Factors associated with having uncontrolled asthma in rural Appalachia.

BACKGROUND: Chronic respiratory disease disproportionately affects residents of Appalachia, particularly those residing in Central Appalachia. Asthma is particularly burdensome to Central Appalachian residents regarding cost and disability. Improving our understanding of how to mitigate these burdens requires understanding the factors influencing asthma control among individuals with asthma living in Central Appalachia, specifically rural Kentucky. METHODS: This community-based, cross-sectional epidemiologic study used survey data to identify characteristics associated with uncontrolled and controlled asthma. The designation of "uncontrolled asthma" was based on a self-report of ≥ 2 asthma exacerbations in the past year. Individuals with ≤ 1 or no exacerbations were considered to have controlled asthma. Chi-square or Fisher exact tests assessed the association between categorical variables and asthma control categories. Logistic regression was conducted to determine the impact of factors on the likelihood of uncontrolled asthma. RESULTS: In a sample of 211 individuals with self-reported asthma, 29% (n = 61, 46 females) had uncontrolled asthma. Predictors of uncontrolled asthma included depression (odds ratio 2.61, 95% CI 1.22-5.61, p = .014) and living in multi-unit housing (odds ratio 4.99, 95% CI 1.47-16.96, p = .010) when controlling for age, sex, financial status, and occupation. Being overweight or obese was not a predictor of uncontrolled asthma. Physical activity and BMI did not predict the likelihood of uncontrolled asthma. CONCLUSION: This study highlights significant challenges rural communities in Appalachian Kentucky face in managing asthma. Factors like depression, housing conditions, and a lack of self-management strategies play pivotal roles in asthma control in this population.

Environmental exposures and pulmonary function among adult residents of rural Appalachian Kentucky.

BACKGROUND: Estimated residential exposures of adults to roadway density and several metrics of resource extraction, including coal mining and oil and gas drilling, were hypothesized to contribute to the prevalence of respiratory disease in rural Appalachia. OBJECTIVE: Determine how small-area geographic variation in residential environmental exposures impacts measures of pulmonary function among adults in a community-based study. METHODS: We examined associations between residential environmental respiratory exposures and pulmonary function among 827 adult participants of the "The Mountain Air Project", a community-based, cross-sectional study in Southeastern Kentucky during 2016-2018. Exposures characterized the density of roadways, oil/gas wells, or current/past surface and underground coal mining at the level of 14-digit hydrologic unit code (HUC), or valley "hollow" where participants resided. Each participant completed an in-person interview to obtain extensive background data on risk factors, health history, and occupational and environmental exposures, as well as a spirometry test administered by experienced study staff at their place of residence. Multivariable linear regression was used to model the adjusted association between each environmental exposure and percent predicted forced expiratory volume in one second (FEV1PP) and forced vital capacity (FVCPP). RESULTS: Adjusted regression models indicate persons living in HUCs with the highest level of roadway density experienced a reduction in both FEV1PP (-4.3: 95% CI: -7.44 -1.15;) and FVCPP (-3.8: 95% CI: -6.38, -1.21) versus persons in HUCs with the lowest roadway density. No associations were detected between the metrics associated with mining and oil and gas operations and individual pulmonary function. IMPACT STATEMENT: Our work demonstrates the potential adverse impact of roadway-related exposures on the respiratory health of rural Appalachia residents. We employed a novel method of small-area exposure classification based on the hydrologic unit code (HUC), representing potential exposure levels per hollow occurring  in proximity to the residence, and controlled for individual-level risk factors for reduced respiratory health. We highlight an overlooked yet ubiquitous source of residential exposure from motor vehicles that may contribute to the regionally high prevalence of respiratory disease in rural Appalachia.

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.

Adult asthma associated with roadway density and housing in rural Appalachia: the Mountain Air Project (MAP).

BACKGROUND: Appalachian Kentucky is a rural area with a high prevalence of asthma among adults. The relative contribution of environmental exposures in the etiology of adult asthma in these populations has been understudied. OBJECTIVE: This manuscript describes the aims, study design, methods, and characteristics of participants for the Mountain Air Project (MAP), and focuses on associations between small area environmental exposures, including roadways and mining operations, and lifetime and current asthma in adults. METHODS: A cohort of residents, aged 21 and older, in two Kentucky counties, was enrolled in a community-based, cross-sectional study. Stratified cluster sampling was used to select small geographic areas denoted as 14-digit USGS hydrologic units (HUCs). Households were enumerated within selected HUCs. Community health workers collected in-person interviews. The proximity of nearby active and inactive coal mining operations, density of oil and gas operations, and density of roadways were characterized for all HUCs. Poisson regression analyses were used to estimate adjusted prevalence ratios. RESULTS: From 1,459 eligible households contacted, 1,190 individuals were recruited, and 972 persons completed the interviews. The prevalence of lifetime asthma was 22.8%; current asthma was 16.3%. Adjusting for covariates, roadway density was positively associated with current asthma in the second (aPR = 1.61; 95% CI 1.04-2.48) and third tertiles (aPR = 2.00; 95% CI 1.32-3.03). Increased risk of current asthma was associated with residence in public, multi-unit housing (aPR = 2.01; 95% CI 1.27-3.18) compared to a residence in a single-family home. There were no notable associations between proximity to coal mining and oil and gas operations and asthma prevalence. CONCLUSIONS: This study suggests that residents in rural areas with higher roadway density and those residing in public housing units may be at increased risk for current asthma after accounting for other known risk factors. Confirming the role of traffic-related particulates in producing high asthma risk among adults in this study contributes to the understanding of the multiple environmental exposures that influence respiratory health in the Appalachia region.

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.

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.

Workers' compensation reported injuries among distillery industry workers, 2010-2019.

BACKGROUND: The objective of this study was to identify the most frequent type, nature, and cause of work-related injuries among distillery workers and the contributing factors for these events to target interventions to reduce injuries. METHODS: Workers' compensation first reports of injury (FROI) from the years 2010 through 2019 were obtained. Variables were created for "occupational category" and "cause of injury" for evaluation of the injurious events. The ratchet circular scan test was used to assess seasonal variation in injury, and kernel density estimation to assess rates of injury by calendar year. RESULTS: A total of 974 FROIs were recorded over these 10 years; 908 of the injuries resulted in lost time, 65 resulted in no lost time, and 1 resulted in a fatality. The most common injuries reported were strains or tears, lacerations, and contusions (33.4%, 14.7%, and 13.5%, respectively). The most frequent anatomical sites of injury were the shoulders, fingers, and low back area (11.8%, 11.4%, and 8.9%, respectively). Barreling operation activities experienced the greatest frequency of work-related injury at 28.5% of all FROIs. A seasonal peak of injuries was observed during May and June. CONCLUSIONS: Implementing ergonomic and safety solutions for transportation and work tasks associated with barreling operations may significantly reduce the rate of work-related injuries in distillery workers. Injury prevention interventions should particularly target strain or tear injuries caused by repetitive motion or bodily reaction and overexertion. Contact with objects or machinery accounted for one-third of distillery industry FROIs.

Cancer diagnosis is associated with a lower burden of dementia and less Alzheimer's-type neuropathology.

Cancer and Alzheimer's disease are common diseases in ageing populations. Previous research has reported a lower incidence of Alzheimer's disease-type (amnestic) dementia among individuals with a diagnosis of cancer. Both cancer and amnestic dementia are prevalent and potentially lethal clinical syndromes. The current study was conducted to investigate the association of cancer diagnosis with neuropathological and cognitive features of dementia. Data were analysed from longitudinally evaluated participants in a community-based cohort study of brain ageing who came to autopsy at the University of Kentucky Alzheimer's Disease Research Center. These data were linked to the Kentucky Cancer Registry, a population-based state cancer surveillance system, to obtain cancer-related data. We examined the relationship between cancer diagnosis, clinical dementia diagnosis, Mini-Mental State Examination scores and neuropathological features using inverse probability weighting to address bias due to confounding and missing data. To address bias due to inclusion of participants with dementia at cohort baseline, we repeated all analyses restricted to the participants who were cognitively normal at baseline. Included participants (n = 785) had a mean ± standard deviation age of death of 83.8 ± 8.6 years; 60.1% were female. Cancer diagnosis was determined in 190 (24.2%) participants, and a diagnosis of mild cognitive impairment or dementia was determined in 539 (68.7%). APOE ɛ4 allele dosage was lower among participants with cancer diagnosis compared to cancer-free participants overall (P = 0.0072); however, this association was not observed among those who were cognitively normal at baseline. Participants with cancer diagnosis had lower odds of mild cognitive impairment or dementia, and higher cognitive test scores (e.g. Mini-Mental State Examination scores evaluated 6 and ≤2 years ante-mortem, P < 0.001 for both comparisons). Cancer diagnosis also associated with lower odds of higher Braak neurofibrillary tangle stages (III/IV) or (V/VI), moderate/frequent neuritic plaques, moderate/frequent diffuse plaques and moderate/severe cerebral amyloid angiopathy (all P < 0.05). By contrast, TDP-43, α-synuclein and cerebrovascular pathologies were not associated with cancer diagnosis. Cancer diagnosis was associated with a lower burden of Alzheimer's disease pathology and less cognitive impairment. These findings from a community-based cohort with neuropathological confirmation of substrates support the hypothesis that there is an inverse relationship between cancer and Alzheimer's disease.

Persistent disparities in smoking among rural Appalachians: evidence from the Mountain Air Project.

BACKGROUND: Adult smoking prevalence in Central Appalachia is the highest in the United States, yet few epidemiologic studies describe the smoking behaviors of this population. Using a community-based approach, the Mountain Air Project (MAP) recruited the largest adult cohort from Central Appalachia, allowing us to examine prevalence and patterns of smoking behavior. METHODS: A cross-sectional epidemiologic study of 972 participants aged 21 years and older was undertaken 2015-2017, with a response rate of 82%. Prevalence ratios and 95% confidence intervals for current smoking (compared to nonsmokers) were computed for the entire cohort then stratified by multiple characteristics, including respiratory health. Adjusted prevalence ratios for current smoking versus not smoking were also computed. RESULTS: MAP participants reported current smoking prevalence (33%) more than double the national adult smoking prevalence. Current smoking among participants with a reported diagnosis of chronic obstructive pulmonary disease and emphysema was 51.5 and 53.3%, respectively. Compared to participants age 65 years and older, those age 45 years or younger reported double the prevalence of smoking (PR: 2.04, 95% CI: 1.51-2.74). Adjusted analyses identified younger age, lower education, unmet financial need, and depression to be significantly associated with current smoking. CONCLUSIONS: Despite declining rates of smoking across the United States, smoking remains a persistent challenge in Central Appalachia, which continues to face marked disparities in education funding and tobacco control policies that have benefitted much of the rest of the nation. Compared with national data, our cohort demonstrated higher rates of smoking among younger populations and reported a greater intensity of cigarette use.

Hollows as Sampling Units for Community-Based Participatory Research in Appalachia: The Mountain Air Project.

BACKGROUND: In rural Appalachia, numerous geographical, historical, and socioeconomic barriers undermine health. We describe a community/academic partnership that leveraged local assets to implement an on-the-ground enumeration approach to enrolling participants, ultimately achieving an 82.1% response rate in a cross-sectional study of adult respiratory disease. We sought to discuss challenges addressed while establishing an accurate sample frame and a broadly accepted data collection procedure. METHODS: Innovative and established epidemiologic methods (household enumeration) were combined within a community-based participatory research (CBPR) framework. Community members partnered with researchers to identify an appropriate, novel sampling unit: hollows. Members of two community advisory boards (CABs) provided extensive guidance, and community health workers (CHWs) administered surveys and spirometry from randomly selected households. RESULTS: Most hollows (28/40) had participation rates of more than 80%. The sample (N = 972) was representative of the study area. CONCLUSIONS: Investigators seeking to recruit hard-to-reach populations may consider on-the-ground enumeration guided by community partners.

"Youth Are More Aware and Intelligent than Imagined": The Mountain Air Youth Photovoice Project.

Appalachian Kentucky reports some of the highest rates of respiratory illness in the United States, including chronic obstructive pulmonary disease and asthma. While smoking rates are high in the region, unexplained variation remains, and community-engaged research approaches are warranted to identify contributing factors. The Mountain Air Project's community advisory board recommended that investigators invite youth to provide their perspectives on possible contributing factors to respiratory illness, and we undertook an exploratory study to determine the utility of photovoice to elicit such perspectives with this population. While photovoice has been employed for other youth-focused health studies in Appalachia, to our knowledge, this work represents the region's first environmental study using photovoice among youth. Over eight weeks, ten participants (age 12-18) represented their perspectives through photographs and accompanying narratives. A brief thematic content analysis of the youth narratives that accompanied the photos revealed three primary themes of environmental determinants of respiratory illness. These themes included compromises community members make regarding respiratory health in order to secure a livelihood; tension between cultural legacies and respiratory health; and consequences of geographic forces. This study demonstrates the value of incorporating youth perspectives in environmental health research, and that photovoice was a valuable approach to elicit such perspectives.

Association between buprenorphine/naloxone and high-dose opioid analgesic prescribing in Kentucky, 2012-2017.

INTRODUCTION: Buprenorphine/naloxone treatment is a highly effective treatment for opioid use disorder decreasing illicit opioid use and both all-cause and opioid-involved overdose mortality. The purpose of this study was to investigate the relationships between buprenorphine/naloxone prescribing and high-dose opioid analgesic prescribing (HDOAP) over time. METHODS: This longitudinal study used 2012-2017 Kentucky All Schedule Prescription Electronic Reporting data and cross-lagged structural equation analysis. For each quarter-county observation, HDOAP rate (per 1,000 residents with opioid analgesic prescriptions) was used to predict buprenorphine/naloxone prescribing rate at the next quarter, and simultaneously buprenorphine/naloxone prescribing rate was used to predict HDOAP at the next quarter, accounting for baseline socioeconomic status, medical needs for opioid analgesics, and heroin availability. RESULTS: On average, HDOAP rates in Kentucky decreased by more than 10% (p < .0001) and buprenorphine/naloxone prescribing rates increased by more than 5% (p < .0001) per quarter over the study period. Every one-per-thousand higher HDOAP rate in an earlier quarter was associated with a 0.01/1,000 increase in the buprenorphine/naloxone prescribing rate in a later quarter (p = .009). Conversely, a one-unit higher buprenorphine/naloxone prescribing rate in an earlier quarter was associated with a 0.01/1,000 reduction in the HDOAP rate in a subsequent quarter (p = .017). CONCLUSIONS: Our results indicate a significant reciprocal relationship between HDOAP and buprenorphine/naloxone prescribing and a clinically meaningful effect of buprenorphine/naloxone prescribing on reducing HDOAP. Future studies on buprenorphine/naloxone treatment expansion should take into account this bi-directional association in the context of longitudinal data and evaluate for public health benefits beyond the reduction of HDOAP.

Trends and Patterns of Opioid Analgesic Prescribing: Regional and Rural-Urban Variations in Kentucky From 2012 to 2015.

PURPOSE: Increased opioid analgesic prescribing (OAP) has been associated with increased risk of prescription opioid diversion, misuse, and abuse. We studied regional and rural-urban variations in OAP trends in Kentucky, from 2012 to 2015, and examined potential county-level risk and protective factors. METHODS: This study used prescription drug monitoring data. Marginal models employing generalized estimating equations were used to model repeated counts of residents with opioid analgesic prescriptions within county-quarter, 2012-2015, with offset for resident population, by rural-urban classification exposure, and adjusting for time-varying socioeconomic and relevant health status measures. FINDINGS: There were significant downward trends in rates of residents receiving dispensed opioid analgesic prescriptions, with no regional or rural/urban differences in the degree of decline over time. The adjusted models showed the Kentucky Appalachian region retained a significantly higher rate of residents with opioid analgesic prescriptions per 1,000 residents (30% higher than Central Kentucky and 19% higher than Kentucky Delta regions). Residents of nonmetropolitan not adjacent-to-metropolitan counties had significantly higher adjusted rates of OAP (33% higher than metropolitan counties and 17% higher compared to nonmetropolitan adjacent-to-metropolitan counties). The rate of OAP was significantly positively associated with emergency department visit injury rates and negatively associated with buprenorphine/naloxone prescribing rates. CONCLUSIONS: Information on OAP trends and patterns will be used by Kentucky stakeholders to inform targeted interventions. Further research is needed to evaluate the availability and accessibility of nonopioid pain treatment in rural counties and the role of geography and time/distance traveled as risk factors for increased OAP.

Missed Work Due to Occupational Illness among Hispanic Horse Workers.

Occupational illnesses are inadequately reported for agriculture, an industry dominated by a vulnerable Hispanic population and high fatal and nonfatal injury rates. Work-related illnesses can contribute to missed work, caused by a combination of personal and work factors, with costs to the individual, employer, and society. To better understand agricultural occupational illnesses, 225 Hispanic horse workers were interviewed via community-based convenience sampling. Descriptive statistics, bivariate analyses, and log binomial regression modeling were used to: (1) describe the prevalence of missed work due to work-related illnesses among Hispanic horse workers, (2) examine work-related and personal factors associated with missed work, and (3) identify health symptoms and work-related characteristics potentially associated with missed work. Key findings reveal that having at least one child (PR = 1.71, 95% CI = 1.03, 2.84), having poor self-reported general health (PR = 0.72, 95% CI = 0.48, 1.08), experiencing stress during a typical workday (PR = 2.58, 95% CI = 1.25, 5.32), or spending less time with horses (PR = 1.87, 95% CI = 1.15, 3.05) are significant predictors of missing work. Interventions can be designed to identify workers most susceptible to missing work and provide resources to reduce absenteeism. Future research should examine work-related illness in agricultural horse production, including personal and work-related factors, in order to diminish occupational health disparities among these workers, who are more likely to be employed in hazardous agricultural work.

Different types of housing and respiratory health outcomes.

Evidence has shown that housing conditions may substantially influence the health of residents. Different types of housing have different structures and construction materials, which may affect indoor environment and housing conditions. This study aimed to investigate whether people living in different types of housing have different respiratory health outcomes. The data from the 1999-2006 National Health and Nutrition Examination Survey were used for the analyses. The types of housing included houses, townhouses, apartments, and mobile homes. Respiratory symptoms included wheezing, coughing, sputum, and dyspnea; respiratory diseases included asthma, chronic bronchitis, emphysema, and chronic obstructive pulmonary disease (COPD). Multiple logistic regression was used to calculate odds ratio (OR) and 95% confidence interval (CI) after adjustment for potential confounding factors. A total of 11,785 participants aged 40 years and older were included in the analyses. Compared with those living in single family houses, participants living in mobile homes were more likely to have respiratory conditions, the OR (95% CI) was 1.38 (1.13-1.69) for wheezing, and 1.49 (1.25-1.78) for dyspnea; whereas participants living in apartments were less likely to have respiratory conditions, the OR (95% CI) was 0.58 (0.36-0.91) for chronic bronchitis, and 0.69 (0.49-0.97) for COPD. Compared with living in single family houses, living in mobile home was associated with worse, whereas living in apartments was associated with better, respiratory health outcomes. Further research is needed to better understand the underlying mechanisms and prevent adverse respiratory effects associated with living in mobile homes.

Geographical Clusters and Predictors of Rabies in Three Southeastern States.

The rabies virus causes progressive encephalomyelitis that is fatal in nearly 100% of untreated cases. In the United States, wildlife act as the primary reservoir for rabies; prevention, surveillance, and control costs remain high. The purpose of this study is to understand the current distribution of wildlife rabies in three southeastern states, with particular focus on raccoons as the primary eastern reservoir, as well as identify demographic and geographic factors which may affect the risk of human exposure. This ecologic study obtained county-level rabies surveillance data from state health departments and the United States Department of Agriculture Wildlife services for North Carolina, Virginia, and West Virginia from 2010 to 2013. A spatial statistical analysis was performed to identify county clusters with high or low rates of raccoon rabies in the three states. Potential demographic and geographic factors associated with these varying rates of rabies were assessed using a multivariable negative binomial regression model. In North Carolina, raccoons constituted 50% of positive tests, in Virginia, 49%, and in West Virginia, 50%. Compared to persons residing in West Virginia counties, persons in North Carolina counties had 1.67 times the risk of exposure (p < 0.0001) to a rabid raccoon and those in Virginia counties had 1.82 times the risk of exposure (p < 0.0001) to a rabid raccoon. Compared to those counties where farmland makes up less than 17% of the total area, persons residing in counties with 17-28% farmland had a 32% increased risk of exposure to a rabid raccoon. In counties with 28-39% farmland, there was an 84% increased risk of exposure. State, rurality, and percent of area designated as farmland were the best predictors of risk of raccoon rabies exposure. Further research is needed to better understand the effect of the oral rabies vaccine program in controlling the risk of human exposure to raccoon rabies.

Poor safety climate, long work hours, and musculoskeletal discomfort among Latino horse farm workers.

This study investigated the prevalence of self-reported musculoskeletal discomfort (MSD) and work-related factors associated with elevated MSD among Latino thoroughbred farm workers. Participants (N = 225) were recruited using a community-based purposive sampling approach to participate in in-person interviews. Of these workers, 85% experienced MSD. MSD was divided into tertiles; the upper tertile was defined as elevated. Multivariable Poisson regression revealed associations between any elevated MSD and longer tenure on horse farms, longer work hours, and poor safety climate. Elevated neck/back MSD was associated with longer tenure, longer work hours, and poor safety climate. Elevated upper extremity MSD was associated with age and poor safety climate. Elevated lower extremity MSD was associated with longer tenure, longer work hours, and being female. Musculoskeletal discomfort is common among these workers. Improving safety climate and minimizing long work hours is recommended.

Farm work injuries among a cohort of children in Kentucky, USA.

Children residing on farms with livestock may be at an increased risk for work-related injuries, compared to children who work on other commodity farms. This study characterizes children's work tasks on Kentucky farms and assesses whether children who work on beef cattle farms are at an increased risk for farm work injuries. The results of a cohort study of children aged 5-18 years (N=999 at baseline) working on family farms in Kentucky, followed for two consecutive years after an initial enumeration five years previously, found that 70% of the children were involved in animal-related chores. Across all age groups, children on beef cattle farms devoted a greater number of hours per week to farm work, compared to children living on other commodity farms, especially during the school year. For all children in the study, working more than 180 days per year, performing farm work independently, and working on a beef cattle farm (compared to other commodity farm), increased the risk of a farm work injury. However, none of these associations were statistically significant. For male children only, the performance of work tasks independently was significantly associated with a 2.4-fold increased risk (OR = 2.41; 95% CI: 1.15-5.06; P=0.02) for a farm work injury, after controlling for days of working, age, period of data collection, and commodity type of the farm.

Self-reported head injury and risk of late-life impairment and AD pathology in an AD center cohort.

AIMS: To evaluate the relationship between self-reported head injury and cognitive impairment, dementia, mortality, and Alzheimer's disease (AD)-type pathological changes. METHODS: Clinical and neuropathological data from participants enrolled in a longitudinal study of aging and cognition (n = 649) were analyzed to assess the chronic effects of self-reported head injury. RESULTS: The effect of self-reported head injury on the clinical state depended on the age at assessment: for a 1-year increase in age, the OR for the transition to clinical mild cognitive impairment (MCI) at the next visit for participants with a history of head injury was 1.21 and 1.34 for the transition from MCI to dementia. Without respect to age, head injury increased the odds of mortality (OR = 1.54). Moreover, it increased the odds of a pathological diagnosis of AD for men (OR = 1.47) but not women (OR = 1.18). Men with a head injury had higher mean amyloid plaque counts in the neocortex and entorhinal cortex than men without. CONCLUSIONS: Self-reported head injury is associated with earlier onset, increased risk of cognitive impairment and dementia, increased risk of mortality, and AD-type pathological changes.

Limited association between perceived control and health-related quality of life in patients with heart failure.

BACKGROUND: Perceived control has been suggested as a modifiable factor associated with health-related quality of life (HRQOL). However, the relationship between perceived control and HRQOL has not been evaluated in patients with heart failure (HF). The purpose of this study was to determine whether perceived control independently predicts HRQOL in HF patients. METHODS: A total of 423 HF patients were included. Hierarchical linear regression was performed to determine the independent association of perceived control to HRQOL after controlling for covariates. RESULTS: Higher levels of perceived control were associated with better HRQOL in univariate analysis. However, this relationship was strongly attenuated after controlling for relevant demographic, clinical, and psychological factors; the variance in HRQOL explained by the addition of perceived control to this model was small (1.4%). CONCLUSIONS: We found only a weak relationship between perceived control and HRQOL when considered in the presence of demographic, clinical, and psychological factors.