Patterns Of Effect Modification Research Articles

Effects of the Implementation of Transport-Driven Poverty Alleviation Policy on Health Care-Seeking Behavior and Medical Expenditure Among Older People in Rural Areas: Quasi-Experimental Study.

Improving the rural residents' accessibility to and affordability of health care is recognized as a common target globally. The Health in All Policies approach, from the Declaration of Helsinki to the United Nations' Decade Of Healthy Ageing, strengthened the far-reaching effect of large-scale public policies on health care-seeking behavior; however, the effects of national transport policy on health care-seeking behavior is unclear. This quasi-experimental study aimed to examine the effects of the implementation of transport-driven poverty alleviation (TPA) policy on health care-seeking behavior and medical expenditure among older adults in rural areas and the mechanism underlying these effects. We designed a quasi-experiment to estimate the effects of TPA policy implementation on health care-seeking behavior and medical expenditure among older adults in rural areas through a difference-in-differences (DID) analysis based on data from the China Health and Retirement Longitudinal Study in 2011, 2013, 2015, and 2018. The underlying mechanism was analyzed and effect modification patterns were further investigated by poor households, health status, and age. Our findings validated a positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas. After the implementation of TPA policy, the number of inpatient visits increased by annually 0.35 times per person, outpatient medical expenditure increased by 192% per month, and inpatient medical expenditure increased by 57% annually compared with those of older adults in rural areas without the implementation of TPA policy. Further, there was a significant modification effect, with a positive effect among poor households, healthier older adults, and those aged 60-80 years. Additionally, the policy improved the patients' capabilities to seek long-distance care (β=23.16, 95% CI -0.99 to 45.31) and high-level hospitals (β=.08, 95% CI -0.02 to 0.13), and increased individual income to acquire more medical services (β=4.57, 95% CI -4.46 to 4.68). These findings validate the positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas; however, the medical expenditure incurred was also high. Concerted efforts are needed to address health care-seeking dilemmas in rural areas, and attention must be paid to curbing medical expenditure growth for older adults in rural areas during TPA policy implementation.

Associations of Greenness, Parks, and Blue Space With Neurodegenerative Disease Hospitalizations Among Older US Adults

Exposure to natural environments has been associated with health outcomes related to neurological diseases. However, the few studies that have examined associations of natural environments with neurological diseases report mixed findings. To evaluate associations of natural environments with hospital admissions for Alzheimer disease and related dementias (ADRD) and Parkinson disease (PD) among older adults in the US. This open cohort study included fee-for-service Medicare beneficiaries aged 65 years or older who lived in the contiguous US from January 1, 2000, to December 31, 2016. Beneficiaries entered the cohort on January 1, 2000, or January 1 of the year after enrollment. Data from US Medicare enrollment and Medicare Provider Analysis and Review files, which contain information about individual-level covariates and all hospital admissions for Medicare fee-for-service beneficiaries, were analyzed between January 2021 and September 2022. Differences in IQRs for zip code-level greenness (normalized difference vegetation index [NDVI]), percentage park cover, and percentage blue space cover (surface water; ≥1.0% vs <1.0%). The main outcome was first hospitalizations with a primary or secondary discharge diagnosis of ADRD or PD. To examine associations of exposures to natural environments with ADRD and PD hospitalization, we used Cox-equivalent Poisson models. We included 61 662 472 and 61 673 367 Medicare beneficiaries in the ADRD and PD cohorts, respectively. For both cohorts, 55.2% of beneficiaries were women. Most beneficiaries in both cohorts were White (84.4%), were not eligible for Medicaid (87.6%), and were aged 65 to 74 years (76.6%) at study entry. We observed 7 737 609 and 1 168 940 first ADRD and PD hospitalizations, respectively. After adjustment for potential individual- and area-level confounders (eg, Medicaid eligibility and zip code-level median household income), NDVI was negatively associated with ADRD hospitalization (hazard ratio [HR], 0.95 [95% CI, 0.94-0.96], per IQR increase). We found no evidence of an association of percentage park and blue space cover with ADRD hospitalization. In contrast, NDVI (HR, 0.94 [95% CI, 0.93-0.95], per IQR increase), percentage park cover (HR, 0.97 [95% CI, 0.97-0.98], per IQR increase), and blue space cover (HR, 0.97 [95% CI, 0.96-0.98], ≥1.0% vs <1.0%) were associated with a decrease in PD hospitalizations. Patterns of effect modification by demographics differed between exposures. The findings of this cohort study suggest that some natural environments are associated with a decreased risk of ADRD and PD hospitalization.

Effects of greenness, public parks, and blue space on neurodegenerative disease hospitalizations in the US Medicare cohort

Background and Aim: Exposure to natural environments has been associated with health outcomes that are related to neurological disorders. However, the few studies that examined associations of natural environments with neurological disorders reported mixed findings. Our goal was to evaluate associations of multiple features of natural environments with Alzheimer’s disease and related dementia’s (ADRD) and Parkinson’s disease (PD) hospital admissions. Methods: We created an open cohort including all fee-for-service Medicare beneficiaries aged 65+, who lived in the contiguous US January 1, 2000 through December 31, 2016 (~63 million individuals). Zip code level greenness (Normalized Difference Vegetation Index, NDVI), percent public park cover, and percent blue space cover (&amp;#x2265;1 % cover vs. &amp;#x3c;1% cover) were assessed. We examined associations of these exposures with first ADRD or PD hospitalizations based on primary or secondary discharge diagnosis, using a novel Cox-equivalent Poisson model. We also assessed if associations varied by demographics and area-level socioeconomic status. Results: We observed 7,910,111 and 1,196,981 first ADRD and PD hospitalizations, respectively. After adjustment for potential individual- and area-level confounders, NDVI was negatively associated with ADRD hospitalization (HR=0.95, 95%CI: 0.94-0.96, per IQR increase). Percent public park cover and blue space cover were not associated with ADRD hospitalization. For PD hospitalization, we observed negative associations of NDVI (HR=0.94, 95%CI: 0.93-0.95, per IQR), percent public park cover (HR=0.97, 95%CI: 0.97-0.98, per IQR), and blue space cover (HR=0.97, 95%CI: 0.96-0.98, &amp;#x2265;1% v. &amp;#x3c;1%). Patterns of effect modification by demographics differed between the exposures. For example, for PD hospitalization, negative associations of NDVI were strongest in the mid and high SES neighbourhoods, while negative associations of percent public park cover were strongest in the low SES neighbourhoods. Conclusions: Features of natural environments are associated with a decreased risk of ADRD and PD hospitalization in this cohort of US-based older adults.

Longitudinal Effects of a Sanitation Intervention on Environmental Fecal Contamination in a Cluster-Randomized Controlled Trial in Rural Bangladesh.

Household latrine access generally is not associated with reduced fecal contamination in the environment, but its long-term effectiveness has not been measured. We conducted an environmental assessment nested within the WASH Benefits Bangladesh randomized controlled trial (NCT01590095). We quantified E. coli and fecal coliforms in samples of stored drinking water, child hands, mother hands, soil, and food among a random sample of households from the sanitation and control arms of the trial. Samples were collected during eight quarterly visits approximately 1–3.5 years after intervention initiation. Overall, there were no substantial differences in environmental fecal contamination between households enrolled in the sanitation and control arms. Statistically significant reductions were found in stored water and child hands after pooling across sampling rounds, but the effects were small and not consistent across rounds. In addition, we assessed potential effect modification of intervention effects by follow-up time, season, wealth, community-level latrine density and coverage, population density, and domestic animal ownership. While the intervention had statistically significant effects within some subgroups, there were no consistent patterns of effect modification. Our findings support a growing consensus that on-site latrines are insufficient to prevent fecal contamination in the rural household environment.

Executive Functions in School Children from Montevideo, Uruguay and their Associations with Concurrent Low-level Arsenic Exposure

Background: Arsenic is a known childhood neurotoxicant, but its neurotoxicity at low exposure levels is still not well established. Our cross-sectional study aimed to test the association between low-level arsenic exposure and executive functions (EF) among children in Montevideo. We also assessed effect modification by arsenic methylation capacity, a susceptibility factor for the health effects of arsenic, and by B-vitamin intake, which impacts arsenic methylation. Methods: Arsenic exposure was assessed as the specific gravity-adjusted sum of urinary arsenic metabolites (U-As) among 255 ~7 year-old children, and methylation capacity as the proportion of urinary monomethylarsonic acid (%MMA). B-vitamin intake was calculated from the average of two 24-hour dietary recalls. EF was measured using three tests from the Cambridge Neuropsychological Test Automated Battery - Stockings of Cambridge (SOC), Intra-dimensional/extra-dimensional shift task (IED), and Spatial Span (SSP). Generalized linear models assessed associations between U-As and EF measures, adjusting for age, sex, maternal education, possessions score, Home Observation for Measurement of the Environment Inventory score, season, and school clusters. A “B-vitamin index” was calculated using principalcomponent analysis. Effect modification by the index and urinary %MMA was assessed in strata split at the respective medians of these variables. Results: The median (range) U-As and water arsenic levels were 9.9 µg/L (2.2, 47.7) and 0.45 µg/L (0.1, 18.9) respectively. U-As was inversely associated with the number of stages completed (β = -0.02; 95% CI: -0.03, -0.002) and pre-executive shift errors (β = -0.08; 95% CI: -0.14, -0.02) of the IED task, and span length of the SSP task (β = -0.01; 95% CI: -0.02, -0.004). There was no clear pattern of effect modification by B-vitamin intake or urinary %MMA. Conclusion: Low-level arsenic exposure may adversely affect executive function among children but additional, including longitudinal, studies are necessary to confirm these findings.

Alcohol use, depressive symptoms, and intimate partner violence perpetration: A longitudinal analysis among men with HIV in northern Vietnam.

BackgroundWhile the link between alcohol use and male-perpetrated intimate partner violence (IPV) has been well-established, research is needed to test whether psychosocial factors interact with alcohol use to exacerbate IPV perpetration. We tested whether depressive symptoms influenced the strength and/or direction of the alcohol-IPV relationship among men with HIV in Vietnam.MethodsThis study is a secondary analysis using data from a randomized controlled trial conducted in Thai Nguyen, Vietnam. Participants were clinic patients with HIV and hazardous alcohol use. Questionnaires were administered at baseline, three, six, and 12 months. Alcohol use was assessed as proportion of days alcohol abstinent. Analyses were restricted to males who reported being married/cohabitating at baseline (N = 313). Multilevel growth models were used to test whether time-varying depressive symptoms modified the time-varying effect of alcohol use on IPV perpetration.ResultsTime-varying depressive symptoms modified the effect of proportion of days alcohol abstinent on IPV perpetration. However, the pattern of effect modification was not as expected, as reporting depressive symptoms weakened the alcohol-IPV relationship. At times when participants screened negative for depressive symptoms, those who reported higher proportion of days alcohol abstinent than usual had significantly lower odds of IPV perpetration (Odds Ratio [OR] = 0.17, 95% Confidence Interval 0.06, 0.45, p = 0.0004). At times when participants screened positive for depressive symptoms, there was no observed effect of alcohol use on IPV perpetration (OR = 4.28, 95% CI 0.80, 22.78, p = 0.09).ConclusionThe findings highlight the complex nature of the alcohol-IPV relationship and the need to investigate the intersection between hazardous drinking, mental health, and IPV. Men who concurrently report depressive symptoms and heightened alcohol use may be socially isolated from an intimate partner or experiencing fatigue, leading to less alcohol-related IPV perpetration. Mental health interventions addressing depression and alcohol misuse integrated into HIV services may reduce IPV perpetration.

Fibroblast Growth Factor 23 and Mortality Among Prevalent Hemodialysis Patients in the Japan Dialysis Outcomes and Practice Patterns Study

IntroductionElevated fibroblast growth factor 23 (FGF23) levels have been strongly associated with mortality in the predialysis and incident hemodialysis populations, but few studies have examined this relationship in a large cohort of prevalent hemodialysis patients and in particular among persons with high dialysis vintage. To address this, we analyzed data from the Japan Dialysis Outcomes and Practice Patterns Study (J-DOPPS).MethodsWe included 1122 prevalent hemodialysis patients from the J-DOPPS phase 5 (2012–2015) who had FGF23 measurements. We evaluated the association of FGF23 levels with all-cause mortality and cardiovascular composite outcome using Cox regression adjusted for potential confounders.ResultsAt study enrollment, median dialysis vintage was 5.8 years (interquartile range, 2.7–12.4 years) and median FGF23 level was 2113 pg/ml (interquartile range, 583–6880 pg/ml). During 3-year follow-up, 154 of the 1122 participants died. In adjusted analyses, higher FGF23 was associated with a greater hazard of death (hazard ratio per doubling of FGF23, 1.12; 95% confidence interval, 1.03–1.21); however, the association became weaker as the dialysis vintage increased and finally disappeared in the highest tertile (>9.4 years). Similar patterns of effect modification by dialysis vintage were observed for cardiovascular composite outcome and in time-dependent models.ConclusionElevated FGF23 was associated with mortality and cardiovascular events in prevalent hemodialysis patients, but the association was attenuated at longer dialysis vintages. This novel finding suggests that long-term hemodialysis patients may be less susceptible to the detrimental effects of FGF23 or correlated biological processes, and additional studies are needed to gain understanding of these possibilities.

Executive functions in school children from Montevideo, Uruguay and their associations with concurrent low-level arsenic exposure

ObjectiveArsenic is a known childhood neurotoxicant, but its neurotoxicity at low exposure levels is still not well established. The aim of our cross-sectional study was to test the association between low-level arsenic exposure and executive functions (EF) among children in Montevideo. We also assessed effect modification by arsenic methylation capacity, a susceptibility factor for the health effects of arsenic, and by B-vitamin intake, which impacts arsenic methylation. MethodsArsenic exposure was assessed as the specific gravity-adjusted sum of urinary arsenic metabolites (U-As) among 255 ~ 7 year-old children, and methylation capacity as the proportion of urinary monomethylarsonic acid (%MMA). Arsenic concentrations from kitchen water samples at participants’ homes were assessed. B-vitamin intake was calculated from the average of two 24-hour dietary recalls. EF was measured using three tests from the Cambridge Neuropsychological Test Automated Battery– Stockings of Cambridge (SOC), Intra-dimensional/extra-dimensional shift task (IED), and Spatial Span (SSP). Generalized linear models assessed the association between U-As and EF measures; models were adjusted for age, sex, maternal education, possessions score, Home Observation for Measurement of the Environment Inventory score, season, and school clusters. Additional analyses were conducted to address issues of residual confounding and sample size. A “B-vitamin index” was calculated using principal component analysis. Effect modification by the index and urinary %MMA was assessed in strata split at the respective medians of these variables. ResultsThe median (range) U-As and water arsenic levels were 9.9 µg/L (2.2, 47.7) and 0.45 µg/L (0.1, 18.9) respectively, indicating that exposure originated mainly from other sources. U-As was inversely associated with the number of stages completed (β = −0.02; 95% CI: −0.03, −0.002) and pre-executive shift errors (β = −0.08; 95% CI: −0.14, −0.02) of the IED task, and span length of the SSP task (β = −0.01; 95% CI: −0.02, −0.004). There was no clear pattern of effect modification by B-vitamin intake or urinary %MMA. ConclusionLow-level arsenic exposure may adversely affect executive function among children but additional, including longitudinal, studies are necessary to confirm these findings.

OP0077 DETERMINANTS OF THE PHYSICIAN'S GLOBAL ASSESSMENT AND INFLUENCE OF CONTEXTUAL FACTORS IN EARLY AXIAL SPONDYLOARTHRITIS

Background:In RMDs, the physician’s global assessment (PhGA) is a major factor of treatment decision. It is not well-known which disease manifestations contribute to PhGA in early axSpA and if contextual factors have an impact.Objectives:To investigate determinants of PhGA and the influence of contextual factors on this relationship in patients with early axSpA.Methods:Five-year data from DESIR, a cohort of early axSpA, were analysed. Clinical data were collected every 6 months up to 2 years and annually thereafter. The primary analysis included all patients, and the subgroup analysis patients with follow-up MRI at 2 and/or 5 years. PhGA over 5 years was the outcome of interest. Univariable generalized estimating equation (GEE) models were used to investigate relationships between potential determinants and PhGA. Longitudinal relationships were investigated in autoregressive models. Effect modification by contextual factors (educational level, gender and age) was tested and, if significant, models were stratified. Univariable analyses were chosen to better assess the contributory explanatory effects of each of the determinants in each of the strata.Results:A total of 708 patients were included, mean age 33.7 (SD 8.6) years, 46% male, 41% lower educated. The subgroup consisted of 220 patients with similar characteristics. Higher BASDAI questions 1-6, SJC28, TJC53, Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), CRP and BASMI were associated with a higher PhGA (Table 1). Gender and age were effect modifiers of SJC28; the effect was largest in the younger male stratum (β [95% CI]; 1.07 [0.71, 1.43]), and smallest in the older female stratum (0.13 [0.04, 0.22]) (Figure 1). Autoregressive GEE models revealed the same determinants of PhGA and the same pattern of effect modification by gender and age.Table 1.Factors associated with PhGA over time in gender/age-stratified groups in univariable analysisFemale/Older(n=200)Female/Younger(n=181)Male/Older(n=154)Male/Younger(n=173)Coefficient (95% CI)BASDAI Q1 (fatigue, 0-10)0.39 (0.34, 0.44)0.39 (0.34, 0.44)0.41 (0.35, 0.46)0.46 (0.41, 0.51)BASDAI Q2 (back pain, 0-10)0.49 (0.45, 0.54)0.53 (0.49, 0.57)0.48 (0.43, 0.53)0.58 (0.54, 0.63)BASDAI Q3 (peripheral joint pain, 0-10)0.31 (0.27, 0.36)0.36 (0.31, 0.41)0.32 (0.27, 0.37)0.43 (0.37, 0.48)BASDAI Q4 (enthesitis, 0-10)0.37 (0.33, 0.41)0.42 (0.37, 0.46)0.36 (0.31, 0.41)0.52 (0.47, 0.56)BASDAI Q5 (severity of morning stiffness, 0-10)0.42 (0.37, 0.46)0.45 (0.40, 0.49)0.44 (0.40, 0.49)0.58 (0.54, 0.63)BASDAI Q6 (duration of morning stiffness, 0-10)0.30 (0.25, 0.35)0.35 (0.30, 0.39)0.36 (0.31, 0.41)0.50 (0.45, 0.56)BASMI linear (0-10)0.61 (0.45, 0.78)0.67 (0.48, 0.86)0.49 (0.30, 0.68)0.95 (0.75, 1.15)SJC28 (0-28)0.13 (0.04, 0.22)0.52 (0.31, 0.73)0.58 (0.40, 0.76)1.07 (0.71, 1.43)TJC53 (0-159) ¶0.05 (0.04, 0.06)0.13 (0.11, 0.16)0.13 (0.11, 0.16)0.15 (0.13, 0.18)MASES (0-39)0.10 (0.08, 0.12)0.15 (0.12, 0.17)0.18 (0.14, 0.23)0.30 (0.25, 0.35)CRP (mg/L)0.02 (0.01, 0.04)0.03 (0.01, 0.05)0.06 (0.04, 0.07)0.04 (0.03, 0.05)Any EAM (presence vs absence)-0.13 (-0.49, 0.23)-0.20 (-0.58, 0.19)-0.26 (-0.68, 0.17)-0.28 (-0.69, 0.14)SPARCC-spine (0-414) §0.06 (-0.11, 0.22)0.05 (-0.11, 0.20)0.02 (-0.03, 0.06)0.05 (-0.04, 0.14)SPARCC-SIJ (0-72) §-0.02 (-0.13, 0.09)0.01 (-0.08, 0.10)0.05 (-0.01, 0.11)0.01 (-0.04, 0.06)¶ Each joint graded 0-3§ Coefficients were estimated in the subgroupConclusion:Patient’s subjective symptoms, peripheral arthritis, enthesitis, higher CRP and impaired spinal mobility contribute to explain PhGA in patients with early axSpA irrespective of gender and age. But physicians consider the presence of swollen joints as more important in males than in females.Disclosure of Interests:Fumio Hirano Paid instructor for: Ono pharmaceuticals, Astellas Pharma Inc, Sumitomo Dainippon Pharma, Chugai Pharmaceutical Co., Ltd., Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly &amp; Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Floris A. van Gaalen: None declared, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Cecile Gaujoux-Viala: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis

Air pollution and Parkinson’s disease

Abstract Background Recent epidemiological findings investigate effects of exposure to air pollution on neurodegenerative disease. We performed a systematic review and meta-analysis to investigate the association between air pollution exposure and Parkinson's disease (PD). Methods We performed an extensive literature search in PubMed and Google Scholar databases and further searched for unpublished results in conference abstracts until November 2018. We identified 102 unique studies referring to air pollution and PD, from which 15 were included in the meta-analyses. We applied random-effects models to combine risk estimates and investigated between studies heterogeneity. We assessed publication bias through plots and the Egger's test in cases of sufficient number of studies. We assessed associations accounting for multi-pollutant exposures and effect modification patterns by sex and smoking habits. Results We identified 13 reports investigating associations of PD with long-term exposure to regulated air pollutants whilst two reported associations for short-term exposure to PM2.5. The pooled relative risk (RR) for incidence of PD following an increase in long-term exposure for 10 μg/m3 in PM2.5 was 1.06 (95% Confidence Interval (CI): 0.99, 1.14) and in NO2 1.01 (95%CI: 0.98, 1.03), while for 5 ppb increase in O3 1.01 (95% CI: 1.00, 1.02) and for 1 mg/m3 in CO 1.34 (95% CI: 0.85, 2.10); the pooled RR for a hospital admission due to PD after a 10 μg/m3 increase in PM2.5 short-term exposure was 1.03 (95% CI: 1.01, 1.05). There was high heterogeneity between study-specific results for most of the analyses, attributed to different populations under study. Effects were robust to multi-pollutant adjustment while there were indications of higher particles’ effects among non smokers. Conclusions We found weak evidence for an association between air pollution, mostly originating from traffic, and PD. Although meta-analysis increases power to detect small associations in rare outcomes, further research is needed to elaborate our suggestive associations. Such results are of public health significance since population aging in developed countries is expected to increase incidence of PD.

Abstract 044: Differential Effects of Sugar-sweetened, Artificially Sweetened, and Unsweetened Beverages on Taste Preference but Not CVD Risk Factors in a 12-Month RCT

Introduction: Given the adverse health effects of added sugars, particularly in liquid form, dietary guidelines recommend replacing sugar-sweetened beverages (SSB) with non-caloric options. However, data are limited regarding the effects of artificially sweetened (ASB) compared to unsweetened (USB) beverages. Hypothesis: We tested the hypothesis that, as replacements for SSB, USB vs. ASB would produce greater reductions in CVD risk factors (USB&lt;ASB&lt;SSB), body weight and adiposity (USB&lt;ASB=SSB), and preference for sweet taste (USB&lt;ASB=SSB). Methods: Participants were adults aged 18 to 40 y who habitually consumed SSB. We randomly assigned 203 participants (121 males, 82 females) to three groups, and delivered SSB, ASB, or USB to their homes for 12 months. Outcomes included ratio of serum triglyceride to HDL-cholesterol (TG:HDLC, primary outcome), insulin sensitivity (HOMA-S), body weight, and fat mass (DXA). To assess preference for sweet taste, we obtained sweetness ratings for sucrose solutions ranging in concentration (mass/volume) from 0% to 18% using a 10-cm visual analog scale (0=not at all sweet; 10=extremely sweet). We fitted a logistic curve to each participant’s ratings, and defined sweetness threshold as the concentration corresponding to 5 cm on the scale. Results: Participant retention was 92% (186 of 203). Consumption of assigned beverages increased by 1 to 2 servings/d (12 fl oz per serving) for each group (P&lt;0.001), and consumption of SSB declined to almost 0 for those receiving ASB or USB. Neither TG:HDLC nor HOMA-S changed significantly for any group (P&gt;0.20). Change in body weight did not differ between groups (P=0.65) despite observed weight gain with consumption of SSB (mean±SE 1.2±0.6 kg, P=0.03) but not with ASB or USB (both 0.6±0.6 kg, P&gt;0.20). Consistent with an a priori hypothesis, we found effect modification by a measure of baseline adiposity (P=0.01). Body weight increased by 0.48±0.17 kg more for each kg of trunk fat with consumption of SSB vs. USB (P=0.005). The increase was 0.39±0.17 kg/kg with SSB vs. ASB (P=0.02). A similar pattern of effect modification was observed for change in fat mass. Change in sweetness threshold differed between groups (P=0.03), due to a decrease with consumption of USB (median -0.5%, interquartile range 1.3, P=0.005) and no change with SSB or ASB. Conclusions: Replacing SSB with non-caloric beverages had no effect on pre-specified CVD risk factors. Among individuals with central adiposity, replacing SSB with either ASB or USB had a favorable effect on body weight, consistent with prior findings. However, USB were a better replacement than ASB for altering taste preference, a finding with plausible implications for promoting adherence to prescribed low-sugar diets. Consistent with epidemiologic data, the benefits of eliminating consumption of SSB on CVD risk factors may require longer periods of study for the general population.

Air pollution and Parkinson's disease: A systematic review and meta-analysis up to 2018.

Recent epidemiological findings investigate effects of exposure to air pollution on neurodegenerative disease. We performed a systematic review and meta-analysis to investigate the association between air pollution exposure and Parkinson's disease (PD). We performed an extensive literature search in PubMed and Google Scholar databases and further searched for unpublished results in conference abstracts until November 2018. We identified 102 unique studies referring to air pollution and PD, from which 15 were included in the meta-analyses. We applied random-effects models to combine risk estimates and investigated between studies heterogeneity. We assessed publication bias through plots and the Egger's test in cases of sufficient number of studies. We assessed associations accounting for multi-pollutant exposures and effect modification patterns by sex and smoking habits. We identified 13 reports investigating associations of PD with long-term exposure to regulated air pollutants whilst two reported associations for short-term exposure to PM2.5. The pooled relative risk (RR) for incidence of PD following an increase in long-term exposure for 10 μg/m3 in PM2.5 was 1.06 (95% Confidence Interval (CI): 0.99, 1.14) and in NO2 1.01 (95%CI: 0.98, 1.03), while for 5 ppb increase in O3 1.01 (95% CI: 1.00, 1.02) and for 1 mg/m3 in CO 1.34 (95% CI: 0.85,2.10); the pooled RR for a hospital admission due to PD after a 10 μg/m3 increase in PM2.5 short-term exposure was 1.03 (95% CI: 1.01, 1.05). There was high heterogeneity between study-specific results for most of the analyses, attributed to different populations under study. Effects were robust to multi-pollutant adjustment while there were indications of higher particles' effects among non smokers. We found weak evidence for an association between air pollution, mostly originating from traffic, and PD. Although meta-analysis increases power to detect small associations in rare outcomes, further research is needed to elaborate our suggestive associations. Such results are of public health significance since population aging in developed countries is expected to increase incidence of PD.

Do Ambient Air Pollutant Concentrations during Pregnancy Impact Birth Weight among Women Living in Monroe County, New York? The Rochester Accountability Study

Increased ambient air pollutant concentrations during pregnancy have been associated with reduced birth weight, but the etiologically-relevant time window during pregnancy is unclear. Therefore, we studied the association between gestational month ambient air pollutant concentrations and birth weight in Monroe County, NY (2005-2016). We also examined whether associations differed BEFORE implementation of several air quality policies (2005-2007), compared to DURING (2008-2013) and AFTER implementation (2014-2016). We used measurement of fine particles (PM2.5), black carbon (BC), ultrafine particles (UFP; &amp;lt;100nm), accumulation mode particles (AMP; 100-500nm), sulfur dioxide (SO2), and ozone (O3) in Rochester, NY (2005-2016) and birth certificate data for 76,500 singleton term births (37-42 gestational weeks at delivery) born to Monroe County residents. For each pollutant, we separately regressed birth weight against the mean concentration in each gestational month and the last 31 days of pregnancy (10 models). We then explored effect modification by PERIOD, season, infant gender, maternal employment, and pregnancy complications. Overall, there were no clear patterns of birth weight change associated with increased pollutant concentrations across gestational months. However, increased and decreased birth weights were associated with interquartile range increases in black carbon in the 1st gestational month (13.4g increase; 95% CI&amp;#61;3.4, 23.4), UFP in the 6th month (7.5g decrease; 95% CI&amp;#61;-14.5, -0.4), O3 in the 1st month (15.8g decrease; 95% CI&amp;#61;-31.5, -0.1) and O3 in the 6th month (17.2g increase; 95% CI&amp;#61;3.1, 31.4). There were also no patterns of effect modification by PERIOD, infant gender, maternal employment, pregnancy complications, or season. However, among Hispanic women only, increases in all pollutants, except O3, in multiple gestational months were associated with decreased birth weight. Further work is needed to understand these differences by ethnicity.

A cross-sectional study of general cognitive abilities among Uruguayan school children with low-level arsenic exposure, potential effect modification by methylation capacity and dietary folate

BackgroundFew studies have evaluated the association between low-level arsenic (As) exposure and cognitive performance among children. ObjectivesIn this cross-sectional study, we assessed the association between low-level As exposure and cognitive performance among 5–8 year-old children in Montevideo, and tested effect modification by As methylation capacity and children's dietary folate intake. MethodsWe measured total urinary As (UAs) concentrations and the proportion of monomethylarsonic acid (MMA) in the urine of 328 children. Seven subtests of the standardized Woodcock-Muñoz cognitive battery were used to assess cognitive performance, from which, the general intellectual abilities (GIA) score was derived. Total folate intake was estimated from two 24-h dietary recalls. Linear regression analyses were performed. Effect modification was assessed by stratifying at the median %MMA value and tertiles of total folate intake calculated as micrograms (µg) of dietary folate equivalents (dfe). ResultsThe median UAs was 11.9 µg/l (range = 1.4–93.9), mean folate intake was 337.4 (SD = 123.3) µg dfe, and median %MMA was 9.42 (range = 2.6–24.8). There was no association between UAs and cognitive abilities, and no consistent effect modification by %MMA. UAs was associated inversely with concept formation, and positively with cognitive efficiency and numbers reversed subtest in the lowest folate intake tertile; UAs was also positively associated with sound integration in the second tertile and concept formation in the highest tertile of folate intake. There was no consistent pattern of effect modification by %MMA or folate intake. ConclusionThere was no association between low-level As exposure and general cognitive abilities.

Environmental manganese exposure and associations with memory, executive functions, and hyperactivity in Brazilian children

Manganese (Mn) is an essential element, however high levels of Mn have been associated with lower neuropsychological performance and behavioral problems in children. We investigated the associations between hair Mn concentrations and neuropsychological and behavioral performances among children with long-term exposure to airborne Mn aged between 7 and 12 years. Neuropsychological performance included tests of: verbal memory, inhibitory control, cognitive flexibility, verbal fluency, and motor function. We used the Conners Abbreviated Rating Scale for teachers to assess students’ behaviors of hyperactivity. Hair manganese (MnH) concentrations in children and exposure to airborne manganese from a ferro-manganese alloy plant were analyzed and correlated with tests scores. Multivariable linear models adjusting for potential confounders showed that elevated levels of MnH were associated with lower performance in verbal memory, as measured by the free recall after interference (β = – 1.8; 95% CI: – 3.4, – 0.2), which indicates susceptibility to interference, and Delayed Effect (β = –2.0; 95% CI: –3.7, – 0.2), representing a loss of information over time. Additionally, we found patterns of effect modification by sex in three subtests measuring verbal memory: the free recall after interference score, Interference Effect, and Delayed Effect (all at p < 0.10). Overall, the results suggest that long-term airborne Mn exposure may be associated with lower performance in verbal memory, and hyperactivity behaviors.

Racial/ethnic heterogeneity in associations of blood pressure and incident cardiovascular disease by functional status in a prospective cohort: the Multi-Ethnic Study of Atherosclerosis

ObjectivesResearch has demonstrated that the association between high blood pressure and outcomes is attenuated among older adults with functional limitations, compared with healthier elders. However, it is not known whether...

The association between neighborhood socioeconomic disadvantage and high-risk injection behavior among people who inject drugs

BackgroundAlthough much research has been conducted on the determinants of HIV risk behavior among people who inject drugs (PWID), the influence of the neighborhood context on high-risk injection behavior remains understudied. To address this gap in the literature, we measured associations between neighborhood socioeconomic disadvantage and high-risk injection behavior, and determined whether these associations were modified by drug-related police activity and syringe exchange program (SEP) accessibility. MethodsOur sample was comprised of 484 pharmacy-recruited PWID in New York City. Measures of neighborhood socioeconomic disadvantage were created using data from the 2006–2010 American Community Survey. Associations with high-risk injection behavior were estimated using multivariable Poisson regression. Effect modification by drug-related police activity and SEP accessibility was assessed by entering cross-product terms into adjusted models of high-risk injection behavior. ResultsNeighborhood socioeconomic disadvantage was associated with decreased receptive syringe sharing and unsterile syringe use. In neighborhoods with high drug-related police activity, associations between neighborhood disadvantage and unsterile syringe use were attenuated to the null. In neighborhoods with high SEP accessibility, neighborhood disadvantage was associated with decreased acquisition of syringes from an unsafe source. ConclusionsPWID in disadvantaged neighborhoods reported safer injection behaviors than their counterparts in neighborhoods that were relatively better off. The contrasting patterns of effect modification by SEP accessibility and drug-related police activity support the use of harm reduction approaches over law enforcement-based strategies for the control of blood borne virus transmission among PWID in disadvantaged urban areas.

Exposure to ultrafine particles and respiratory hospitalizations in five European cities.

Introduction. Epidemiological evidence on the associations between exposure to ultrafine particles (UFP), with electrical mobility diameters &lt;100 nm, and health is limited. We gathered data on UFP from five European cities (Barcelona, Spain; Copenhagen, Denmark; Helsinki, Finland; Rome, Italy and Stockholm, Sweden) within 2001-11 to investigate associations between short-term changes in concentrations and respiratory hospitalizations. Methods. We applied city-specific Poisson regression models and combined city-specific estimates to obtain pooled estimates. We evaluated the sensitivity of our findings to co-pollutant adjustment and investigated effect modification patterns by period of the year, age at admission and specific diagnoses. Results. Our main analysis effect estimates do not support an association between UFP and respiratory hospitalizations, although we found suggestive associations among those 0-14 years or those diagnosed with asthma. We report consistent adverse effect estimates during the warm period of the year, statistically significant after lag 2 when an increase by 10,000 particles per cm3 was associated with 3.62% (95% CI: 0.94%, 6.38%) increase in hospitalizations. These effect estimates were robust to particles’ mass or gaseous pollutants adjustment. Conclusions. We report associations between daily levels of UFP and increased rates of hospitalizations due to respiratory disease during the warm period possibly reflecting less exposure missclassification. As UFP are mainly generated by traffic in urban areas, our findings call for improved regulation of traffic emissions.

Exposure to ultrafine particles and respiratory hospitalisations in five European cities.

Epidemiological evidence on the associations between exposure to ultrafine particles (UFP), with aerodynamic electrical mobility diameters <100 nm, and health is limited. We gathered data on UFP from five European cities within 2001-2011 to investigate associations between short-term changes in concentrations and respiratory hospitalisations.We applied city-specific Poisson regression models and combined city-specific estimates to obtain pooled estimates. We evaluated the sensitivity of our findings to co-pollutant adjustment and investigated effect modification patterns by period of the year, age at admission and specific diagnoses.Our results for the whole time period do not support an association between UFP and respiratory hospitalisations, although we found suggestive associations among those 0-14 years old. We nevertheless report consistent adverse effect estimates during the warm period of the year, statistically significant after lag 2 when an increase by 10 000 particles per cm(3) was associated with a 4.27% (95% CI 1.68-6.92%) increase in hospitalisations. These effect estimates were robust to particles' mass or gaseous pollutants adjustment.Considering that our findings during the warm period may reflect better exposure assessment and that the main source of non-soluble UFP in urban areas is traffic, our results call for improved regulation of traffic emissions.

Is daily exposure to ozone associated with respiratory morbidity and lung function in a representative sample of schoolchildren? Results from a panel study in Greece.

Previous time series or panel studies of asthmatics have reported respiratory health effects following short-term exposure to ozone (O3). We followed 186 children aged 10 years old in Athens and Thessaloniki, Greece for 5 weeks during the academic year 2013-2014 and recorded daily their respiratory symptoms, absenteeism and peak expiratory flow (PEF). We applied mixed models controlling for various possible confounders to investigate the daily associations between O3 exposure - derived from weekly personal and fixed school site measurements calibrated using daily values of the fixed monitoring site nearest to the child's school location - and PEF, presence of any symptom, cough and stuffy nose, as well as absenteeism. We tested the robustness of our findings to varying modeling assumptions and confounders and investigated effect modification patterns by medication use, time spent outdoors and prevalence of asthma. A 10 μg/m3 increase in O3 personal exposure was associated with increased odds of any symptom (odds ratio (OR): 1.19, 95% confidence interval (CI): 0.98, 1.44), largely attributed to the increase in the odds of stuffy nose (OR: 1.23, 95% CI: 1.00, 1.51). PEF and absenteeism were not related to O3 exposure. Our results were robust to several sensitivity analyses. Effects were modified by medication use as presence of symptoms but also decreases in PEF were mainly reported among non-users, while our effect estimates were not driven by the asthmatic subgroup of children. Our findings indicate that short-term O3 exposure may be associated with respiratory symptoms extending previously reported results for asthmatics to the general population.