training for improving team behaviors, reducing errors, and improving staff attitudes among the ETCC-trained hospitals.