A comparison of passive surveillance and active cluster-based surveillance for dengue fever in southern coastal Ecuador.

BACKGROUND: Dengue is a major emerging infectious disease, endemic throughout the tropics and subtropics, with approximately 2.5 billion people at risk globally. Active (AS) and passive surveillance (PS), when combined, can improve our understanding of dengue's complex disease dynamics to guide effective, targeted public health interventions. The objective of this study was to compare findings from the Ministry of Health (MoH) PS to a prospective AS arbovirus research study in Machala, Ecuador in 2014 and 2015. METHODS: Dengue cases in the PS system were compared to laboratory confirmed acute dengue illness cases that entered the AS study during the study period. Variables of interest included age class and sex. Outbreak detection curves by epidemiologic week, overall cumulative incidence and age-specific incidence proportions were calculated. Descriptive statistics were tabulated for all variables of interest. Chi-square tests were performed to compare demographic characteristics between the AS and PS data sets in 2014 and 2015. RESULTS: 177 and 245 cases were identified from 1/1/2014 to 12/31/2015 by PS and AS, respectively; nine cases appeared in both systems. AS identified a greater number of laboratory-confirmed cases in 2014, accounting for more than 60% of dengue cases in the study area. In 2015, the opposite trend was observed with PS identifying 60% of the dengue cases in the study area. Peak transmission time in laboratory confirmed dengue illness, as noted by AS and PS was similar in 2014, whereas earlier detection (7 weeks) was observed by AS in 2015. Younger patients were more frequently identified by PS, while older patients were identified more frequently by AS. The cumulative incidence proportion for laboratory confirmed dengue illness reported via PS to the MoH was 4.12 cases per 10,000 residents in 2014, and 2.21 cases per 10,000 residents in 2015. CONCLUSIONS: Each surveillance system captured distinct demographic subgroups within the Machala population, possibly due to differences in healthcare seeking behaviors, access to care, emerging threats of other viruses transmitted by the same mosquito vector and/or differences in clinical presentation. Integrating AS with pre-existing PS can aid in identifying additional cases in previously underdiagnosed subpopulations, improving our understanding of disease dynamics, and facilitating the implementation of timely public health interventions.

Hypertension in Relation to Dioxins and Polychlorinated Biphenyls from the Anniston Community Health Survey Follow-Up.

BACKGROUND: In 2014, we conducted a longitudinal study [Anniston Community Health Survey (ACHS II)] 8 y after the baseline (ACHS I). OBJECTIVES: We investigated the relationship between persistent chlorinated compounds and hypertension in residents living around the former polychlorinated biphenyl (PCB) production plant in Anniston, Alabama. We also examined the potential role of inflammatory cytokines in those with hypertension. METHODS: A total of 338 participants had their blood pressure measured and medications recorded, gave a blood sample, and completed a questionnaire. Prevalent hypertension was defined as taking antihypertensive medication or having systolic blood pressure >140 mmHg and/or diastolic pressure >90 mmHg; incident hypertension used similar criteria in those who developed hypertension since the baseline in 2005-2007. PCB congeners were categorized into structure-activity groups, and toxic equivalencies (TEQs) were calculated for dioxin-like compounds. Descriptive statistics, logistic and linear regressions, as well as Cox proportional hazard models, were used to analyze the associations between exposures and hypertension. RESULTS: Prevalent hypertension (78%) in ACHS II showed statistically significant adjusted odds ratios (ORs) for PCBs 74, 99, 138, 153, 167, 177, 183, and 187, ranging from 2.18 [95% confidence interval (CI): 1.10, 4.33] to 2.76 (95% CI: 1.14, 6.73), as well as for two estrogenic-like PCB groups, and the thyroid-like group [ORs ranging from 2.25 (95% CI: 1.07, 4.75) to 2.54 (95% CI: 1.13, 5.74)]. Furthermore, analysis of quartiles demonstrated a monotonic relationship for dioxin-like non-ortho (non-o)-PCB TEQs [fourth vs. first quartile: 3.66 (95% CI: 1.40, 9.56)]. Longitudinal analyses of incident hypertension supported those positive associations. The results were strongest for the di-o-PCBs [hazard ratio (HR)=1.93 (95% CI: 0.93, 4.00)] and estrogenic II PCB group [HR=1.90 (95% CI: 0.96, 3.78)] but were weaker for the dioxin TEQs. DISCUSSION: Findings supportive of positive associations were reported for dioxin-like mono-o- and non-o-PCBs as well as for nondioxin-like estrogenic and thyroid-like congeners with prevalent and incident hypertension, suggesting that multiple pathways may be involved in hypertension development. https://doi.org/10.1289/EHP5272.

The Effects of Timing of Soft Tissue Coverage on Outcomes After Reconstruction of Type IIIB Open Tibia Fractures.

High-energy open fractures of the tibia are frequently associated with tissue loss, wound contamination, and compromised vascularity that often result in amputation. The management of these severe injuries remains a challenge for orthopedic reconstructive surgeons. Studies have compared the timing of soft tissue coverage of Gustilo type IIIB open tibia fractures with associated outcomes such as rate of deep infection, primary union, length of hospitalization, flap failure, and eventual secondary amputation. These studies often highlight better outcomes with specific time domains that are not always attainable at a large tertiary hospital with multi-system trauma patients. Many studies do not account for delayed patient transfers after initial open fracture management elsewhere. This retrospective analysis of the limb salvage outcomes included 140 consecutive patients with Gustilo type IIIB open tibia fractures who presented to the authors' level I trauma center between 2001 and 2014. The authors included patients who required delayed coverage or who were transferred from outside institutions. The majority (77%) were male, and the mean age was 39.4 years. Motor vehicle accidents were the most common cause of injury, and 83% of patients obtained full weight-bearing status with successful limb salvage. Twenty patients had a secondary amputation, with the cause being refractory osteomyelitis in 52%. This study provides guidance on treating a heterogeneous patient population with severe open tibia fractures typically seen in a large tertiary hospital orthopedic trauma service. [Orthopedics. 2019; 42(5):260-266.].

Outcomes Following Stereotactic Body Radiotherapy with Intensity-Modulated Therapy versus Three-Dimensional Conformal Radiotherapy in Early Stage Non-Small Cell Lung Cancer.

INTRODUCTION: The treatment techniques used for stereotactic body radiation therapy (SBRT) for early-stage lung cancer continue to evolve. In this study, clinical outcomes following SBRT were evaluated according to the use of either 3D conformal radiotherapy (3DCRT) or intensity-modulated radiation therapy (IMRT). PATIENTS AND METHODS: Patients with stage I NSCLC who received SBRT from 2007 to 2015 were retrospectively reviewed. Disease control and survival were assessed using Kaplan-Meier estimates. Dosimetric analyses for target dose heterogeneity and coverage were performed. RESULTS: A total of 297 patients with 351 lesions were included. 3DCRT was used in 52% and IMRT in 48%. IMRT was utilized at a higher rate in more recent years. The most common regimens were 48 Gy in 4 fractions and 54-60 Gy in 3 fractions. With a median follow up of 22.7 months, there were 17 local failures for a crude relapse rate of 5.7%. Local failure did not differ in patients treated with 3DCRT and IMRT (4.9% vs 6.5%, p=0.573). Mean dose to gross tumor volume (GTV) as a percent of prescription dose was higher with 3DCRT compared with IMRT (107.7% vs 103.6%, p < 0.0001). Tumor stage, histology, and SBRT regimen did not correlate with local tumor control. Overall survival for the entire population approximated 72% at 2 years. Treatment was well tolerated with 6 documented grade 3+ events. CONCLUSION: In this single-institution cohort of SBRT for early-stage NSCLC, there was no discernible difference in clinical outcomes between those treated with 3DCRT and IMRT.

Clinical outcomes following advanced respiratory motion management (respiratory gating or dynamic tumor tracking) with stereotactic body radiation therapy for stage I non-small-cell lung cancer.

PURPOSE: To report the outcomes of stereotactic body radiation therapy (SBRT) for stage I non-small-cell lung cancer (NSCLC) according to respiratory motion management method. METHODS: Patients with stage I NSCLC who received SBRT from 2007 to 2015 were reviewed. Computed tomography (CT) simulation with four-dimensional CT was performed for respiratory motion assessment. Tumor motion >1 cm in the craniocaudal direction was selectively treated with advanced respiratory management: either respiratory gating to a pre-specified portion of the respiratory cycle or dynamic tracking of an implanted fiducial marker. Comparisons were made with internal target volume approach, which treated all phases of respiratory motion. RESULTS: Of 297 patients treated with SBRT at our institution, 51 underwent advanced respiratory management (48 with respiratory gating and three with tumor tracking) and 246 underwent all-phase treatment. Groups were similarly balanced with regard to mean age (P=0.242), tumor size (P=0.315), and histology (P=0.715). Tumor location in the lower lung lobes, as compared to middle or upper lobes, was more common in those treated with advanced respiratory management (78.4%) compared to all-phase treatment (25.6%, P<.0001). There were 17 local recurrences in the treated lesions. Kaplan-Meier analyses showed that there were no differences with regard to mean time to local failure (91.5 vs 98.8 months, P=0.56), mean time to any failure (73.2 vs 78.7 months, P=0.73), or median overall survival (43.3 vs 45.5 months, P=0.56) between patients who underwent advanced respiratory motion management and all-phase treatment. CONCLUSION: SBRT with advanced respiratory management (the majority with respiratory gating) showed similar efficacy to all-phase treatment approach for stage I NSCLC.

A Cross-Sectional Study Evaluating the Use of Free Clinics in Syracuse, NY: Patient Demographics and Barriers to Accessing Healthcare in Traditional Settings.

Free clinics provide healthcare to underserved patient populations, playing a critical role in the medical safety-net. Syracuse, New York has notable racial, socioeconomic, and educational disparities and is home to four free clinics. Little is known about these clinics' patient population. This study attempts to better define this population and the barriers they face accessing traditional care. We developed a 27-question survey investigating patient demographics, barriers to traditional healthcare, and experience at local free clinics. Our analysis included descriptive statistics, t-tests, one-way ANOVA and Chi square testing. Of 287 patients surveyed, 55% of patients were employed, 78% were uninsured, and 43% cited cost as their primary barrier to insurance. 29% rated their health as fair or poor. 21% had been to the Emergency Room (ER) in the past six months. 38% stated they would go to the ER if free clinics did not exist. Insurance coverage was unrelated to education or employment status (p = .52 and .81, respectively), but differed significantly between racial and ethnic groups (p < .007). Insured patients were more likely to have visited an ER in the past 6 months (p = .01), received preventive health services (p = .02), and seen a provider outside of the free clinic as compared to patients without insurance (p < .001). Free clinic patients represent a heterogeneous population with poor health indicators and several barriers to traditional care, especially cost. This information may aid public health agencies in developing policies to increase access to medical care and decrease morbidity and mortality among this population.

Perceived Importance of Wellness Features at a Cancer Center: Patient and Staff Perspectives.

OBJECTIVES: Determine the relative impact of 11 building wellness features on preference and on the ability to deliver/receive quality care for two groups: patients and caregivers. BACKGROUND: The impact of building features that promote wellness is of increasing interest to the building owners, designers, and occupants. METHODS: This study performed a postoccupancy evaluation of two user groups at a healthcare facility with specific wellness features. Seventy-six staff and 62 patients of a cancer center were polled separately to determine their preferences in 11 categories. RESULTS: Results showed that all wellness features were viewed favorably by the two groups, with natural lighting, views of nature, and thermal comfort as top categories for both. The t-test comparisons were performed, and significant differences ( p < .05) between the two groups were found for three of the features (views of nature, art and murals, and indoor plants). Discussion of these differences and the interaction of competing design goals (thermal comfort, views of nature, natural light, and desire for privacy) are included. CONCLUSIONS: Designers and owners will want to consider the preferred use of roof gardens, art and murals, and indoor plants for patient spaces, where their relative value is greater. Access to private and quiet spaces is the top need for caregivers. Ease of movement, thermal comfort, and natural light were top needs for patients.

Polychlorinated biphenyls, indicators of thyroid function and thyroid autoantibodies in the Anniston Community Health Survey I (ACHS-I).

In this study, we examined associations between serum concentrations of 35 polychlorinated biphenyl (PCB) congeners, pesticides, and indicators of thyroid function in participants of the Anniston Community Health Survey (ACHS). Study subjects lived in the vicinity of a former PCB production facility and had PCB concentrations 2 to 3 times higher than similar age and race groups from the general population. We investigated associations among serum levels of thyroid hormones (thyroxin [T4], free thyroxin [fT4], triiodothyronine [T3], thyroid stimulation hormone [TSH]) and auto-antibodies (thyroglobulin antibody [TgAb] or thyroperoxidase antibody [TPOAb]) and combined indicators of thyroid function with the sum of PCBs, varying PCB groups, individual PCB congeners, and 8 pesticides. Logistic and linear regression models were adjusted for log10 transformed total lipids, age, sex, ethnicity, BMI, smoking, and family history of thyroid disease. We also performed analyses stratified by ethnicity and sex. Linear regression showed inverse associations between TT3 and thyroid-like PCBs (sum of PCBs 28, 52, 74, 101, 105, and 118; p = .0004), two pesticides (hexachlorobenzene, and pp'-DDE), and individual congeners (PCBs 74, 105). Null associations were observed between PCBs, pesticides, TSH, TT4, and fT4. Logistic regression analyses did not provide support for TT3 findings and found no association with other thyroid hormones, antibodies, or combined indicator of thyroid function. These results suggest there is little evidence that these chemicals have any major clinical effect on thyroid function in this highly PCB exposed population.

Cross-Calibrated Dual-Energy X-Ray Absorptiometry Scanners Demonstrate Systematic Bias in Pediatric and Young Adult Females.

Consistency of dual-energy X-ray absorptiometry (DXA) scan results is critical for data integrity. For pediatric subjects, the extent to which cross-calibration of DXA scanners alleviates model-to-model scanner differences is unclear. In the current study, DXA bone outcomes were compared for same-day measurements performed using different scanners, cross-calibrated to alleviate discrepancies (Hologic; Discovery A [DISCO] and QDR 4500W [QDR]). Interscanner differences were evaluated in approximately 130 females aged 8-24 yr. Scans were performed in a single session on both QDR and DISCO scanners to compare projected area, bone mineral content, and areal bone mineral density (BMD) outputs for the whole body (total, subhead, head, arm, and leg), forearm (1/3 and ultradistal radius), lumbar spine (vertebra L3 and L1-L4), and proximal femur (femoral neck). Paired t tests evaluated interscanner differences; concordance correlation coefficients (CCCs) evaluated interscanner correlations. Root mean square error coefficients of variation were compared to same-day duplicate DISCO scan root mean square error coefficients of variation for approximately 30 adult females. Deming regression equations were generated for conversion of QDR to DISCO results and vice versa. Interscanner correlations were very high (95% confidence interval for CCC > 0.90), for all outcomes except for femoral neck area and subhead area (95% confidence interval for CCC = 0.83-0.94, 0.57-073). However, QDR values were systematically lower than Discovery values (p < 0.05), except for head area, head bone mineral content, head BMD, ultradistal BMD (QDR > Discovery, p ≤ 0.05) and L1-L4 area, L3 area, and femoral neck BMD (no differences). Most Bland-Altman and Deming regression plots indicated good interscanner agreement, with little systematic variation based on bone or body size. In pediatric and young adult females, subtle but systematic differences were noted between scans obtained on DISCO and QDR scanners, despite cross-calibration, such that most outcomes are systematically higher for DISCO than for QDR. The use of conversion equations is warranted.

Metabolic syndrome is associated with exposure to organochlorine pesticides in Anniston, AL, United States.

The Anniston Community Health Survey, a cross-sectional study, was undertaken in 2005-2007 to study environmental exposure to polychlorinated biphenyl (PCB) and organochlorine (OC) pesticides and health outcomes among residents of Anniston, AL, United States. The examination of potential risks between these pollutants and metabolic syndrome, a cluster of cardiovascular risk factors (i.e., hypertension, central obesity, dyslipidemia and dysglycemia) was the focus of this analysis. Participants were 548 adults who completed the survey and a clinic visit, were free of diabetes, and had a serum sample for clinical laboratory parameters as well as PCB and OC pesticide concentrations. Associations between summed concentrations of 35 PCB congeners and 9 individual pesticides and metabolic syndrome were examined using generalized linear modeling and logistic regression; odds ratios (OR) and 95% confidence intervals (CI) are reported. Pollutants were evaluated as quintiles and as log transformations of continuous serum concentrations. Participants were mostly female (68%) with a mean age (SD) of 53.6 (16.2) years. The racial distribution was 56% white and 44% African American; 49% met the criteria for metabolic syndrome. In unadjusted logistic regression, statistically significant and positive associations across the majority of quintiles were noted for seven individually modeled pesticides (p,p'-DDT, p,p'-DDE, HCB, ß-HCCH, oxychlor, tNONA, Mirex). Following adjustment for covariables (i.e., age, sex, race, education, marital status, current smoking, alcohol consumption, positive family history of diabetes or cardiovascular disease, liver disease, BMI), significant elevations in risk were noted for p,p'-DDT across multiple quintiles (range of ORs 1.61 to 2.36), for tNONA (range of ORs 1.62-2.80) and for p,p'-DDE [OR (95% CI)] of 2.73 (1.09-6.88) in the highest quintile relative to the first. Significant trends were observed in adjusted logistic models for log10 HCB [OR=6.15 (1.66-22.88)], log10 oxychlor [OR=2.09 (1.07-4.07)] and log10 tNONA [3.19 (1.45-7.00)]. Summed PCB concentrations were significantly and positively associated with metabolic syndrome only in unadjusted models; adjustment resulted in attenuation of the ORs in both the quintile and log-transformed models. In conclusion, several OC pesticides were found to have significant associations with metabolic syndrome in the Anniston study population while no association was observed for PCBs.

Rapid Weight Gain in Pediatric Refugees after US Immigration.

Prior studies of immigrants to the United States show significant weight gain after 10 years of US residence. Pediatric refugees are a vulnerable population whose post-immigration weight trajectory has not been studied. We examined the longitudinal weight trajectory of 1067 pediatric refugees seen in a single university based refugee health program between the dates of September 3, 2012 and September 3, 2014 to determine how quickly significant weight gain occurs post-arrival. The most recent BMI was abstracted from the electronic health record and charts reviewed to obtain serial BMI measurements in 3 year increments after the date of US arrival. The mean arrival BMI percentile for all refugees was 47th percentile. This increased significantly to the 63rd percentile within 3 years of US arrival (p < 0.01). This rapid increase was largely attributable to African and South and Southeast Asian refugees. The overall prevalence of age and sex adjusted obesity rose from 7.4 % at arrival to 18.3 % within 9 years of US immigration exceeding the pediatric US national obesity prevalence of 16.9 %. Pediatric refugees are at increased risk of rapid weight gain after US immigration. Targeted interventions focused on prevention of weight gain in specific populations are warranted.

Efficacy and Toxicity of Every 2 Weeks Docetaxel Regimen in Comparison With Weekly or Every 3 Weeks in Metastatic Prostate Cancer: A Retrospective Analysis.

OBJECTIVES: The aim of this study was to compare weekly (q1w), 2 weekly (q2w), and 3 weekly (q3w) regimens of docetaxel in metastatic castration-resistant prostate cancer (CRPC). MATERIALS AND METHODS: We retrospectively studied patients treated with q1w, q2w, or q3w docetaxel regimens at 30, 60, and 75 mg/m, respectively. The choice and duration of treatment was decided by their oncologist. Patients were assessed for response, progression-free survival (PFS), and overall survival (OS), and toxicity. RESULTS: Twelve, 14, and 15 patients were in the q1w, q2w, and q3w arms, respectively. Patients' age, metastases, and mean prostate-specific antigen at start and nadir were similar among groups. Mean total dose (MTD) was higher (not significantly) in the q2w group. Response rates, mean, and median PFS and OS ranked q2w>q3w>q1w (not significantly). However, hazard ratios for PFS for the q2w and q3w arms were statistically superior to the q1w arm when adjusted for age and total dose. The same was true for OS when q3w was compared with q1w. There were no significant differences between the q2w and q3w arms. Toxicities were not different between any of the arms, save for grade 1/2 neuropathy (lower in q1w compared with q2w). CONCLUSIONS: The MTD, response rates, PFS, and OS in the q1w and q3w arms were similar to published reports. Although we had a small number of patients, our findings suggest that both dose concentration and total docetaxel dose may be important in the treatment of CRPC and q2w dosing is an option in patients intolerant of a higher dose concentration.

Indicators of airborne fungal concentrations in urban homes: understanding the conditions that affect indoor fungal exposures.

Indoor fungal exposure can compromise respiratory health. Low-income urban areas are of concern because of high asthma and allergy rates and housing disrepair. Understanding the conditions that affect indoor fungal exposures is important for assessing health risks and for developing mitigation strategies. We examined the types and concentrations of airborne fungi inside and outside of homes in low-income areas of Syracuse, NY as well as the effect of snow cover on fungal levels. At 103 homes, air samples for viable fungi were collected, occupants were interviewed and homes were inspected for visible mold, musty odors, water problems and other factors. Multivariable logistic regression was used to relate high fungal levels to home conditions. Predominant indoor fungi included Cladosporium, Penicillium, Aspergillus, Alternaria and hyaline unknowns. Basidiomycetes and an uncommon genus Acrodontium were also found frequently due to analysis methods developed for this project. With snow cover, outdoor total fungal levels were depressed and indoor concentrations were three times higher than outdoor on average with a maximum of 29 times higher. Visible mold was related to elevated levels of Penicillium (OR 4.11 95% CI 1.37-14.0) and bacteria (OR 3.79 95% CI 1.41-11.2). Musty, moldy odors were associated with elevated concentrations of total fungi (OR 3.48 95% CI 1.13-11.6) and basidiomycetes. Cockroaches, an indicator of moisture, were associated with elevated levels of Penicillium (OR 3.66 95% CI 1.16-13.1) and Aspergillus (OR 4.36 95% CI 1.60-13.4). Increasing relative humidity was associated with higher concentrations of Penicillium, yeasts and basidiomycetes. Visible mold, musty odors, indoor humidity and cockroaches are modifiable factors that were important determinants of indoor fungal exposures. Indoor air investigators should interpret indoor:outdoor fungal ratios cautiously when snow cover is present.

The Influence of Organized Physical Activity (Including Gymnastics) on Young Adult Skeletal Traits: Is Maturity Phase Important?

We prospectively evaluated adolescent organized physical activity (PA) as a factor in adult female bone traits. Annual DXA scans accompanied semiannual records of anthropometry, maturity, and PA for 42 participants in this preliminary analysis (criteria: appropriately timed DXA scans at ~1 year premenarche [predictor] and ~5 years postmenarche [dependent variable]). Regression analysis evaluated total adolescent interscan PA and PA over 3 maturity subphases as predictors of young adult bone outcomes: 1) bone mineral content (BMC), geometry, and strength indices at nondominant distal radius and femoral neck; 2) subhead BMC; 3) lumbar spine BMC. Analyses accounted for baseline gynecological age (years pre- or postmenarche), baseline bone status, adult body size and interscan body size change. Gymnastics training was evaluated as a potentially independent predictor, but did not improve models for any outcomes (p > .07). Premenarcheal bone traits were strong predictors of most adult outcomes (semipartial r2 = .21-0.59, p ≤ .001). Adult 1/3 radius and subhead BMC were predicted by both total PA and PA 1-3 years postmenarche (p < .03). PA 3-5 years postmenarche predicted femoral narrow neck width, endosteal diameter, and buckling ratio (p < .05). Thus, participation in organized physical activity programs throughout middle and high school may reduce lifetime fracture risk in females.

Influenza vaccine hesitancy in a low-income community in central New York State.

OBJECTIVE: Influenza vaccine (IV) coverage rates remain suboptimal among US adults. Socioeconomic disparities exist in IV coverage. We describe influenza vaccine attitudes among a low-income community in central New York. METHODS: Adults attending a Salvation Army function during December 2012 were surveyed regarding IV including their intention to be immunized. On-site IV was offered to eligible participants. RESULTS: The 1041 participants included Whites (non-Hispanics), African Americans, Hispanics, Native Americans, and multi-racial ethnicities. At time of enrollment, 386 (37%) participants had already received 2012-13 IV. Of the 655 unimmunized participants, 299 (46%) stated intent to receive IV, evenly distributed by age, gender, and ethnicity. Of the 312 participants who declined IV, 46% did so because of IV misperceptions. Of the 299 participants who intended to receive vaccine but had not yet done so, 284 (95%) stated the reason for delay was difficult access to vaccine. Intent to receive vaccine was strongly associated with the belief that IV is safe and/or effective (P < 0.05). CONCLUSION: IV misperceptions regarding IV efficacy and safety result in suboptimal vaccine uptake in this low-income community, regardless of age, gender, or ethnicity.

Poor air quality in homes of Medicare recipients with diabetes.

Poor air quality has been associated with chronic illness such as diabetes. This can be of particular importance for older adults with diabetes and other chronic conditions who spend most of their time indoors. The purpose of this study was to assess home air quality and residents' awareness and concerns about air quality in rural underserved areas of upstate New York. Implications for home care clinicians are discussed.

Muscle function, dynamic loading, and femoral neck structure in pediatric females.

PURPOSE: Muscle forces influence the development of bone mass and structure, but dynamic loading via impact exercise is considered particularly osteogenic. We hypothesized that indices of local muscle function and physical activity exposure would predict femoral neck (FN) structure in premenarcheal females. METHODS: We tested this hypothesis in 76 healthy, premenarcheal girls (46 gymnasts and 30 nongymnasts). Height, weight, Tanner breast stage, and prior year nonaquatic, organized physical activity level (PAL) were recorded semiannually. Hologic dual-energy x-ray absorptiometry scans (whole body, left FN) yielded total body nonbone lean mass and bone outcomes, including narrow neck (NN) hip structural analysis data. Dynamometers assessed nondominant hand grip and left hip flexion/extension indices. Parsimonious regression models tested the following as predictors of bone outcomes: local muscle function, PAL, gymnast status, and lean mass, accounting for Tanner breast stage and height, as appropriate. RESULTS: Hip flexion indices were significantly correlated with indices of FN mass, density, structure, and strength (P < 0.05). However, the entry of PAL, gymnast status, and lean mass into regression models supplanted local muscle function explanatory value. In contrast, for many variables, the significant association of gymnast status persisted after accounting for physical maturity, body size/lean mass, and PAL. For all skeletal indices except FNArea, NNwidth, NN endosteal diameter, and NN buckling ratio, gymnast status was more strongly associated with bone outcomes than PAL. CONCLUSIONS: Greater activity doses and exposure to extreme dynamic loading provide independent benefits to FN structure during growth. Furthermore, weight-bearing activity and high-impact exercise exposure appear superior to local muscle force measures for prediction of FN structure.

Parenting style, parent-youth conflict, and medication adherence in youth with type 2 diabetes participating in an intensive lifestyle change intervention.

Parenting behaviors and family conflict relate to type 1 diabetes outcomes in youth. Our purpose was to understand these relationships in parents and youth with type 2 diabetes (T2DM). The TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth) trial enrolled youth (10-17 years) with T2DM and parent/guardian. For this ancillary study, we enrolled a sample of youth-parent pairs (N = 137) in 1 study arm (metformin plus lifestyle intervention). They completed questionnaires measuring parenting style related to normative (e.g., completing homework) and diabetes self-care (e.g., testing blood glucose) tasks, and parent-youth verbal conflict (baseline, 6, and 12 months). Parenting style was consistent across normative and diabetes tasks, with gradual increases in autonomy perceived by youth. Conversations were generally calm, with greater conflict regarding normative than diabetes tasks at baseline (youth: p < .001, parent: p = .01), 6 months (youth: p = .02, parent: p > .05), and 12 months (youth: p > .05., parent: p = .05). A permissive parenting style toward normative tasks and a less authoritarian style toward diabetes tasks, at baseline, predicted better medication adherence (8-12 months) (normative: adjusted R2 = 0.48, p < .001; diabetes: adjusted R2 = 0.47, p < .001). Parent-youth conflict did not predict medication adherence. Youth with T2DM who perceive more autonomy (less parental control) in day-to-day and diabetes tasks are more likely to adhere to medication regimens. It may be valuable to assess youth perceptions of parenting style and help parents understand youths' needs for autonomy.

Radiotherapy for stage III non-small-cell lung carcinoma in the elderly (age ≥ 70 years).

BACKGROUND: Elderly patients are underrepresented in trials that establish definitive chemoradiotherapy as the standard of care for inoperable stage III non-small-cell lung carcinoma (NSCLC). This study analyzed radiotherapy treatment delivery and outcomes at our institution according to elderly (≥ 70 years old) or younger (< 70 years) age. METHODS: Records of patients who received radiotherapy for stage III NSCLC between January 1998 and February 2010 were reviewed. Factors analyzed included Eastern Cooperative Oncology Group Performance Status (ECOG PS), weight loss, radiation therapy intent, and chemotherapy administered. RESULTS: A total of 189 patients with stage III NSCLC were analyzed (age range, 28-92 years). Elderly patients (n = 86) were more likely to have ECOG PS ≥ 2 (P < .05) and receive palliative treatment (P < .05). Elderly patients less often received concurrent chemoradiotherapy (P < .05) as well as cisplatin (P < .05). Median survival was 10.3 months for elderly patients compared with 17.2 months for younger patients (P < .05 ). In addition, elderly patients with ECOG PS (P < .05) as well as those who received definitive concurrent chemoradiotherapy (P < .05) had inferior outcomes compared with otherwise similar younger patients. However, on multivariate analysis, elderly age was not associated (P = .428) with increased risk of death, whereas poor ECOG PS (≥ 2) was significant (P < .05). In elderly patients, definitive treatment (P < .05), chemotherapy administration (P < .05), and ECOG PS of 0-1 (P < .05) were associated with improved outcome. CONCLUSIONS: Although elderly patients with stage III NSCLC experience inferior outcomes than younger patients with comparable disease, they are also more likely to receive suboptimal therapy. On multivariate analysis, advanced age was not associated with worse survival, which indicates that appropriately selected elderly patients should receive definitive chemoradiotherapy.

Improved body composition assessment using biceps skinfold and physical activity score in premenarcheal girls: a DXA-based validation study.

OBJECTIVE: Age-specific body mass index (BMI) is commonly employed as an index of adiposity for pediatric clinical and research purposes. However, BMI fails to discriminate between fat and lean mass, making it an imperfect monitor for obesity. We hypothesized that simple anthropometry and organized non-aquatic physical activity assessment (PA) would provide superior explanatory value for pediatric body composition outcomes. RESEARCH METHODS AND PROCEDURES: In a cross-sectional analysis, whole body DXA assessed body composition in 120 pre-menarcheal girls. Questionnaires were used to record and generate annual means for PA. Age, Tanner breast self-stage, height, weight, BMI, skinfold thicknesses, girths and PA were examined as potential predictors of body composition outcomes, using backward stepwise multiple linear regression. A parsimonious regression model was developed in 75% and cross-validated in 25% of the total sample; models were rerun with the total sample. RESULTS: Subject means were as follows: age = 10.4±1.2 y; lean soft tissue (LST) = 24.4±4.2 kg; fat mass (FM) = 8.1±4.1 kg; BMI = 17.6±2.5 kg/m2; PA = 6.8±5.0 h/wk; Tanner breast self-stage ranged from 1 to 3. BMI for age Z scores ranged from -2 to 2.1. Age and BMI alone yielded adjusted model r2=0.44 to 0.78. The final model, including age, height, weight, biceps skinfold and PA, yielded adjusted r2=0.61 to 0.92, P <0.001. Prediction of LST and FM increased from r2=0.64 and 0.76 to r2=0.92 and 0.91, respectively. DISCUSSION: Compared to BMI and age alone, models including biceps skinfold, PA, height, weight and age had superior explanatory value for clinically-relevant body composition outcomes, and are feasible for clinical use.