A comparison of vaginal versus buccal misoprostol for cervical ripening in women for labor induction at term (the IMPROVE trial): a triple-masked randomized controlled trial.

BACKGROUND: Cervical ripening is commonly needed for labor induction. Finding an optimal route of misoprostol dosing for efficacy, safety, and patient satisfaction is important and not well studied for the buccal route. OBJECTIVE: To compare the efficacy and safety of vaginal and buccal misoprostol for women undergoing labor induction at term. STUDY DESIGN: The IMPROVE trial was an institutional review board-approved, triple-masked, placebo-controlled randomized noninferiority trial for women undergoing labor induction at term with a Bishop score ≤6. Enrolled women received 25 mcg (first dose), then 50 mcg (subsequent doses) of misoprostol by assigned route (vaginal or buccal) and a matching placebo tablet by the opposite route. The primary outcomes were time to delivery and the rate of cesarean delivery performed urgently for fetal nonreassurance. A sample size of 300 was planned to test the noninferiority hypothesis. RESULTS: The trial enrolled 319 women, with 300 available for analysis, 152 in the vaginal misoprostol group and 148 in the buccal. Groups had similar baseline characteristics. We were unable to demonstrate noninferiority. The time to vaginal delivery was lower for the vaginal misoprostol group (median [95% confidence interval] in hours: vaginal: 20.1 [18.2, 22.8] vs buccal: 28.1 [24.1, 31.4], log-rank test P = .006, Pnoninferiority = .663). The rate of cesarean deliveries for nonreassuring fetal status was 3.3% for the vaginal misoprostol group and 9.5% for the buccal misoprostol group (P = .033). The rate of vaginal delivery in <24 hours was higher in the vaginal group (58.6% vs 39.2%, P = .001). CONCLUSION: We were unable to demonstrate noninferiority. In leading to a higher rate of vaginal deliveries, more rapid vaginal delivery, and fewer cesareans for fetal issues, vaginal misoprostol may be superior to buccal misoprostol for cervical ripening at term.

Local pollutants go global: The impacts of intercontinental air pollution from China on air quality and morbidity in California.

China is among the greatest emitters of air pollution in the world and one concern is the effects of intercontinental air pollution traveling across the Pacific Ocean from China to the U.S. We exploit a natural experiment by observing the effects of changes in intercontinental air pollution associated with Chinese New Year, a 7-day national holiday, and sandstorms from China on air quality and morbidity in California. The timing of these events are unlikely correlated to other factors affecting air quality and health in California. Chinese New Year follows the Lunar New Year which varies each traditional calendar year while sandstorms are a naturally occurring phenomenon. We examine effects on morbidity using restricted emergency department and inpatient hospitalization data for the universe of patients with respiratory and heart disease between 2005 and 2012 in California. This is the first study to use patient-level data to examine the effects of trans-Pacific air pollution from China on morbidity in the U.S. We show that heavy sandstorms are associated with a modest increase in acute respiratory disease per capita, representing 0.5-4.6% of average weekly hospitalizations. However, we find no significant effect on morbidity in California from Chinese New Year. Results suggest that policymakers could prepare for changes in air quality following major sandstorms in China.

Emission Standards, Public Transit, and Infant Health.

Transit buses are an integral part of urban life. They reduce externalities generated from private vehicles and increase geographic mobility. However, unlike most private vehicles in the United States, they use diesel fuel and emit higher amounts of toxic pollutants. The U.S. Environmental Protection Agency set emission standards for transit buses starting in 1988 that have been continually updated, but their public health and economic impacts are unclear due to scarce emissions data. I construct a novel panel dataset for the New York City (NYC) Transit bus fleet between 1990 and 2009 and examine the impact of bus pollution on infant health by using bus vintage as a proxy for emissions. I exploit the variation in vintage as older buses are retired and replaced with newer, lower-emitting buses forced to adhere to stricter emission standards. I then assign maternal exposure to bus vintage at the census block level. Findings suggest that maternal exposure to the oldest, unregulated buses is associated with modest reductions in birth weight and gestational age relative to newer buses that abide by emissions policies. I then conduct a back-of-the-envelope cost-benefit calculation and find net economic benefits of $53.3 million resulting from improved emission standards for the 2009 birth cohort in NYC. Since the treatment in this study clearly maps to federal emissions policies, these results are the first to provide credible evidence that transit bus emission standards had a positive effect on infant health.

Climate change and fetal health: The impacts of exposure to extreme temperatures in New York City.

BACKGROUND: Climate change is projected to increase the frequency, intensity, and duration of heat waves while reducing cold extremes, yet few studies have examined the relationship between temperature and fetal health. OBJECTIVES: We estimate the impacts of extreme temperatures on birth weight and gestational age in Manhattan, a borough in New York City, and explore differences by socioeconomic status (SES). METHODS: We combine average daily temperature from 1985 to 2010 with birth certificate data in Manhattan for the same time period. We then generate 33 downscaled climate model time series to project impacts on fetal health. RESULTS: We find exposure to an extra day where average temperature <25 °F and >85 °F during pregnancy is associated with a 1.8 and 1.7 g (respectively) reduction in birth weight, but the impact varies by SES, particularly for extreme heat, where teen mothers seem most vulnerable. We find no meaningful, significant effect on gestational age. Using projections of temperature from these climate models, we project average net reductions in birth weight in the 2070-2099 period of 4.6g in the business-as-usual scenario. CONCLUSIONS: Results suggest that increasing heat events from climate change could adversely impact birth weight and vary by SES.

Analyzing the Relationship Between Bus Pollution Policies and Morbidity Using a Quasi-Experiment.

Transit buses are used by millions of commuters every day, but they emit toxic diesel fumes. In 1988, the U.S. Environmental Protection Agency implemented emission standards for transit buses, which have been continually updated. Yet there is no quantitative evidence of the health benefits from these bus pollution policies due to data constraints and confounding variables. In this study, a quasi-experiment is used to exploit the geographic and temporal variation in emission standards by using bus vintage as a proxy for bus emissions. This is accomplished using a unique, rich panel data set, which includes daily information on bus vintage and route for the New York City Transit bus fleet between 2006 and 2009. This information is merged with daily data on emergency department (ED) visits for respiratory illnesses, which include patients' residences at the census block level and exact admission date. Economic benefits resulting from these bus pollution policies are then estimated. Results show that stricter transit bus emission standards by the U.S. Environmental Protection Agency for particulate matter are associated with reduced ED visits for respiratory diseases for patients living within a few hundred feet of a bus route. These findings demonstrate that bus pollution policies have made critical improvements to public health.

Occupational exposure to roadway emissions and inside informal settlements in sub-Saharan Africa: A pilot study in Nairobi, Kenya.

Few studies examine urban air pollution in sub-Saharan Africa (SSA), yet urbanization rates there are among the highest in the world. In this study, we measured 8-hr average occupational exposure levels of fine particulate matter (PM2.5), black carbon (BC), ultra violet active-particulate matter (UV-PM), and trace elements for individuals who worked along roadways in Nairobi, specifically bus drivers, garage workers, street vendors, and women who worked inside informal settlements. We found BC and re-suspended dust were important contributors to PM2.5 levels for all study populations, particularly among bus drivers, while PM2.5 exposure levels for garage workers, street vendors, and informal settlement residents were not statistically different from each other. We also found a strong signal for biomass emissions and trash burning, which is common in Nairobi's low-income areas and open-air garages. These results suggest that the large portion of urban residents in SSA who walk along roadways would benefit from air quality regulations targeting roadway emissions from diesel vehicles, dust, and trash burning. This is the first study to measure occupational exposure to urban air pollution in SSA and results imply that roadway emissions are a serious public health concern.

Traffic Impacts on PM(2.5) Air Quality in Nairobi, Kenya.

Motor vehicle traffic is an important source of particulate pollution in cities of the developing world, where rapid growth, coupled with a lack of effective transport and land use planning, may result in harmful levels of fine particles (PM(2.5)) in the air. However, a lack of air monitoring data hinders health impact assessments and the development of transportation and land use policies that could reduce health burdens due to outdoor air pollution. To address this important need, a study of traffic-related PM(2.5) was carried out in the city of Nairobi, Kenya, a model city for sub-Saharan Africa, in July 2009. Sampling was carried out using portable filter-based air samplers carried in backpacks by technicians on weekdays over two weeks at several sites in and around Nairobi ranging from high-traffic roadways to rural background. Mean daytime concentrations of PM(2.5) ranged from 10.7 at the rural background site to 98.1 µg/m(3) on a sidewalk in the central business district. Horizontal dispersion measurements demonstrated a decrease in PM(2.5) concentration from 128.7 to 18.7 µg/m(3) over 100 meters downwind of a major intersection in Nairobi. A vertical dispersion experiment revealed a decrease from 119.5 µg/m(3) at street level to 42.8 µg/m(3) on a third-floor rooftop in the central business district. Though not directly comparable to air quality guidelines, which are based on 24-hour or annual averages, the urban concentrations we observed raise concern with regard to public health and related policy. Taken together with survey data on commuting patterns within Nairobi, these results suggest that many Nairobi residents are exposed on a regular basis to elevated concentrations of fine particle air pollution, with potentially serious long-term implications for health.