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Li J, Liu Q, Tian Z, Wang J, Zhang Y, Cheng X, Wang Y, Wang H, Guo X, Li H, Sun L, Hu B, Zhang D, Liang C, Sheng J, Tao F, Chen G, Yang L. The interaction between physical activity and ambient particulate matters on cognitive function among Chinese community-dwelling older adults. J Affect Disord 2024; 363:391-400. [PMID: 39029694 DOI: 10.1016/j.jad.2024.07.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/21/2024] [Accepted: 07/16/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND The interaction between physical activity (PA) and ambient particulate matters (PMs) on cognition is rarely investigated. Our study aimed to assess the interactions of PA and PMs on cognitive function in older adults. METHODS Our study comprised 3937 Chinese community-dwelling older adults. Cognition was evaluated using the Mini-Mental State Examination. PA information was gathered using the International Physical Activity Questionnaire. The data of PMs were obtained from China High Air Pollutants (CHAP). Linear regressions model and interaction plots were applied to assess and visualize the interaction of PA and PMs on cognition, respectively. Bayesian kernel machine regression (BKMR) method was employed to visualize discernible thresholds for the interaction. RESULTS PMs were negatively associated with MMSE scores (PM1: β = -0.40, 95 % CI: -0.58, -0.28; PM2.5: β = -0.46, 95 % CI: -0.64, -0.29; PM10: β = -0.44, 95 % CI: -0.61, -0.26), and PA was positively affiliated with MMSE scores (β = 0.18, 95 % CI: -0.01, 0.38). Interaction plots and BKMR demonstrated that adverse connotations of PMs with MMSE increased with the elevated PA levels, and the positive associations of PA with MMSE scores were attenuated by increased PMs (all Pinteraction < 0.20). Discernible thresholds for the interaction between PMs and PA on MMSE were found. CONCLUSIONS Our findings suggest that PA should not be taken at higher PMs concentrations, and that low level of PA could be performed in PMs polluted environment to improve cognitive function. Further experimental and cohort researches are required to reproduce our discovery.
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Affiliation(s)
- Junzhe Li
- Department of Epidemiology and Health Statistics, Center for Big Data and Population Health of IHM, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China
| | - Qiang Liu
- Department of Epidemiology and Health Statistics, Center for Big Data and Population Health of IHM, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China
| | - Ziwei Tian
- Department of Epidemiology and Health Statistics, Center for Big Data and Population Health of IHM, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China
| | - Jun Wang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China
| | - Yan Zhang
- Department of Epidemiology and Health Statistics, Center for Big Data and Population Health of IHM, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China
| | - Xuqiu Cheng
- Department of Epidemiology and Health Statistics, Center for Big Data and Population Health of IHM, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China
| | - Yuan Wang
- Department of Epidemiology and Health Statistics, Center for Big Data and Population Health of IHM, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China
| | - Hongli Wang
- Department of Epidemiology and Health Statistics, Center for Big Data and Population Health of IHM, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China
| | - Xianwei Guo
- Department of Epidemiology and Health Statistics, Center for Big Data and Population Health of IHM, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China
| | - Huaibiao Li
- Fuyang Center for Diseases Prevention and Control, Fuyang 236069, Anhui, China
| | - Liang Sun
- Fuyang Center for Diseases Prevention and Control, Fuyang 236069, Anhui, China
| | - Bing Hu
- Fuyang Center for Diseases Prevention and Control, Fuyang 236069, Anhui, China
| | - Dongmei Zhang
- School of Health Services Management, Anhui Medical University, Hefei 230032, Anhui, China
| | - Chunmei Liang
- Department of Hygiene Inspection and Quarantine, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China
| | - Jie Sheng
- Scientific Research Center in Preventive Medicine, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China
| | - Fangbiao Tao
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Hefei 230032, Anhui, China
| | - Guimei Chen
- School of Health Services Management, Anhui Medical University, Hefei 230032, Anhui, China
| | - Linsheng Yang
- Department of Epidemiology and Health Statistics, Center for Big Data and Population Health of IHM, School of Public Health, Anhui Medical University, Hefei 230032, Anhui, China.
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Basilio E, Chen R, Fernandez AC, Padula AM, Robinson JF, Gaw SL. Wildfire Smoke Exposure during Pregnancy: A Review of Potential Mechanisms of Placental Toxicity, Impact on Obstetric Outcomes, and Strategies to Reduce Exposure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13727. [PMID: 36360613 PMCID: PMC9657128 DOI: 10.3390/ijerph192113727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/07/2022] [Accepted: 10/19/2022] [Indexed: 06/16/2023]
Abstract
Climate change is accelerating the intensity and frequency of wildfires globally. Understanding how wildfire smoke (WS) may lead to adverse pregnancy outcomes and alterations in placental function via biological mechanisms is critical to mitigate the harms of exposure. We aim to review the literature surrounding WS, placental biology, biological mechanisms underlying adverse pregnancy outcomes as well as interventions and strategies to avoid WS exposure in pregnancy. This review includes epidemiologic and experimental laboratory-based studies of WS, air pollution, particulate matter (PM), and other chemicals related to combustion in relation to obstetric outcomes and placental biology. We summarized the available clinical, animal, and placental studies with WS and other combustion products such as tobacco, diesel, and wood smoke. Additionally, we reviewed current recommendations for prevention of WS exposure. We found that there is limited data specific to WS; however, studies on air pollution and other combustion sources suggest a link to inflammation, oxidative stress, endocrine disruption, DNA damage, telomere shortening, epigenetic changes, as well as metabolic, vascular, and endothelial dysregulation in the maternal-fetal unit. These alterations in placental biology contribute to adverse obstetric outcomes that disproportionally affect the most vulnerable. Limiting time outdoors, wearing N95 respirator face masks and using high quality indoor air filters during wildfire events reduces exposure to related environmental exposures and may mitigate morbidities attributable to WS.
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Affiliation(s)
- Emilia Basilio
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Rebecca Chen
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | | | - Amy M. Padula
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Joshua F. Robinson
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Stephanie L. Gaw
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
- Center for Reproductive Sciences, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
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Nitrogen Dioxide Pollutant Exposure and Exercise-induced Bronchoconstriction in Urban Childhood Asthma: A Pilot Study. Ann Am Thorac Soc 2022; 19:139-142. [PMID: 34214020 PMCID: PMC8787788 DOI: 10.1513/annalsats.202103-254rl] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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Janjua S, Powell P, Atkinson R, Stovold E, Fortescue R. Individual-level interventions to reduce personal exposure to outdoor air pollution and their effects on people with long-term respiratory conditions. Cochrane Database Syst Rev 2021; 8:CD013441. [PMID: 34368949 PMCID: PMC8407478 DOI: 10.1002/14651858.cd013441.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND More than 90% of the global population lives in areas exceeding World Health Organization air quality limits. More than four million people each year are thought to die early due to air pollution, and poor air quality is thought to reduce an average European's life expectancy by one year. Individuals may be able to reduce health risks through interventions such as masks, behavioural changes and use of air quality alerts. To date, evidence is lacking about the efficacy and safety of such interventions for the general population and people with long-term respiratory conditions. This topic, and the review question relating to supporting evidence to avoid or lessen the effects of air pollution, emerged directly from a group of people with chronic obstructive pulmonary disease (COPD) in South London, UK. OBJECTIVES 1. To assess the efficacy, safety and acceptability of individual-level interventions that aim to help people with or without chronic respiratory conditions to reduce their exposure to outdoor air pollution. 2. To assess the efficacy, safety and acceptability of individual-level interventions that aim to help people with chronic respiratory conditions reduce the personal impact of outdoor air pollution and improve health outcomes. SEARCH METHODS We identified studies from the Cochrane Airways Trials Register, Cochrane Central Register of Controlled Trials, and other major databases. We did not restrict our searches by date, language or publication type and included a search of the grey literature (e.g. unpublished information). We conducted the most recent search on 16 October 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies (NRS) that included a comparison treatment arm, in adults and children that investigated the effectiveness of an individual-level intervention to reduce risks of outdoor air pollution. We included studies in healthy individuals and those in people with long-term respiratory conditions. We excluded studies which focused on non-respiratory long-term conditions, such as cardiovascular disease. We did not restrict eligibility of studies based on outcomes. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Two review authors independently selected trials for inclusion, extracted study characteristics and outcome data, and assessed risk of bias using the Cochrane Risk of Bias tool for RCTs and the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) as appropriate. One review author entered data into the review; this was spot-checked by a second author. We planned to meta-analyse results from RCTs and NRS separately, using a random-effects model. This was not possible, so we presented evidence narratively. We assessed certainty of the evidence using the GRADE approach. Primary outcomes were: measures of air pollution exposure; exacerbation of respiratory conditions; hospital admissions; quality of life; and serious adverse events. MAIN RESULTS We identified 11 studies (3372 participants) meeting our inclusion criteria (10 RCTs and one NRS). Participants' ages ranged from 18 to 74 years, and the duration of studies ranged from 24 hours to 104 weeks. Six cross-over studies recruited healthy adults and five parallel studies included either people with pre-existing conditions (three studies) or only pregnant women (two studies). Interventions included masks (e.g. an N95 mask designed to filter out airborne particles) (five studies), an alternative cycle route (one study), air quality alerts and education (five studies). Studies were set in Australia, China, Iran, the UK, and the USA. Due to the diversity of study designs, populations, interventions and outcomes, we did not perform any meta-analyses and instead summarised results narratively. We judged both RCTs and the NRS to be at risk of bias from lack of blinding and lack of clarity regarding selection methods. Many studies did not provide a prepublished protocol or trial registration. From five studies (184 participants), we found that masks or altered cycle routes may have little or no impact on physiological markers of air pollution exposure (e.g. blood pressure and heart rate variability), but we are very uncertain about this estimate using the GRADE approach. We found conflicting evidence regarding health care usage from three studies of air pollution alerts, with one non-randomised cross-over trial (35 participants) reporting an increase in emergency hospital attendances and admissions, but the other two randomised parallel trials (1553 participants) reporting little to no difference. We also gave the evidence for this outcome a very uncertain GRADE rating. None of our included trials reported respiratory exacerbations, quality of life or serious adverse events. Secondary outcomes were not well reported, but indicated inconsistent impacts of air quality alerts and education interventions on adherence, with some trials reporting improvements in the intervention groups and others reporting little or no difference. Symptoms were reported by three trials, with one randomised cross-over trial (15 participants) reporting a small increase in breathing difficulties associated with the mask intervention, one non-randomised cross-over trial (35 participants) reporting reduced throat and nasal irritation in the lower-pollution cycle route group (but no clear difference in other respiratory symptoms), and another randomised parallel trial (519 participants) reporting no clear difference in symptoms between those who received a smog warning and those who did not. AUTHORS' CONCLUSIONS The lack of evidence and study diversity has limited the conclusions of this review. Using a mask or a lower-pollution cycle route may mitigate some of the physiological impacts from air pollution, but evidence was very uncertain. We found conflicting results for other outcomes, including health care usage, symptoms and adherence/behaviour change. We did not find evidence for adverse events. Funders should consider commissioning larger, longer studies, using high-quality and well-described methods, recruiting participants with pre-existing respiratory conditions. Studies should report outcomes of importance to people with respiratory conditions, such as exacerbations, hospital admissions, quality of life and adverse events.
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Affiliation(s)
- Sadia Janjua
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | | | - Richard Atkinson
- Population Health Research Institute, St George's, University of London, London, UK
| | - Elizabeth Stovold
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Rebecca Fortescue
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
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Locations of Adolescent Physical Activity in an Urban Environment and Their Associations with Air Pollution and Lung Function. Ann Am Thorac Soc 2021; 18:84-92. [PMID: 32813558 DOI: 10.1513/annalsats.201910-792oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Physical activity while being exposed to high concentrations of air pollution may lead to greater inhalation of pollutant particles and gases. Thus, owing to features of the built city environment, specific locations where physical activity take place may put individuals at increased risk for harmful inhaled exposures leading to decrements in lung function.Objectives: The objectives were to determine locations throughout an urban landscape where children engage in moderate to vigorous activity (MVA). We hypothesized that outdoor activity would be associated with increased exposure to air pollution and reduced lung function.Methods: Children aged 9-14 years living in New York City (NYC) (n = 151) wore global positioning system devices and wrist accelerometers for two 24-hour periods. Time-stamped global positioning system points and accelerometer data were aggregated and mapped using ArcGIS to determine locations where children engaged in MVA. Location-specific particulate matter <2.5 microns and nitrogen dioxide (NO2) was determined based on land use regression models of street-level pollution. Temporal air pollution exposure was determined based on daily concentrations collected at one central site in NYC. Forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and forced expiratory flow, midexpiratory phase (FEF25-75) were collected following each 24-hour period. Data were analyzed using multivariable linear regression models to examine associations between MVA time and both lung function and air pollution in separate models. Additionally, a multiplicative interaction term (MVA time × season) was included to test whether the association between MVA time and lung function outcomes varied by warmer versus colder months.Results: On average, children spent less MVA time outdoors (38.2 ± 39.6 min/d) compared with indoors (71.9 ± 74.7 min/d, P < 0.01), regardless of season. The majority of outdoor MVA occurred along sidewalks and roadbeds (30.2 ± 33.3 min/d, 76.9% of outdoor) where annual average concentrations of NO2 were relatively high. Interquartile range (IQR) increase in outdoor MVA time (44 min) was associated with higher levels of annual average NO2 (P < 0.01) but not particulate matter <2.5 microns. In warmer months, for IQR increase in outdoor MVA time, children had 1.41% lower FEV1/FVC (95% confidence interval [95% CI], -2.46 to -0.36) and 4.40% lower percent predicted FEF25-75 (95% CI, -8.02 to -0.78). These results persisted even after adjustment for location-specific annual average concentrations of NO2. No association was observed between MVA time and lung function in colder months (P > 0.05), and a formal test for interaction (MVA time × season) was significant (P value for interaction = 0.01 and 0.03 for FEV1/FVC and FEF25-75, respectively).Conclusions: Children in NYC spent less time active outdoors compared with indoors. Outdoor activity was greatest near traffic sources and associated with higher annual average concentrations of NO2. In warmer months, outdoor activity was associated with lower lung function, but this association did not appear to be mediated by higher exposure to outdoor pollution during exercise.
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McCarthy MC, Mukherjee AD, Ogletree M, Furst J, Gosselin MI, Tigges M, Thomas G, Brown SG. Assessment of mobile source air toxics in an Environmental Justice Denver community adjacent to a freeway. JOURNAL OF THE AIR & WASTE MANAGEMENT ASSOCIATION (1995) 2021; 71:231-246. [PMID: 32091969 DOI: 10.1080/10962247.2020.1734113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 06/10/2023]
Abstract
Air pollutant concentrations are often higher near major roadways than in the surrounding environments owing to emissions from on-road mobile sources. In this study, we quantified the gradient in black carbon (BC) and air toxics concentrations from the I-70 freeway in the Elyria-Swansea environmental justice neighborhood in Denver, Colorado, during three measurement campaigns in 2017-2018. The average hourly upwind-downwind gradient of BC concentrations from the roadway was 500-800 ng/m3, equal to an increment of approximately 30-80% above local background levels within 180 m of the freeway. When integrated over all wind directions, the gradients were smaller, approximately 150-300 ng/m3 (~11-18%) over the course of nearly four months of measurements. No statistically significant gradient in air toxics (e.g., benzene, formaldehyde, etc.) was found, likely because the uncertainties in the mean concentrations were larger than the magnitude of the gradient (<25%). This finding is in contrast to some earlier studies in which small gradients of benzene and other VOCs were found. We estimate that sample sizes of at least 100 individual measurements would have been required to estimate mean concentrations with sufficient certainty to quantify gradients on the order of ±10% uncertainty. These gradient estimates are smaller than those found in previous studies over the past two decades; more stringent emissions standards, the local fleet age distribution, and/or the steady turnover of the vehicle fleet may be reducing the overall impact of roadway emissions on near-road communities. Implications: Gradients of near-road pollution may be declining in the near-road environment as tailpipe emissions from the vehicle fleet continue to decrease. Near-road concentration gradients of mobile source air toxics, including benzene, 1,3-butadiene, and ethylbenzene, will require higher sample sizes to quantify as emissions continue to decline.
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Affiliation(s)
| | | | - Michael Ogletree
- Colorado Department of Public Health & Environment , Denver, CO, USA
| | | | | | - Mark Tigges
- Air Resource Specialists, Inc ., Fort Collins, CO, USA
| | - Gregg Thomas
- Colorado Department of Public Health & Environment , Denver, CO, USA
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Ha S, Nobles C, Kanner J, Sherman S, Cho SH, Perkins N, Williams A, Grobman W, Biggio J, Subramaniam A, Ouidir M, Chen Z, Mendola P. Air Pollution Exposure Monitoring among Pregnant Women with and without Asthma. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17134888. [PMID: 32645870 PMCID: PMC7369909 DOI: 10.3390/ijerph17134888] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/18/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022]
Abstract
Background: We monitored exposure to fine particulates (PM2.5), ozone, nitrogen dioxide (NO2), and ambient temperature for pregnant women with and without asthma. Methods: Women (n = 40) from the Breathe—Well-Being, Environment, Lifestyle, and Lung Function Study (2015–2018) were enrolled during pregnancy and monitored for 2–4 days. Daily pollutants were measured using personal air monitors, indoor air monitors, and nearest Environmental Protection Agency’s stationary monitors based on GPS tracking and home address. Results: Personal-monitor measurements of PM2.5, ozone, and NO2 did not vary by asthma status but exposure profiles significantly differed by assessment methods. EPA stationary monitor-based methods appeared to underestimate PM2.5 and temperature exposure and overestimate ozone and NO2 exposure. Higher indoor-monitored PM2.5 exposures were associated with smoking and the use of gas appliances. The proportion of waking-time during which personal monitors were worn was ~56%. Lower compliance was associated with exercise, smoking, being around a smoker, and the use of a prescription drug. Conclusions: Exposure did not vary by asthma status but was influenced by daily activities and assessment methods. Personal monitors may better capture exposures but non-compliance merits attention. Meanwhile, larger monitoring studies are warranted to further understand exposure profiles and the health effects of air pollution during pregnancy.
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Affiliation(s)
- Sandie Ha
- Department of Public Health, Health Sciences Research Institute, College of Social Sciences, Humanities, and Arts, University of California, Merced, CA 95343, USA
- Correspondence: ; Tel.: +1-209-228-3615
| | - Carrie Nobles
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA; (C.N.); (J.K.); (N.P.); (M.O.); (Z.C.); (P.M.)
| | - Jenna Kanner
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA; (C.N.); (J.K.); (N.P.); (M.O.); (Z.C.); (P.M.)
| | | | - Seung-Hyun Cho
- RTI International, Research Triangle Park, NC 27709, USA;
| | - Neil Perkins
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA; (C.N.); (J.K.); (N.P.); (M.O.); (Z.C.); (P.M.)
| | - Andrew Williams
- School of Medicine & Health Sciences, University of North Dakota, Grand Forks, ND 58202, USA;
| | - William Grobman
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA;
| | | | - Akila Subramaniam
- Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA;
| | - Marion Ouidir
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA; (C.N.); (J.K.); (N.P.); (M.O.); (Z.C.); (P.M.)
| | - Zhen Chen
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA; (C.N.); (J.K.); (N.P.); (M.O.); (Z.C.); (P.M.)
| | - Pauline Mendola
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA; (C.N.); (J.K.); (N.P.); (M.O.); (Z.C.); (P.M.)
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