County incidence and geospatial trends of early-onset hypertensive disorders of pregnancy in Kentucky, 2008-2017.

BACKGROUND: Early-onset hypertensive disorders of pregnancy (eHDP) are associated with more severe maternal and infant outcomes than later-onset disease. However, little has been done to evaluate population-level trends. Therefore, in this paper, we seek to address this understudied area by describing the geospatial and temporal patterns of county-level incidence of eHDP and assessing county-level demographics that may be associated with an increased incidence of eHDP. METHODS: Employing Kentucky certificates of live and stillbirth from 2008-2017, this ecological study detected county-level clusters of early-onset hypertensive disorders of pregnancy using SaTScan, calculated average annual percent change (AAPC) with a join point analysis, and identified county-level covariates (% of births to women ≥ 35 years of age, % with BMI ≥ 30 kg/m2, % currently smoking, % married, and % experienced eHDP) with a fixed-effects negative binomial regression model for longitudinal data with an autoregressive (AR) correlation structure offset with the natural log of the number of births in each county and year. RESULTS: County-level incidence of eHDP had a non-statistically significant increase of almost 3% (AAPC: 2.84, 95% CI: -4.26, 10.46), while maternal smoking decreased by almost 6% over the study period (AAPC:-5.8%, 95%CI: -7.5, -4.1), Risk factors for eHDP such as pre-pregnancy BMI ≥ 30 and proportion of births to women ≥ 35 years of age increased by 2.3% and 3.4% respectively (BMI AAPC:2.3, 95% CI: 0.94, 3.7; ≥ 35 years AAPC:3.4, 95% CI: 0.66, 6.3). After adjusting for race, county-level proportions of college attainment, and maternal smoking throughout pregnancy, counties with the highest proportion of births to women with BMI ≥ 30 kg/m2 reported an eHDP incidence 20% higher than counties with a lower proportion of births to mothers with a BMI ≥ 30 kg/m2 and a 20% increase in eHDP incidence (aRR = 1.20, 95% CI: 1.00, 1.44). We also observed that counties with the highest proportion vs. the lowest of mothers ≥ 35 years old (> 6.1%) had a 26% higher incidence of eHDP (RR = 1.26, 95%CI: 1.04, 1.50) compared to counties with the lowest incidence (< 2.5%). We further identified two county-level clusters of elevated eHDP rates. We also observed that counties with the highest vs. lowest proportion of mothers ≥ 34 years old (> 6.1% vs. < 2.5%) had a 26% increase in the incidence of eHDP (RR = 1.26, 95% CI: 1.04, 1.50). We further identified two county-level clusters of elevated incidence of eHDP. CONCLUSIONS: This study identified two county-level clusters of eHDP, county-level covariates associated with eHDP, and that while increasing, the average rate of increase for eHDP was not statistically significant. This study also identified the reduction in maternal smoking over the study period and the concerning increase in rates of elevated pre-pregnancy BMI among mothers. Further work to explore the population-level trends in this understudied pregnancy complication is needed to identify community factors that may contribute to disease and inform prevention strategies.

Investigating the Relation between Electronic Cigarette Use and Sleep Duration in Kentucky Using the BRFSS, 2016-2017.

OBJECTIVES: Like traditional cigarettes, electronic cigarettes (e-cigarettes) contain nicotine, which is known to negatively influence sleep quality. Few studies, however, have examined the relation between e-cigarettes and sleep quality using population-based survey data because of the relatively recent appearance of these products on the market. This study investigated the relation between e-cigarette and cigarette use and sleep duration in Kentucky, a state with high rates of nicotine dependence and related chronic diseases. METHODS: Data from two consecutive years of the Behavioral Risk Factor Surveillance System survey-2016 and 2017-were analyzed using χ2 statistics and multivariable Poisson regression analyses to control for socioeconomic and demographic variables, the presence of other chronic diseases, and traditional cigarette use. RESULTS: This study was conducted using responses from 18,907 Kentucky adults aged 18 years and older. Overall, almost 40% reported short (<7 hours) sleep duration. After adjusting for other covariates, including the presence of chronic diseases, those who had currently or formerly used both traditional and e-cigarettes had the highest risk of short sleep duration. Those who currently or formerly smoked only traditional cigarettes also had significantly higher risk, unlike those who had only used e-cigarettes. CONCLUSIONS: Survey respondents who used e-cigarettes were more likely to report short sleep duration, but only if they currently or formerly smoked traditional cigarettes. Those who used both products, regardless of whether current or former, were more likely to report short sleep duration than those who had used just one of these tobacco products.

The Intersectionality between Race, Ethnicity, and Residential-Level Socioeconomic Status in Disparities of Head and Neck Cancer Outcomes: A SEER Study.

BACKGROUND: Head and neck cancer (HNC) mortality differs by race, ethnicity, and socioeconomic status (SES). However, it is unclear whether the relationship between race/ethnicity and HNC-specific mortality varies according to the residence-level SES. METHODS: Data from the Surveillance Epidemiology and End Results database included participants with primary HNC between 2006 and 2017 (followed through 2018) to assess the joint association of race/ethnicity and census-tract level SES Yost-index groups (quintiles) with all-cause and HNC-specific mortalities. Relative survival rates at 1, 5, and 10 years were calculated. Multivariable Cox proportional hazard regression models estimated hazard-ratios and 95% confidence intervals for all-cause mortality, and Fine-Gray subdistribution hazard models for HNC-specific mortality. Cumulative incidence curves for HNC-specific deaths were estimated. RESULTS: 76,095 patients were included in the analysis: 63.2% were <65 years, 73.4% male, and 11.3% non-Hispanic (NH) Black. Most patients (58.3%) were diagnosed at regional or distant stages and 20.6% died of HNC. The five-year relative survival rate increased with SES group, with 51.6% in the lowest SES group, and 74.1% in the highest SES group. NH-Black patients had higher risk of all-cause and HNC-specific mortality than NH-White patients, regardless of the SES group. NH-Asian/Pacific Islander and Hispanic patients had higher risk of HNC-specific mortality in some SES groups. CONCLUSIONS: NH-Black patients of all SES strata had significantly worse outcomes. Other factors, such as healthcare quality, may be associated with persistent disparities. IMPACT: The study highlights the persistence of significant racial disparities in HNC survival across socioeconomic categories. There is need to consider additional factors underlying these disparities.

A cross-sectional examination of the early-onset hypertensive disorders of pregnancy and industrial emissions of toxic metals using Kentucky birth records, 2008-2017.

This cross-sectional study assessed geospatial patterns of early-onset hypertensive disorders of pregnancy (eHDP) in primiparous mothers and exposure to industrial emissions using geocoded residential information from Kentucky live (N = 210,804) and still (N = 1,247) birth records (2008-2017) and census block group estimates of aerosol concentrations of arsenic (As), cadmium (Cd), chromium (Cr), lead (Pb), mercury (Hg), selenium (Se), and zinc (Zi) from the Risk Screening Environmental Indicators (RSEI) model. A latent class analysis allowed for the identification of four district exposure classes-As, Cd, and Pb (12.6%); Se and Zi (21.4%); Pb and Cr (8%); and low or no exposures (57.9%). Women classified as having a high probability of exposure to both Pb and Cr had a statistically significantly greater prevalence of eHDP after adjusting for demographic factors (aPR = 1.22, 95% CI: 1.04, 1.44) relative to those with low or no exposure. Our findings contribute to the emerging literature on the association of metal exposures with pregnancy outcomes.

Maternal proximity to mountain-top removal mining and birth defects in Appalachian Kentucky, 1997-2003.

Extraction of coal through mountaintop removal mining (MTR) alters many dimensions of the landscape. Explosive blasts, exposed rock, and coal washing have the potential to pollute air and water. Previous research suggests that infants born to mothers living in areas with MTR have a higher prevalence of birth defects. In this cross-sectional study, we further examine the relationship between MTR activity and several types of birth defects. Maternal exposure to MTR was assessed using remote sensing data from Skytruth, which captures MTR activity in the Central Appalachian region of the United States. Active MTR area was quantified within a five-kilometer buffer surrounding geocoded maternal address captured on birth records for live births to Appalachian Kentucky mothers between 1997 and 2003 (N = 95,581). We assigned high, medium, and low exposure based on the tertile of total MTR area within 5-km, and births with no MTR within this buffer were assigned zero exposure. The presence or absence of a birth defect grouped into six major organ systems was identified using birth records alone. Finally, we applied conditional multiple imputation for variables with missing values before conducting separate multivariable log-binomial regression models for each birth defect group. Prevalence ratio (PR) estimates were adjusted for individual level covariates from birth records. The prevalence of gastro-intestinal defects was significantly higher in birth records with high and low active MTR exposure compared to records with no exposure. (High exposure: PR = 1.99, 95% CI = 1.14-3.47; low exposure PR = 1.88, 95% CI = 1.06-3.31). This study supports some of the existing findings of previous ecological studies. Research addressing the relationship between gastro-intestinal birth defects and MTR coal mining is warranted but should carefully consider temporal dimensions of exposure.

Geocoding precision of birth records from 2008 to 2017 in Kentucky, USA.

Maternal address information captured on birth records is increasingly used to estimate residential environmental exposures during pregnancy. However, there has been limited assessment of the geocoding precision of birth records, particularly since the adoption of the 2003 standard birth certificate in 2015. To address this gap, this study evaluated the geocoding precision of live and stillbirth records of Kentucky residents over ten years, from 2008 through 2017. This study summarized the demographic characteristics of imprecisely geocoded records and, using a bivariate logistic regression, identified covariates associated with poor geocoding precision among three population density designations-metro, non-metro, and rural. We found that in metro areas, after adjusting for area deprivation, education, and the race, age and education of both parents, records for Black mothers had 48% lower odds of imprecise geocoding (aOR=0.52, 95% CI: 0.48, 0.56), while Black women in rural areas had 96% higher odds of imprecise geocoding (aOr=1.96, 95% CI: 1.68, 2.28). This study also found that over the study period, rural and non-metro areas began with a high proportion of imprecisely geocoded records (38% in rural areas, 19% in non-metro), but both experienced an 8% decline in imprecisely geocoded records over the study period (aOr=0.92, 95% CI: 0.92, 0.94). This study shows that, while geocoding precision has improved in Kentucky, further work is needed to improve geocoding in rural areas and address racial and ethnic disparities.

Examining Adult E-cigarette Use in Kentucky and Its Appalachian Region Using the Behavioral Risk Factor Surveillance System, 2016-2017.

OBJECTIVES: Electronic cigarette (e-cigarette) use has increased steadily in the United States, but little research has examined its prevalence in states comprising Appalachia, a rural region known for high rates of tobacco use. This study assessed lifetime and current e-cigarette use among adults by sociodemographic characteristics, geographic region, and cigarette smoking in Kentucky, with a focus on the Appalachian region. METHODS: We used data from the 2016-2017 Behavioral Risk Factor Surveillance System (BRFSS) surveys to calculate the prevalence of lifetime and current e-cigarette use, and we used weighted multivariable logistic regression analyses to examine the relative influence of other factors. RESULTS: Among adults in Kentucky, 5.8% (95% CI, 5.2%-6.4%) were current e-cigarette users and 27.0% (95% CI, 25.9%-28.0%) were lifetime users, compared with state medians of 4.6% (95% CI, 4.0%-5.1%) and 21.4% (95% CI, 19.4%-23.5%) for the United States. Multivariable regression models showed similar patterns for all regions: higher prevalence odds of current e-cigarette use among adults aged 18-24, current conventional smokers, and adults unable to work. Generally, Appalachian residents of Kentucky did not have significantly higher rates of lifetime or current e-cigarette use as compared with other non-Appalachian residents of Kentucky. Hispanic residents of Appalachian Kentucky, however, had higher rates of e-cigarette use than Hispanic residents of other regions of Kentucky. CONCLUSIONS: Rates of e-cigarette use were higher in Kentucky than in the United States but were not further elevated in Kentucky's Appalachian region. High rates of e-cigarette use among Hispanic residents of Appalachia indicate a need to focus future interventions in the region.

Estimating the Population Attributable Fraction of Asthma Due to Electronic Cigarette Use and Other Risk Factors Using Kentucky Behavioral Risk Factor Survey Data, 2016-2017.

Introduction: Electronic nicotine delivery systems ENDS have become popular in the United States among both new users of nicotine and those seeking less harmful alternatives to traditional cigarettes. Users often perceive ENDS as being less harmful than traditional cigarettes. This study investigated the relationship between use of ENDS and asthma in a representative sample of adults. Methods: For this cross-sectional study, we used data from the Kentucky Behavioral Risk Factor Surveillance System telephone survey data from 2016-2017. Using a weighted multivariable logistic regression analysis, we identified important covariates to adjust for to calculate the population attributable fraction (PAF) of asthma due to ENDS and other modifiable risk factors factors (cigarette use, obesity, education, and employment). The confidence intervals for the PAFs were estimated using bootstrap methods of variance estimation. Results: We found that 10.6% of those aged 18-30 reported currently had asthma. After adjusting for noted covariates, ENDS use did not significantly increase the odds of asthma. In the final PAF model, the PAF of asthma due to ENDS was 0.4% (95% CI: -5.41, 6.21). Conclusion: While these findings suggest only modest effects of ENDS use on asthma prevalence, future research including older age groups and more long-term users might produce different results.

Effect of Local Smoke-Free Ordinances on Smoking Prevalence in Kentucky, 2002-2009.

OBJECTIVES: Many local communities in Kentucky, a state with one of the highest smoking prevalence rates in the United States, have enacted smoke-free ordinances that prohibit smoking in workplaces and enclosed buildings open to the public. Research has shown that such ordinances are clearly beneficial for public health, but their influence on smoking prevalence in the populations they cover remains unclear. This study explores the effect of local smoke-free ordinances on smoking prevalence in Kentucky. METHODS: We used a database of smoke-free ordinances maintained by the Kentucky Center for Smoke-Free Policy, Kentucky Behavioral Risk Factor Surveillance System survey data, and US Census data. We estimated the proportion of Kentucky adults living in counties with smoke-free ordinances of varying strength; examined bivariate associations between smoke-free ordinances and smoking prevalence; and fit regression models that adjusted for various county-level demographic, socioeconomic, and geographic factors. RESULTS: Smoking prevalence was approximately 5% lower in counties with smoke-free ordinances, even after adjusting for other relevant factors, including a trend in decreasing prevalence throughout the study region. There was a slight dose-response effect related to the strength of smoke-free ordinances after adjustment for these covariates. Smoke-free ordinances appear to have a modest effect on smoking prevalence across the span of several years. CONCLUSIONS: Findings demonstrate that although smoking prevalence fell throughout the state during the study period, counties with smoke-free ordinances experienced a greater decline. Future research should examine the strength of smoke-free ordinances in greater detail to better understand their influence on smoking prevalence.

Spatiotemporal Analysis of Lung Cancer Histological Types in Kentucky, 1995-2014.

Recent metabolic and genetic research has demonstrated that risk for specific histological types of lung cancer varies in relation to cigarette smoking and obesity. This study investigated the spatial and temporal distribution of lung cancer histological types in Kentucky, a largely rural state with high rates of smoking and obesity, to discern population-level trends that might reflect variation in these and other risk factors. The Kentucky Cancer Registry provided residential geographic coordinates for lung cancer cases diagnosed from 1995 through 2014. We used multinomial and discrete Poisson spatiotemporal scan statistics, adjusted for age, gender, and race, to characterize risk for specific histological types-small cell, adenocarcinoma, squamous cell, and other types-throughout Kentucky and compared to maps of risk factors. Toward the end of the study period, adenocarcinoma was more common among all population subgroups in north-central Kentucky, where smoking and obesity are less prevalent. During the same time frame, squamous cell, small cell, and other types were more common in rural Appalachia, where smoking and obesity are more prevalent, and in some high poverty urban areas. Spatial and temporal patterns in the distribution of histological types of lung cancer are likely related to regional variation in multiple risk factors. High smoking and obesity rates in the Appalachian region, and likely in high poverty urban areas, appeared to coincide with high rates of squamous cell and small cell lung cancer. In north-central Kentucky, environmental exposures might have resulted in higher risk for adenocarcinoma specifically.

Oropharyngeal colonization by Streptococcus pneumoniae among HIV-infected adults in Uganda: assessing prevalence and antimicrobial susceptibility.

OBJECTIVES: To evaluate characteristics of Streptococcus pneumoniae associated with oropharyngeal colonization in the Ugandan adult HIV population. METHODS: We conducted a cross-sectional study at the outpatient HIV clinic at the Joint Clinical Research Centre in Kampala, Uganda between July 2004 and February 2005. Six hundred HIV-infected individuals were interviewed and had oropharyngeal specimens collected. Pneumococci were isolated from these specimens and antimicrobial susceptibility patterns determined using standard microdilution methods. Serotypes of the pneumococcal isolates were evaluated by capsular swelling reaction with commercial antisera. RESULTS: The prevalence of oropharyngeal colonization with pneumococci was 18% (108/600). Thirty-two different pneumococcal serotypes were identified, and the most common were serotypes 3 (14.7%), 19F (6.4%), 23F (6.4%), and 16 (5.5%). Seventy-two percent of the isolates were penicillin (PCN) intermediate (MICs 0.12-1 microg/mL), the remainder all being PCN susceptible, and >99% were trimethoprim-sulfamethoxazole (TMP-SMX) resistant. Novel PCN intermediate serotypes included 7, 11, 16, 20, 22, 24, and 34. Only one isolate was resistant to macrolides, and resistance to other antibiotics was rare. CONCLUSIONS: HIV-infected adults in Uganda are colonized with pneumococci that exhibit a high degree of TMP-SMX and PCN non-susceptibility, with several unique PCN non-susceptible serotypes that are not included in current vaccine preparations.