Prenatal air pollution and children's autism traits score: Examination of joint associations with maternal intake of vitamin D, methyl donors, and polyunsaturated fatty acids using mixture methods.

Background: Maternal nutrient intake may moderate associations between environmental exposures and children's neurodevelopmental outcomes, but few studies have assessed joint effects. We aimed to evaluate whether prenatal nutrient intake influences the association between air pollutants and autism-related trait scores. Methods: We included 126 participants from the EARLI (Early Autism Risk Longitudinal Investigation, 2009-2012) cohort, which followed US pregnant mothers who previously had a child with autism. Bayesian kernel machine regression and traditional regression models were used to examine joint associations of prenatal nutrient intake (vitamins D, B12, and B6; folate, choline, and betaine; and total omega 3 and 6 polyunsaturated fatty acids, reported via food frequency questionnaire), air pollutant exposure (particulate matter <2.5 µm [PM2.5], nitrogen dioxide [NO2], and ozone [O3], estimated at the address level), and children's autism-related traits (measured by the Social Responsiveness Scale [SRS] at 36 months). Results: Most participants had nutrient intakes and air pollutant exposures that met US standards. Bayesian kernel machine regression mixture models and traditional regression models provided little evidence of individual or joint associations of nutrients and air pollutants with SRS scores or of an association between the overall mixture and SRS scores. Conclusion: In this cohort with a high familial likelihood of autism, we did not observe evidence of joint associations between air pollution exposures and nutrient intake with autism-related traits. Future work should examine the use of these methods in larger, more diverse samples, as our results may have been influenced by familial liability and/or relatively high nutrient intakes and low air pollutant exposures.

Addressing spatial misalignment in population health research: a case study of US congressional district political metrics and county health data.

Areal spatial misalignment, which occurs when data on multiple variables are collected using mismatched boundary definitions, is a ubiquitous obstacle to data analysis in public health and social science research. As one example, the emerging sub-field studying the links between political context and health in the United States faces significant spatial misalignment-related challenges, as the congressional districts (CDs) over which political metrics are measured and administrative units, e.g., counties, for which health data are typically released, have a complex misalignment structure. Standard population-weighted data realignment procedures can induce measurement error and invalidate inference, which has prompted the development of fully model-based approaches for analyzing spatially misaligned data. One such approach, atom-based regression models (ABRM), holds particular promise but has scarcely been used in practice due to the lack of appropriate software or examples of implementation. ABRM use "atoms", the areas created by intersecting all sets of units on which variables of interest are measured, as the units of analysis and build models for the atom-level data, treating the atom-level variables (generally unmeasured) as latent variables. In this paper, we demonstrate the feasibility and strengths of the ABRM in a case study of the association between political representatives' voting behavior (CD-level) and COVID-19 mortality rates (county-level) in a post-vaccine period. The adjusted ABRM results suggest that more conservative voting record is associated with an increase in COVID-19 mortality rates, with estimated associations smaller in magnitude but consistent in direction with those of standard realignment methods. The results also indicate that ABRM may enable more robust confounding adjustment and more realistic uncertainty estimates, properly representing the uncertainties arising from all analytic procedures. We also implement the ABRM in modern optimized Bayesian computing programs and make our code publicly available, which may enable these methods to be more widely adopted.

Historical redlining and cardiovascular health: The Multi-Ethnic Study of Atherosclerosis.

We investigated historical redlining, a government-sanctioned discriminatory policy, in relation to cardiovascular health (CVH) and whether associations were modified by present-day neighborhood physical and social environments. Data included 4,779 participants (mean age 62 y; SD = 10) from the baseline sample of the Multi-Ethnic Study of Atherosclerosis (MESA; 2000 to 2002). Ideal CVH was a summary measure of ideal levels of seven CVH risk factors based on established criteria (blood pressure, fasting glucose, cholesterol, body mass index, diet, physical activity, and smoking). We assigned MESA participants' neighborhoods to one of four grades (A: best, B: still desirable, C: declining, and D: hazardous) using the 1930s federal Home Owners' Loan Corporation (HOLC) maps, which guided decisions regarding mortgage financing. Two-level hierarchical linear and logistic models, with a random intercept to account for participants nested within neighborhoods (i.e., census tracts) were used to assess associations within racial/ethnic subgroups (non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Chinese). We found that Black adults who lived in historically redlined areas had a 0.82 (95% CI -1.54, -0.10) lower CVH score compared to those residing in grade A (best) neighborhoods, in a given neighborhood and adjusting for confounders. We also found that as the current neighborhood social environment improved the association between HOLC score and ideal CVH weakened (P < 0.10). There were no associations between HOLC grade and CVH measures or effect modification by current neighborhood conditions for any other racial/ethnic group. Results suggest that historical redlining has an enduring impact on cardiovascular risk among Black adults in the United States.

Changes in overdose knowledge and attitudes in an incarcerated sample of people living with HIV.

PURPOSE: The purpose of this paper is to present evaluation results. People exiting incarceration who use opioids are at an elevated risk for overdose following release. People living with HIV (PLWH) who use drugs are also at increased overdose risk. Overdose education and naloxone distribution (OEND) is an effective community-based intervention, but few OEND programs have been evaluated in a correctional setting and none have specifically targeted PLWH. DESIGN/METHODOLOGY/APPROACH: An OEND pilot program was implemented in the Philadelphia jail from December 2017 to June 2019. OEND was provided through an HIV case management program and naloxone given at release. Participants (n = 68) were assessed for changes in overdose knowledge and beliefs in their ability to respond to an overdose from baseline to one month later while still incarcerated. Other demographic variables were assessed via publicly available records and case manager chart abstraction. FINDINGS: A total of 120 incarcerated PLWH were OEND trained; 68 (56.7%) were still incarcerated one month later and received post-tests. The 68-person sample was predominantly male (79.4%) and Black (64.7%). One-fifth reported heroin use, a third reported cocaine use and nearly 2/3 reported use of any illegal drug on date of arrest. Among these 68, overdose knowledge and overdose attitudes improved significantly (p = 0.002 and p < 0.001, respectively). ORIGINALITY/VALUE: OEND in correctional settings is feasible and knowledge and overdose attitudes improved significantly from baseline. OEND programs should be implemented within the general population of incarcerated people but, as with PLWH, can be extended to other vulnerable populations within correctional settings, such as persons with mental health conditions and a history of homelessness.

Spatial Inequities in COVID-19 Testing, Positivity, Confirmed Cases, and Mortality in 3 U.S. Cities : An Ecological Study.

BACKGROUND: Preliminary evidence has shown inequities in coronavirus disease 2019 (COVID-19)-related cases and deaths in the United States. OBJECTIVE: To explore the emergence of spatial inequities in COVID-19 testing, positivity, confirmed cases, and mortality in New York, Philadelphia, and Chicago during the first 6 months of the pandemic. DESIGN: Ecological, observational study at the ZIP code tabulation area (ZCTA) level from March to September 2020. SETTING: Chicago, New York, and Philadelphia. PARTICIPANTS: All populated ZCTAs in the 3 cities. MEASUREMENTS: Outcomes were ZCTA-level COVID-19 testing, positivity, confirmed cases, and mortality cumulatively through the end of September 2020. Predictors were the Centers for Disease Control and Prevention Social Vulnerability Index and its 4 domains, obtained from the 2014-2018 American Community Survey. The spatial autocorrelation of COVID-19 outcomes was examined by using global and local Moran I statistics, and estimated associations were examined by using spatial conditional autoregressive negative binomial models. RESULTS: Spatial clusters of high and low positivity, confirmed cases, and mortality were found, co-located with clusters of low and high social vulnerability in the 3 cities. Evidence was also found for spatial inequities in testing, positivity, confirmed cases, and mortality. Specifically, neighborhoods with higher social vulnerability had lower testing rates and higher positivity ratios, confirmed case rates, and mortality rates. LIMITATIONS: The ZCTAs are imperfect and heterogeneous geographic units of analysis. Surveillance data were used, which may be incomplete. CONCLUSION: Spatial inequities exist in COVID-19 testing, positivity, confirmed cases, and mortality in 3 large U.S. cities. PRIMARY FUNDING SOURCE: National Institutes of Health.

"I probably got a minute": Perceptions of fentanyl test strip use among people who use stimulants.

BACKGROUND: Fentanyl dominates the heroin supply in many regions of the United States. One harm reduction response has been the distribution of fentanyl test strips to people who use heroin to test for the presence of fentanyl. Reports increasingly indicate that fentanyl contamination is occurring in the illicit stimulant market, but whether people who use stimulants would use fentanyl test strips is unknown. METHODS: Between January 2019 and January 2020, fifteen people in Philadelphia, PA who reported stimulant use completed a semi-structured interview with questions about their perceptions of fentanyl and willingness to use fentanyl test strips. Data were coded and analyzed for thematic content using constructs from the Health Belief Model and risk environment theory. RESULTS: Participants primarily reported using crack cocaine or crack cocaine/heroin, while some used methamphetamine, powder cocaine, or prescription opioids. All were aware of fentanyl and believed they were susceptible to a fentanyl overdose as stimulant users. Participants perceived benefits of using test strips but reported barriers, such as the unpredictable nature of buying or using drugs and not wanting to delay drug use to test. Structural conditions impeded participant actions to reduce overdose risk if their drugs tested positive for fentanyl. CONCLUSION: Fentanyl test strips were a desired harm reduction tool by many participants who used stimulants. In addition to providing access to the strips, programs should tailor overdose prevention education to these clients by acknowledging susceptibility, amplifying benefits, and addressing drug-specific barriers to use of fentanyl test strips.

The Familial Risk of Autism Spectrum Disorder with and without Intellectual Disability.

Autism spectrum disorder (ASD) is highly heritable, yet how its familial risk and heritability may vary by cognitive ability is not well understood. In this population-based cohort study, we examined the familial risk and heritability of ASD with and without co-occurring intellectual disability (ID). We estimated odds ratios and heritability of ASD with ID (ASD+ID) and ASD without ID (ASD-ID) using register-based diagnosis data of 567,436 index persons born in 1984-2009 in Stockholm County, Sweden, and their parents, siblings, cousins, aunts, and uncles. The familial risk profile exhibited differences between ASD-ID and ASD+ID, most notably for index persons with affected parents. For example, for an index person who had at least one parent with ASD, the child's odds of ASD-ID and ASD+ID (95% confidence interval (CI)) increased by 16.2 (14.2-18.6) and 7.4 (5.5-10.0) folds, respectively. The more closely related a family member with ASD was, the greater the observed risk was of ASD in the index person, especially for ASD-ID. The broad-sense heritability (95% CI) for ASD - ID and ASD+ID were 64.6% (46.0-100.0%) and 33.4% (14.4-58.4%), respectively. Familial risk and heritability of ASD may vary by intellectual ability, which implies that risk factors between these ASD phenotypes may differ. Our findings from the heritability analysis and familial risk analysis suggest that ASD-ID may have a greater genetic basis than ASD+ID, although this should be verified in future studies. LAY SUMMARY: Autism spectrum disorder (ASD) is highly heritable, yet how its familial risk and heritability may vary by cognitive ability is not well-understood. In a population-based cohort study on families of 567,436 index persons using Swedish registers data, we found that the familial risk profile differed between ASD with and without intellectual disability. Our findings from the heritability analysis and familial risk analysis suggest that ASD-ID may have a greater genetic basis than ASD+ID, although this should be verified in future studies.

The heterogeneous effect of marijuana decriminalization policy on arrest rates in Philadelphia, Pennsylvania, 2009-2018.

BACKGROUND: Marijuana decriminalization holds potential to reduce health inequities. However, limited attention has focused on assessing the impact of decriminalization policies across different populations. This study aims to determine the differential effect of a marijuana decriminalization policy change in Philadelphia, PA on marijuana arrests by demographic characteristics. METHODS: Using a comparative interrupted time series design, we assessed whether the onset of marijuana decriminalization in Philadelphia County was associated with reduction in arrests rates from 2009 to 2018 compared to Dauphin County. Stratified models were used to describe the differential impact of decriminalization across different demographic populations. RESULTS: Compared to Dauphin, the mean arrest rate for all marijuana-related crimes in Philadelphia declined by 19.9 per 100,000 residents (34.9% reduction), 17.1 per 100,000 residents (43.1% reduction) for possession, and 2.8 per 100,000 resident (15.9% reduction) for sales/manufacturing. Arrest rates also differed by demographic characteristics post-decriminalization. Notably, African Americans had a greater absolute/relative reduction in possession-based arrests than Whites. However, relative reductions for sales/manufacturing-based arrests was nearly 3 times lower for African Americans. Males had greater absolute/relative reduction for possession-based arrests, but lower relative reduction for sales/manufacturing-based arrests compared to females. There were no substantial absolute differences by age; however, youths (vs. adults) experienced higher relative reduction in arrest rates. CONCLUSIONS: Findings suggest an absolute/relative reduction for possession-based arrests post-decriminalization; however, relative disparities in sales/manufacturing-based arrests, specifically for African Americans, increased. More consideration towards the heterogeneous effect of marijuana decriminalization are needed given the unintended harmful effects of arrest on already vulnerable populations.

Development and validation of a method to quantify benefits of clean-air taxi legislation.

Air pollution from motor vehicle traffic remains a significant threat to public health. Using taxi inspection and trip data, we assessed changes in New York City's taxi fleet following Clean Air Taxi legislation enacted in 2005-2006. Inspection and trip data between 2004 and 2015 were used to assess changes in New York's taxi fleet and to estimate and spatially apportion annual taxi-related exhaust emissions of nitric oxide (NO) and total particulate matter (PMT). These emissions changes were used to predict reductions in NO and fine particulate matter (PM2.5) concentrations estimates using data from the New York City Community Air Survey (NYCCAS) in 2009-2015. Efficiency trends among other for-hire vehicles and spatial variation in traffic intensity were also considered. The city fuel efficiency of the medallion taxi fleet increased from 15.7 MPG to 33.1 MPG, and corresponding NO and PMT exhaust emissions estimates declined by 82 and 49%, respectively. These emissions reductions were associated with changes in NYCCAS-modeled NO and PM2.5 concentrations (p < 0.001). New York's clean air taxi legislation was effective at increasing fuel efficiency of the medallion taxi fleet, and reductions in estimated taxi emissions were associated with decreases in NO and PM2.5 concentrations.

The Effect of PrEP on HIV Incidence Among Men Who Have Sex With Men in the Context of Condom Use, Treatment as Prevention, and Seroadaptive Practices.

BACKGROUND: HIV preexposure prophylaxis (PrEP) is an effective tool in preventing HIV infection among high-risk men who have sex with men (MSM). It is unknown how effective PrEP is in the context of other implemented HIV prevention strategies, including condom use, seroadaption, and treatment as prevention (TasP). We evaluate the impact of increasing uptake of PrEP in conjunction with established prevention strategies on HIV incidence in a high-risk population of MSM through simulation. METHODS: Agent-based simulation models representing the sexual behavior of high-risk, urban MSM in the United States over the period of 1 year were used to evaluate the effect of PrEP on HIV infection rates. Simulations included data for 10,000 MSM and compared increasing rates of PrEP uptake under 8 prevention paradigms: no additional strategies, TasP, condom use, seroadaptive behavior, and combinations thereof. RESULTS: We observed a mean of 103.2 infections per 10,000 MSM in the absence of any prevention method. PrEP uptake at 25% without any additional prevention strategies prevented 30.7% of infections. In the absence of PrEP, TasP, condom use, and seroadaptive behavior independently prevented 27.1%, 48.8%, and 37.7% of infections, respectively, and together prevented 72.2%. The addition of PrEP to the 3 aforementioned prevention methods, at 25% uptake, prevented an additional 5.0% of infections. CONCLUSIONS: To achieve a 25% reduction in HIV infections by 2020, HIV prevention efforts should focus on significantly scaling up access to PrEP in addition to HIV testing, access to antiretroviral therapy, and promoting condom use.

Spatial and environmental correlates of organism colonization and infection in the neonatal intensive care unit.

OBJECTIVE: To examine organism colonization and infection in the neonatal intensive care unit as a result of environmental and spatial factors. STUDY DESIGN: A retrospective cohort of infants admitted between 2006 and 2015 (n = 11 428), to assess the relationship between location and four outcomes: methicillin-resistant Staphylococcus aureus (MRSA) colonization; culture-confirmed late-onset sepsis; and, if intubated, endotracheal tube colonization with Pseudomonas aeruginosa or Klebsiella pneumonia. Independent risk factors were identified with mixed-effects logistic regression models and Moran's I for spatial autocorrelation. RESULT: All four outcomes statistically clustered by location; neighboring colonization also influenced risk of MRSA (p < 0.05). For P. aeruginosa, being in a location with space for more medical equipment was associated with 2.61 times the odds of colonization (95% CrI: 1.19, 5.78). CONCLUSION: Extrinsic factors partially explained risk for neonatal colonization and infection. For P. aeruginosa, infection prevention efforts at locations with space for more equipment may lower future colonization.

The benefits of data linkage for firefighter injury surveillance.

BACKGROUND: While survey data are available for national estimates of fire events and firefighter fatalities, data on firefighter injury at the national and local levels remain incomplete and unreliable. Data linkage provides a vehicle to maximise case detection and deepen injury description for the US fire service. METHODS: By linking departmental Human Resources records, despatch data, workers' compensation and first reports of injury, researchers were able to describe reported non-fatal injuries to 3063 uniformed members of the Philadelphia Fire Department (PFD), for the period of 2005 through 2013. RESULTS: Among all four databases, the overall linkage rate was 56%. Among three of the four databases, the linkage rate was 88%. Because there was duplication of some variables among the datasets, we were able to deeply describe all the linked injuries in the master database. 45.5% of uniformed PFD members reported at least one injury during the study period. Strains, falls, burns and struck-by injuries were the most common causes. Burns resulted in the highest lost time claim payout, and strains accounted for the highest medical claim cost. More than 70% of injuries occurred in the first 15 years of experience. DISCUSSION: Data linkage provided three new benefits: (1) creation of a new variable-years of experience, (2) reduction of misclassification bias when determining cause of injury, leading to more accurate estimates of cost and (3) visualisation of injury rates when controlling for the number of fire department responses, allowing for the generation of hypotheses to investigate injury hot spots.

Umbilical cord blood androgen levels and ASD-related phenotypes at 12 and 36 months in an enriched risk cohort study.

BACKGROUND: Autism spectrum disorder (ASD) affects more than 1% of children in the USA. The male-to-female prevalence ratio of roughly 4:1 in ASD is a well-recognized but poorly understood phenomenon. An explicit focus on potential etiologic pathways consistent with this sex difference, such as those involving prenatal androgen exposure, may help elucidate causes of ASD. Furthermore, the multi-threshold liability model suggests that the genetic mechanisms in females with ASD may be distinct and may modulate ASD risk in families with female ASD in the pedigree. METHODS: We examined umbilical cord blood from 137 children in the Early Autism Risk Longitudinal Investigation (EARLI) cohort. EARLI is an ASD-enriched risk cohort with all children having an older sibling already diagnosed with ASD. Fetal testosterone (T), androstenedione (A4), and dehyroepiandrosterone (DHEA) levels were measured in cord blood using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Robust linear regression models were used to determine associations between cord blood androgen levels and 12-month Autism Observation Scales for Infants (AOSI) scores and 36-month Social Responsiveness Scale (SRS) scores adjusting for potential confounders. RESULTS: Increasing androgens were not associated with increasing 12-month AOSI score or 36-month total SRS score in either boys or girls. However, the association between T and autistic traits among subjects with a female older affected sibling was greater at 12 months (test of interaction, P = 0.008) and deficits in reciprocal social behavior at 36 months were also greater (test of interaction, P = 0.006) than in subjects whose older affected sibling was male. CONCLUSIONS: While increased prenatal testosterone levels were not associated with autistic traits at 12 or 36 months, our findings of a positive association in infants whose older ASD-affected siblings were female suggests an androgen-related mechanism that may be dependent on, or related to, genetic liability factors present more often in families containing female ASD cases. However, this initial finding, based on a small subgroup of our sample, should be interpreted with considerable caution.

Bayesian Correction of Misclassification of Pertussis in Vaccine Effectiveness Studies: How Much Does Underreporting Matter?

Diagnosis of pertussis remains a challenge, and consequently research on the risk of disease might be biased because of misclassification. We quantified this misclassification and corrected for it in a case-control study of children in Philadelphia, Pennsylvania, who were 3 months to 6 years of age and diagnosed with pertussis between 2011 and 2013. Vaccine effectiveness (VE; calculated as (1 - odds ratio) × 100) was used to describe the average reduction in reported pertussis incidence resulting from persons being up to date on pertussis-antigen containing vaccines. Bayesian techniques were used to correct for purported nondifferential misclassification by reclassifying the cases per the 2014 Council of State and Territorial Epidemiologists pertussis case definition. Naïve VE was 50% (95% confidence interval: 16%, 69%). After correcting for misclassification, VE ranged from 57% (95% credible interval: 30, 73) to 82% (95% credible interval: 43, 95), depending on the amount of underreporting of pertussis that was assumed to have occurred in the study period. Meaningful misclassification was observed in terms of false negatives detected after the incorporation of infant apnea to the 2014 case definition. Although specificity was nearly perfect, sensitivity of the case definition varied from 90% to 20%, depending on the assumption about missed cases. Knowing the degree of the underreporting is essential to the accurate evaluation of VE.

Neighborhood social capital and achieved mobility of older adults.

OBJECTIVE: Evaluate associations of neighborhood social capital and mobility of older adults. METHOD: A community-based survey (Philadelphia, 2010) assessed mobility (Life-Space Assessment [LSA]; range = 0-104) of older adults (n = 675, census tracts = 256). Social capital was assessed for all adults interviewed from 2002-2010 (n = 13,822, census tracts = 374). Generalized estimating equations adjusted for individual- and neighborhood-level characteristics estimated mean differences and 95% confidence intervals (CIs) in mobility by social capital tertiles. Interactions by self-rated health, living arrangement, and race were tested. RESULTS: Social capital was not associated with mobility after adjustment for other neighborhood characteristics (mean difference for highest versus lowest tertile social capital = 0.79, 95% CI = [-3.3, 4.8]). We observed no significant interactions. In models stratified by race, Black participants had higher mobility in high social capital neighborhoods (mean difference = 7.4, CI = [1.0, 13.7]). DISCUSSION: Social capital may not contribute as much as other neighborhood characteristics to mobility. Interactions between neighborhood and individual-level characteristics should be considered in research on mobility.

Distal tibia fractures: locked or non-locked plating? A systematic review of outcomes.

BACKGROUND AND PURPOSE: Although plating is considered to be the treatment of choice in distal tibia fractures, controversies abound regarding the type of plating for optimal fixation. We conducted a systematic review to evaluate and compare the outcomes of locked plating and non-locked plating in treatment of distal tibia fractures. PATIENTS AND METHODS: A systematic review was conducted using PubMed to identify articles on the outcomes of plating in distal tibia fractures that were published up to June 2012. We included English language articles involving a minimum of 10 adult cases with acute fractures treated using single-plate, minimally invasive techniques. Study-level binomial regression on the pooled data was conducted to determine the effect of locking status on different outcomes, adjusted for age, sex, and other independent variables. RESULTS: 27 studies met the inclusion criteria and were included in the final analysis of 764 cases (499 locking, 265 non-locking). Based on descriptive analysis only, delayed union was reported in 6% of cases with locked plating and in 4% of cases with non-locked plating. Non-union was reported in 2% of cases with locked plating and 3% of cases with non-locked plating. Comparing locked and non-locked plating, the odds ratio (OR) for reoperation was 0.13 (95% CI: 0.03-0.57) and for malalignment it was 0.10 (95% CI: 0.02-0.42). Both values were statistically significant. INTERPRETATION: This study showed that locked plating reduces the odds of reoperation and malalignment after treatment for acute distal tibia fracture. Future studies should accurately assess causality and the clinical and economic impact of these findings.

Performance outcomes after repair of complete achilles tendon ruptures in national basketball association players.

BACKGROUND: A complete rupture of the Achilles tendon is a devastating injury. Variables affecting return to competition and performance changes for National Basketball Association (NBA) players are not readily evident. HYPOTHESIS: Players in the NBA who ruptured their Achilles tendons and who underwent surgical repair would have more experience in the league, and the performance of those who were able to return to competition would be decreased when compared with their performance before injury and with their control-matched peers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data for 18 basketball players with Achilles tendon repair over a 23-year period (1988-2011) were obtained from injury reports, press releases, and player profiles. Variables included age, body mass index (BMI), player position, and number of years playing in the league. Individual season statistics were obtained, and the NBA player efficiency rating (PER) was calculated for 2 seasons before and after injury. Controls were matched by playing position, number of seasons played, and performance statistics. Univariate and multivariate analyses were performed to assess the effect of each factor. RESULTS: At the time of injury, the average age was 29.7 years, average BMI was 25.6, and average playing experience was 7.6 years. Seven players never returned to play an NBA game, whereas 11 players returned to play 1 season, with 8 of those players returning for ≥2 seasons. Players who returned missed an average of 55.9 games. The PER was reduced by 4.57 (P = .003) in the first season and by 4.38 (P = .010) in the second season. When compared with controls, players demonstrated a significant decline in the PER the first season (P = .038) and second season (P = .081) after their return. CONCLUSION: The NBA players who returned to play after repair of complete Achilles tendon ruptures showed a significant decrease in playing time and performance. Thirty-nine percent of players never returned to play.

Neighborhood amenities and mobility in older adults.

Diversity of neighborhood amenities may promote the mobility of older adults. A 2010 community-based sample of 510 adults aged ≥65 years in Philadelphia, Pennsylvania, and geospatial data from the Esri Business Analyst database (Esri, Inc., Redlands, California) were used to assess associations of neighborhood amenity diversity with mobility. Neighborhoods were defined by census tract, and diversity of amenities was derived by using the Leadership in Energy and Environmental Design's neighborhood development index (US Green Building Council, Washington, DC). Generalized estimating equations adjusted for demographic, socioeconomic, and neighborhood characteristics were used to estimate differences in mobility score by tertile of amenity diversity. Analyses were stratified by participants' routine travel habits (stayed at home, stayed in home zip code, or traveled beyond home zip code). We found that for those who spent most of their time in their home neighborhoods, mobility scores (from the Life-Space Assessment, which ranges from 0 to 104 points) were 8.3 points higher (95% confidence interval: 0.1, 16.6) among those who lived in neighborhoods with the most amenity diversity compared with those who lived in neighborhoods with the least amenity diversity. No significant associations between amenity diversity and mobility were observed for those who did not leave home or who regularly traveled outside their neighborhoods. Neighborhoods with a high diversity of amenities may be important promoters of mobility in older adults who do not routinely travel outside their neighborhoods.