Prescription analgesia and adjuvant use by pain severity at admission among nursing home residents with non-malignant pain

Objective: We estimated the use of prescribed analgesics and adjuvants among nursing home residents without cancer who reported pain at their admission assessment, in relation to resident-reported pain severity. Methods: Medicare Part D claims were used to define 3 classes of analgesics and 7 classes of potential adjuvants on the 21st day after nursing home admission (or the day of discharge for residents discharged before that date) among 180,780 residents with complete information admitted between January 1, 2011 and December 9, 2016, with no cancer diagnosis. Results: Of these residents, 27.9% reported mild pain, 46.6% moderate pain, and 25.6% reported severe pain. The prevalence of residents in pain without Part D claims for prescribed analgesic and/or adjuvant medications was 47.3% among those reporting mild pain, 35.7% among those with moderate pain, and 24.8% among those in severe pain. Among residents reporting severe pain, 33% of those ≥ 85 years of age and 35% of those moderately cognitively impaired received no prescription analgesics/adjuvants. Use of all classes of prescribed analgesics and adjuvants increased with resident-reported pain severity, and the concomitant use of medications from multiple classes was common. Conclusion: Among nursing home residents with recognized pain, opportunities to improve the pharmacologic management of pain, especially among older residents, and those living with cognitive impairments exist

Separate and Unequal: Residential Segregation and Estimated Cancer Risks Associated with Ambient Air Toxics in U.S. Metropolitan Areas

This study examines links between racial residential segregation and estimated ambient air toxics exposures and their associated cancer risks using modeled concentration estimates from the U.S. Environmental Protection Agency’s National Air Toxics Assessment. We combined pollutant concentration estimates with potencies to calculate cancer risks by census tract for 309 metropolitan areas in the United States. This information was combined with socioeconomic status (SES) measures from the 1990 Census. Estimated cancer risks associated with ambient air toxics were highest in tracts located in metropolitan areas that were highly segregated. Disparities between racial/ethnic groups were also wider in more segregated metropolitan areas. Multivariate modeling showed that, after controlling for tract-level SES measures, increasing segregation amplified the cancer risks associated with ambient air toxics for all racial groups combined [highly segregated areas: relative cancer risk (RCR) = 1.04; 95% confidence interval (CI), 1.01–107; extremely segregated areas: RCR = 1.32; 95% CI, 1.28–1.36]. This segregation effect was strongest for Hispanics (highly segregated areas: RCR = 1.09; 95% CI, 1.01–1.17; extremely segregated areas: RCR = 1.74; 95% CI, 1.61–1.88) and weaker among whites (highly segregated areas: RCR = 1.04; 95% CI, 1.01–1.08; extremely segregated areas: RCR = 1.28; 95% CI, 1.24–1.33), African Americans (highly segregated areas: RCR = 1.09; 95% CI, 0.98–1.21; extremely segregated areas: RCR = 1.38; 95% CI, 1.24–1.53), and Asians (highly segregated areas: RCR = 1.10; 95% CI, 0.97–1.24; extremely segregated areas: RCR = 1.32; 95% CI, 1.16–1.51). Results suggest that disparities associated with ambient air toxics are affected by segregation and that these exposures may have health significance for populations across racial lines

Race, Ethnicity, Income Concentration and 10-Year Change in Urban Greenness in the United States

Background: Cross-sectional studies suggest urban greenness is unequally distributed by neighborhood demographics. However, the extent to which inequalities in greenness have changed over time remains unknown. Methods: We estimated 2001 and 2011 greenness using Moderate-resolution Imaging Spectroradiometer (MODIS) satellite-derived normalized difference vegetative index (NDVI) in 59,483 urban census tracts in the contiguous U.S. We fit spatial error models to estimate the association between baseline census tract demographic composition in 2000 and (1) 2001 greenness and (2) change in greenness between 2001 and 2011. Results: In models adjusted for population density, climatic factors, housing tenure, and Index of Concentration at the Extremes for income (ICE), an SD increase in percent White residents (a 30% increase) in 2000 was associated with 0.021 (95% CI: 0.018, 0.023) higher 2001 NDVI. We observed a stepwise reduction in 2001 NDVI with increased concentration of poverty. Tracts with a higher proportion of Hispanic residents in 2000 lost a small, statistically significant amount of greenness between 2001 and 2011 while tracts with higher proportions of Whites experienced a small, statistically significant increase in greenness over the same period. Conclusions: Census tracts with a higher proportion of racial/ethnic minorities, compared to a higher proportion of White residents, had less greenness in 2001 and lost more greenness between 2001 and 2011. Policies are needed to increase greenness, a health-promoting neighborhood asset, in disadvantaged communities

Ambient air pollution exposure and full-term birth weight in California

<p>Abstract</p> <p>Background</p> <p>Studies have identified relationships between air pollution and birth weight, but have been inconsistent in identifying individual pollutants inversely associated with birth weight or elucidating susceptibility of the fetus by trimester of exposure. We examined effects of prenatal ambient pollution exposure on average birth weight and risk of low birth weight in full-term births.</p> <p>Methods</p> <p>We estimated average ambient air pollutant concentrations throughout pregnancy in the neighborhoods of women who delivered term singleton live births between 1996 and 2006 in California. We adjusted effect estimates of air pollutants on birth weight for infant characteristics, maternal characteristics, neighborhood socioeconomic factors, and year and season of birth.</p> <p>Results</p> <p>3,545,177 singleton births had monitoring for at least one air pollutant within a 10 km radius of the tract or ZIP Code of the mother's residence. In multivariate models, pollutants were associated with decreased birth weight; -5.4 grams (95% confidence interval -6.8 g, -4.1 g) per ppm carbon monoxide, -9.0 g (-9.6 g, -8.4 g) per pphm nitrogen dioxide, -5.7 g (-6.6 g, -4.9 g) per pphm ozone, -7.7 g (-7.9 g, -6.6 g) per 10 <it>μ</it>g/m³particulate matter under 10 μm, -12.8 g (-14.3 g, -11.3 g) per 10 <it>μ</it>g/m³particulate matter under 2.5 μm, and -9.3 g (-10.7 g, -7.9 g) per 10 <it>μ</it>g/m³of coarse particulate matter. With the exception of carbon monoxide, estimates were largely unchanged after controlling for co-pollutants. Effect estimates for the third trimester largely reflect the results seen from full pregnancy exposure estimates; greater variation in results is seen in effect estimates specific to the first and second trimesters.</p> <p>Conclusions</p> <p>This study indicates that maternal exposure to ambient air pollution results in modestly lower infant birth weight. A small decline in birth weight is unlikely to have clinical relevance for individual infants, and there is debate about whether a small shift in the population distribution of birth weight has broader health implications. However, the ubiquity of air pollution exposures, the responsiveness of pollutant levels to regulation, and the fact that the highest pollution levels in California are lower than those regularly experienced in other countries suggest that precautionary efforts to reduce pollutants may be beneficial for infant health from a population perspective.</p

The Racial/Ethnic Distribution of Heat Risk–Related Land Cover in Relation to Residential Segregation

Objective: We examined the distribution of heat risk–related land cover (HRRLC) characteristics across racial/ethnic groups and degrees of residential segregation.Methods: Block group–level tree canopy and impervious surface estimates were derived from the 2001 National Land Cover Dataset for densely populated urban areas of the United States and Puerto Rico, and linked to demographic characteristics from the 2000 Census. Racial/ethnic groups in a given block group were considered to live in HRRLC if at least half their population experienced the absence of tree canopy and at least half of the ground was covered by impervious surface (roofs, driveways, sidewalks, roads). Residential segregation was characterized for metropolitan areas in the United States and Puerto Rico using the multigroup dissimilarity index.Results: After adjustment for ecoregion and precipitation, holding segregation level constant, non-Hispanic blacks were 52% more likely (95% CI: 37%, 69%), non-Hispanic Asians 32% more likely (95% CI: 18%, 47%), and Hispanics 21% more likely (95% CI: 8%, 35%) to live in HRRLC conditions compared with non-Hispanic whites. Within each racial/ethnic group, HRRLC conditions increased with increasing degrees of metropolitan area-level segregation. Further adjustment for home ownership and poverty did not substantially alter these results, but adjustment for population density and metropolitan area population attenuated the segregation effects, suggesting a mediating or confounding role.Conclusions: Land cover was associated with segregation within each racial/ethnic group, which may be explained partly by the concentration of racial/ethnic minorities into densely populated neighborhoods within larger, more segregated cities. In anticipation of greater frequency and duration of extreme heat events, climate change adaptation strategies, such as planting trees in urban areas, should explicitly incorporate an environmental justice framework that addresses racial/ethnic disparities in HRRLC

Birth Weight following Pregnancy during the 2003 Southern California Wildfires

Background: In late October 2003, a series of wildfires exposed urban populations in Southern California to elevated levels of air pollution over several weeks. Previous research suggests that short-term hospital admissions for respiratory outcomes increased specifically as a result of these fires.Objective: We assessed the impact of a wildfire event during pregnancy on birth weight among term infants.Methods: Using records for singleton term births delivered to mothers residing in California’s South Coast Air Basin (SoCAB) during 2001–2005 (n = 886, 034), we compared birth weights from pregnancies that took place entirely before or after the wildfire event (n = 747, 590) with those where wildfires occurred during the first (n = 60, 270), second (n = 39, 435), or third (n = 38, 739) trimester. The trimester-specific effects of wildfire exposure were estimated using a fixed-effects regression model with several maternal characteristics included as covariates.Results: Compared with pregnancies before and after the wildfires, mean birth weight was estimated to be 7.0 g lower [95% confidence interval (CI): –11.8, –2.2] when the wildfire occurred during the third trimester, 9.7 g lower when it occurred during the second trimester (95% CI: –14.5, –4.8), and 3.3 g lower when it occurred during the first trimester (95% CI: –7.2, 0.6)