Moving to a Highly Walkable Neighborhood and Incidence of Hypertension: A Propensity-Score Matched Cohort Study

BACKGROUND

The impact of moving to a neighborhood more conducive to utilitarian walking on the risk of incident hypertension is uncertain.

OBJECTIVE

Our study aimed to examine the effect of moving to a highly walkable neighborhood on the risk of incident hypertension.

METHODS

A population-based propensity-score matched cohort study design was used based on the Ontario population from the Canadian Community Health Survey (2001-2010). Participants were adults ≥ 20 years of age who moved from a low-walkability neighborhood (defined as any neighborhood with a Walk Score < 90) to either a high- (Walk Score ≥ 90) or another low-walkability neighborhood. The incidence of hypertension was assessed by linking the cohort to administrative health databases using a validated algorithm. Propensity-score matched Cox proportional hazard models were used. Annual health examination was used as a control event.

RESULTS

Among the 1,057 propensity-score matched pairs there was a significantly lower risk of incident hypertension in the low to high vs. the low to low-walkability groups [hazard ratio = 0.46; 95% CI, 0.26, 0.81, p < 0.01]. The crude hypertension incidence rates were 18.0 per 1,000 person-years (95% CI: 11.6, 24.8) among the low- to low-walkability movers compared with 8.6 per 1,000 person-years (95% CI: 5.3, 12.7) among the low- to high-walkability movers (p < 0.001). There were no significant differences in the hazard of annual health examination between the two mover groups.

CONCLUSIONS

Moving to a highly walkable neighborhood was associated with a significantly lower risk of incident hypertension. Future research should assess whether specific attributes of walkable neighborhoods (e.g., amenities, density, land-use mix) may be driving this relationship.

CITATION

Chiu M, Rezai MR, Maclagan LC, Austin PC, Shah BR, Redelmeier DA, Tu JV. 2016. Moving to a highly walkable neighborhood and incidence of hypertension: a propensity-score matched cohort study. Environ Health Perspect 124:754-760; http://dx.doi.org/10.1289/ehp.1510425.

Traffic Crash Risks in Morbidly Obese Drivers Before and After Weight Loss Surgery

Morbidly obese drivers have a higher risk of road crashes because of associated conditions such as obstructive sleep apnea. We assessed whether weight loss surgery has an impact on subsequent road crash risks in morbidly obese drivers. Our longitudinal self-matched cohort analyses suggest that road crash risks are three times higher in morbidly obese drivers than the population norm. Yet, weight loss surgery yields no significant reductions in crash risks. We found similar results in patients not previously diagnosed with sleep disorders, suggesting the need to clarify the relationship of obesity with road crash risk.

When More Pain Is Preferred to Less: Adding a Better End

Subjects were exposed to two aversive experiences: in the short trial, they immersed one hand in water at 14 °C for 60 s; in the long trial, they immersed the other hand at 14 °C for 60 s, then kept the hand in the water 30 s longer as the temperature of the water was gradually raised to 15 °C, still painful but distinctly less so for most subjects. Subjects were later given a choice of which trial to repeat. A significant majority chose to repeat the long trial, apparently preferring more pain over less. The results add to other evidence suggesting that duration plays a small role in retrospective evaluations of aversive experiences; such evaluations are often dominated by the discomfort at the worst and at the final moments of episodes.

Risk of suicide after a concussion

BACKGROUND

Head injuries have been associated with subsequent suicide among military personnel, but outcomes after a concussion in the community are uncertain. We assessed the long-term risk of suicide after concussions occurring on weekends or weekdays in the community.

METHODS

We performed a longitudinal cohort analysis of adults with diagnosis of a concussion in Ontario, Canada, from Apr. 1, 1992, to Mar. 31, 2012 (a 20-yr period), excluding severe cases that resulted in hospital admission. The primary outcome was the long-term risk of suicide after a weekend or weekday concussion.

RESULTS

We identified 235,110 patients with a concussion. Their mean age was 41 years, 52% were men, and most (86%) lived in an urban location. A total of 667 subsequent suicides occurred over a median follow-up of 9.3 years, equivalent to 31 deaths per 100,000 patients annually or 3 times the population norm. Weekend concussions were associated with a one-third further increased risk of suicide compared with weekday concussions (relative risk 1.36, 95% confidence interval 1.14-1.64). The increased risk applied regardless of patients' demographic characteristics, was independent of past psychiatric conditions, became accentuated with time and exceeded the risk among military personnel. Half of these patients had visited a physician in the last week of life.

INTERPRETATION

Adults with a diagnosis of concussion had an increased long-term risk of suicide, particularly after concussions on weekends. Greater attention to the long-term care of patients after a concussion in the community might save lives because deaths from suicide can be prevented.

Fluoroquinolones and collagen associated severe adverse events: a longitudinal cohort study

OBJECTIVES

Fluoroquinolone-associated tendon ruptures are a recognised complication, but other severe collagen-associated adverse events may also be possible. Our objectives were to confirm the association of fluoroquinolones and tendon rupture, to clarify the potential association of fluoroquinolones and retinal detachment, and to test for a potentially lethal association between fluoroquinolones and aortic aneurysms.

SETTING

Population-based longitudinal cohort study in Ontario, Canada.

PARTICIPANTS

Older adults turning 65 years between April 1 1997 and March 31 2012 were followed until primary outcome, death, or end of follow-up (March 31 2014). Fluoroquinolone prescriptions were measured as a time-varying covariate, with patients considered at risk during and for 30 days following a treatment course.

PRIMARY OUTCOME MEASURES

Severe collagen-associated adverse events defined as tendon ruptures, retinal detachments and aortic aneurysms diagnosed in hospital and emergency departments.

RESULTS

Among the 1,744,360 eligible patients, 657,950 (38%) received at least one fluoroquinolone during follow-up, amounting to 22,380,515 days of treatment. The patients experienced 37,338 (2.1%) tendon ruptures, 3246 (0.2%) retinal detachments, and 18,391 (1.1%) aortic aneurysms. Severe collagen-associated adverse events were more common during fluoroquinolone treatment than control periods, including tendon ruptures (0.82 vs 0.26/100-person years, p<0.001), retinal detachments (0.03 vs 0.02/100-person-years, p=0.003) and aortic aneurysms (0.35 vs 0.13/100-person-years, p<0.001). Current fluoroquinolones were associated with an increased hazard of tendon rupture (HR 3.13, 95% CI 2.98 to 3.28; adjusted HR 2.40, 95% CI 2.24 to 2.57) and an increased hazard of aortic aneurysms (HR 2.72, 95% CI 2.53 to 2.93; adjusted HR2.24, 95% CI 2.02 to 2.49) that were substantially greater in magnitude than the association of these outcomes with amoxicillin. The hazard of retinal detachment was marginal (HR 1.28, 95% CI 0.99 to 1.65; adjusted HR 1.47, 95% CI 1.08 to 2.00) and not greater in magnitude than that observed with amoxicillin.

CONCLUSIONS

Fluoroquinolones are associated with subsequent tendon ruptures and may also contribute to aortic aneurysms.

Intravitreal anti-vascular endothelial growth factor treatment and the risk of thromboembolism

PURPOSE

To evaluate the subsequent risk of thromboembolic events in patients receiving intravitreal ranibizumab and bevacizumab for age-related macular degeneration or macular edema.

DESIGN

Population-based crossover analysis with self-matched historical control data.

METHODS

setting: Ontario, Canada, between April 1, 2006, and March 31, 2013.

STUDY POPULATION

Consecutive patients 65 and older who initiated intravitreal treatment (N = 57 919).

INTERVENTION

Intravitreal injection of ranibizumab or bevacizumab.

MAIN OUTCOME MEASURES

Emergency visits for thromboembolic events spanning 1-4 years before treatment were compared to 1 year after treatment. Also examined were other secondary events including hip fractures, congestive heart failure, angina, falls, depression, cholecystitis, and total emergencies, as well as a control group following cataract surgery.

RESULTS

A total of 57 919 patients were included who accounted for 1858 thromboembolic emergencies (48 per month) during the 3-year Baseline interval and 1077 thromboembolic emergencies (83 per month) during the 1-year Subsequent interval after initiating treatment. The absolute change in risk equaled an increase from 10.7 to 18.6 per 1000 patients annually after initiation of treatment (rate ratio 1.74; 95% confidence interval 1.58-1.92; P < .0001). The relative increase was particularly pronounced for ischemic stroke (rate ratio 2.18; 95% confidence interval 1.94-2.46; P < .0001). The observed increase exceeded trends due to aging, applied across patients with diverse characteristics, occurred with each medication (ranibizumab and bevacizumab), was not apparent for emergencies unrelated to thromboembolic events, and did not occur in a control group following cataract surgery.

CONCLUSIONS

Intravitreal anti-vascular endothelial growth factor medications ranibizumab and bevacizumab may contribute to systemic thromboembolic events in patients aged 65 years or older.

Fibromyalgia and the Risk of a Subsequent Motor Vehicle Crash

OBJECTIVE

Motor vehicle crashes are a widespread contributor to mortality and morbidity, sometimes related to medically unfit motorists. We tested whether patients diagnosed with fibromyalgia (FM) have an increased risk of a subsequent serious motor vehicle crash.

METHODS

We conducted a population-based self-matched longitudinal cohort analysis to estimate the incidence rate ratio of crashes among patients diagnosed with FM relative to the population norm in Ontario, Canada. We included adults diagnosed from April 1, 2006, to March 31, 2012, excluding individuals younger than 18 years, living outside Ontario, lacking valid identifiers, or having only a single visit for the diagnosis. The primary outcome was an emergency department visit as a driver involved in a motor vehicle crash.

RESULTS

The patients (n = 137,631) accounted for 738 crashes during the first year of followup after diagnosis, equal to an incidence rate ratio of 2.44 compared with the population norm (95% CI 2.27-2.63, p < 0.001). The crash rate was more than twice the population norm for those with a new or a persistent diagnosis. The increased risk included patients with diverse characteristics, approached the rate observed among other patients diagnosed with alcoholism, and was mitigated among those who received dedicated FM care or a physician warning for driving safety.

CONCLUSION

A diagnosis of FM is associated with an increased risk of a subsequent motor vehicle crash that might justify medical interventions for traffic safety.

Synchronized personalized music audio-playlists to improve adherence to physical activity among patients participating in a structured exercise program: a proof-of-principle feasibility study

Background

Preference-based tempo-pace synchronized music has been shown to reduce perceived physical activity exertion and improve exercise performance. The extent to which such strategies can improve adherence to physical activity remains unknown. The objective of the study is to explore the feasibility and efficacy of tempo-pace synchronized preference-based music audio-playlists on adherence to physical activity among cardiovascular disease patients participating in a cardiac rehabilitation.

Methods

Thirty-four cardiac rehabilitation patients were randomly allocated to one of two strategies: (1) no music usual-care control and (2) tempo-pace synchronized audio-devices with personalized music playlists + usual-care. All songs uploaded onto audio-playlist devices took into account patient personal music genre and artist preferences. However, actual song selection was restricted to music whose tempos approximated patients’ prescribed exercise walking/running pace (steps per minute) to achieve tempo-pace synchrony. Patients allocated to audio-music playlists underwent further randomization in which half of the patients received songs that were sonically enhanced with rhythmic auditory stimulation (RAS) to accentuate tempo-pace synchrony, whereas the other half did not. RAS was achieved through blinded rhythmic sonic-enhancements undertaken manually to songs within individuals’ music playlists. The primary outcome consisted of the weekly volume of physical activity undertaken over 3 months as determined by tri-axial accelerometers. Statistical methods employed an intention to treat and repeated-measures design.

Results

Patients randomized to personalized audio-playlists with tempo-pace synchrony achieved higher weekly volumes of physical activity than did their non-music usual-care comparators (475.6 min vs. 370.2 min, P < 0.001). Improvements in weekly physical activity volumes among audio-playlist recipients were driven by those randomized to the RAS group which attained weekly exercise volumes that were nearly twofold greater than either of the two other groups (average weekly minutes of physical activity of 631.3 min vs. 320 min vs. 370.2 min, personalized audio-playlists with RAS vs. personalized audio-playlists without RAS vs. non-music usual-care controls, respectively, P < 0.001). Patients randomized to music with RAS utilized their audio-playlist devices more frequently than did non-RAS music counterparts (P < 0.001).

Conclusions

The use of tempo-pace synchronized preference-based audio-playlists was feasibly implemented into a structured exercise program and efficacious in improving adherence to physical activity beyond the evidence-based non-music usual standard of care. Larger clinical trials are required to validate these findings.

Trial registration

ClinicalTrials.gov ID (NCT01752595)

Electronic supplementary material

The online version of this article (doi:10.1186/s40798-015-0017-9) contains supplementary material, which is available to authorized users.

Validation of a Modified Version of the National Nosocomial Infections Surveillance System Risk Index for Health Services Research

Objective.

To validate the National Nosocomial Infections Surveillance system risk index through administrative data to predict surgical site infections.

Design.

Retrospective cohort study.

Setting.

Population-based analysis in Ontario, Canada.

Patients.

All elderly patients who underwent elective surgery from April 1, 1992, through March 31, 2006 (n = 469,349).

Methods.

Data on procedural and patient outcomes were gathered from linked population-wide hospital discharge records and physician claims. The 75th percentile of surgical duration was estimated through anesthesiologist billing fees recorded in 15-minute increments; the American Society of Anesthesiology score of at least 3 out of 5 was estimated by diagnostic codes for severe systemic illness; and all surgeries were classified as clean or clean-contaminated because of their elective nature (thus, the maximum score on the modified index was 2).

Results.

A total of 147,216 surgeries (31%) had a score of 0;246,592 (53%) had a score of 1; and 75,541 (16%) had a score of 2 on the modified index. The 30-day risk of surgical site infection increased with each increment in the modified index (score of 0, 5.4%; score of 1, 8.0%; score of 2, 14.3%; P < .001). The association was evident for surgical site infection diagnosed during the index admission (score of 0, 2.0%; score of 1, 3.7%; score of 2, 8.9%; P < .001), as well as that associated with reoperation or death (score of 0, 0.04%; score of 1, 0.23%; score of 2, 0.73%; P < .001). The modified index predicted increases in surgical site infection risk within each of 11 surgical subgroups. In accord with past research, the modified index had modest discrimination (C statistic, 0.59), and the majority of surgical site infections (72%) occurred within lower risk strata.

Conclusions.

The modified index predicts surgical site infection in population-based analyses and is associated with incremental increases in risk.

Maternal organ donation and acute injuries in surviving children

PURPOSE

The purpose of this study is to test whether maternal deceased organ donation is associated with rates of subsequent acute injuries among surviving children after their mother's death.

METHODS

This is a longitudinal cohort analysis of children linked to mothers who died of a catastrophic brain event in Ontario, Canada, between April 1988 and March 2012. Surviving children were distinguished by whether their mother was an organ donor after death. The primary outcome was an acute injury event in surviving children during the year after their mother's death.

RESULTS

Surviving children (n=454) had a total of 293 injury events during the year after their mother's death, equivalent to an average of 65 events per 100 children per year and a significant difference comparing children of mothers who were organ donors to children of mothers who were not organ donors (21 vs 82, P<.001). This difference in subsequent injury rates between groups was equal to a 76% relative reduction in risk (95% confidence interval, 62%-85%).

CONCLUSIONS

Deceased organ donation was associated with a reduction in excess acute injuries among surviving children after their mother's death. An awareness of this positive association provides some reassurance about deceased organ donation programs.

Risk of cerebral palsy among the offspring of immigrants

BACKGROUND

Cerebral palsy (CP) has a multifactorial etiology, and placental vascular disease may be one major risk factor. The risk of placental vascular disease may be lower among some immigrant groups. We studied the association between immigrant status and the risk of CP.

METHODS

We conducted a population-based retrospective cohort study of all singleton and twin livebirths in Ontario between 2002-2008, and who survived ≥28 days after birth. Each child was assessed for CP up to age 4 years, based on either a single inpatient or ≥2 outpatient pediatric diagnoses of CP. Relative to non-immigrants (n = 566,668), the risk of CP was assessed for all immigrants (n = 177,390), and further evaluated by World region of origin. Cox proportional hazard ratios (aHR) were adjusted for maternal age, income, diabetes mellitus, obesity, tobacco use, Caesarean delivery, year of delivery, physician visits, twin pregnancy, preterm delivery, as well as small- and large-for-gestational age birthweight.

RESULTS

There were 1346 cases of CP, with a lower rate among immigrants (1.45 per 1000) than non-immigrants (1.92 per 1000) (aHR 0.77, 95% confidence interval [CI] 0.67 to 0.88). Mothers from East Asia and the Pacific (aHR 0.54, 95% CI 0.39 to 0.77) and the Caribbean (aHR 0.58, 95% CI 0.37 to 0.93) were at a significantly lower risk of having a child with CP. Whether further adjusting for preeclampsia, gestational hypertension, placental abruption or placental infraction, or upon using a competing risk analysis that further accounted for stillbirth and neonatal death, these results did not change.

CONCLUSIONS

Immigration and ethnicity appear to attenuate the risk of CP, and this effect is not fully explained by known risk factors.

Pregnancy and the risk of a traffic crash

INTRODUCTION

Pregnancy causes diverse physiologic and lifestyle changes that may contribute to increased driving and driving error. We compared the risk of a serious motor vehicle crash during the second trimester to the baseline risk before pregnancy.

METHODS

We conducted a population-based self-matched longitudinal cohort analysis of women who gave birth in Ontario between April 1, 2006, and March 31, 2011. We excluded women less than age 18 years, those living outside Ontario, those who lacked a valid health card identifier under universal insurance, and those under the care of a midwife. The primary outcome was a motor vehicle crash resulting in a visit to an emergency department.

RESULTS

A total of 507,262 women gave birth during the study period. These women accounted for 6922 motor vehicle crashes as drivers during the 3-year baseline interval (177 per mo) and 757 motor vehicle crashes as drivers during the second trimester (252 per mo), equivalent to a 42% relative increase (95% confidence interval 32%-53%; p<0.001). The increased risk extended to diverse populations, varied obstetrical cases and different crash characteristics. The increased risk was largest in the early second trimester and compensated for by the third trimester. No similar increase was observed in crashes as passengers or pedestrians, cases of intentional injury or inadvertent falls, or self-reported risky behaviours.

INTERPRETATION

Pregnancy is associated with a substantial risk of a serious motor vehicle crash during the second trimester. This risk merits attention for prenatal care.