Modeling health and well-being measures using ZIP code spatial neighborhood patterns

Individual-level assessment of health and well-being permits analysis of community well-being and health risk evaluations across several dimensions of health. It also enables comparison and rankings of reported health and well-being for large geographical areas such as states, metropolitan areas, and counties. However, there is large variation in reported well-being within such large spatial units underscoring the importance of analyzing well-being at more granular levels, such as ZIP codes. In this paper, we address this problem by modeling well-being data to generate ZIP code tabulation area (ZCTA)-level rankings through spatially informed statistical modeling. We build regression models for individual-level overall well-being index and scores from five subscales (Physical, Financial, Social, Community, Purpose) using individual-level demographic characteristics as predictors while including a ZCTA-level spatial effect. The ZCTA neighborhood information is incorporated by using a graph Laplacian matrix; this enables estimation of the effect of a ZCTA on well-being using individual-level data from that ZCTA as well as by borrowing information from neighboring ZCTAs. We deploy our model on well-being data for the U.S. states of Massachusetts and Georgia. We find that our model can capture the effects of demographic features while also offering spatial effect estimates for all ZCTAs, including ones with no observations, under certain conditions. These spatial effect estimates provide community health and well-being rankings of ZCTAs, and our method can be deployed more generally to model other outcomes that are spatially dependent as well as data from other states or groups of states.

Impact of heatwaves on all-cause mortality in India: A comprehensive multi-city study

BACKGROUND

Heatwaves are expected to increase with climate change, posing a significant threat to population health. In India, with the world's largest population, heatwaves occur annually but have not been comprehensively studied. Accordingly, we evaluated the association between heatwaves and all-cause mortality and quantifying the attributable mortality fraction in India.

METHODS

We obtained all-cause mortality counts for ten cities in India (2008-2019) and estimated daily mean temperatures from satellite data. Our main extreme heatwave was defined as two-consecutive days with an intensity above the 97th annual percentile. We estimated city-specific heatwave associations through generalised additive Poisson regression models, and meta-analysed the associations. We reported effects as the percentage change in daily mortality, with 95% confidence intervals (CI), comparing heatwave vs non-heatwave days. We further evaluated heatwaves using different percentiles (95th, 97th, 99th) for one, two, three and five-consecutive days. We also evaluated the influence of heatwave duration, intensity and timing in the summer season on heatwave mortality, and estimated the number of heatwave-related deaths.

FINDINGS

Among ∼ 3.6 million deaths, we observed that temperatures above 97th percentile for 2-consecutive days was associated with a 14.7 % (95 %CI, 10.3; 19.3) increase in daily mortality. Alternative heatwave definitions with higher percentiles and longer duration resulted in stronger relative risks. Furthermore, we observed stronger associations between heatwaves and mortality with higher heatwave intensity. We estimated that around 1116 deaths annually (95 %CI, 861; 1361) were attributed to heatwaves. Shorter and less intense definitions of heatwaves resulted in a higher estimated burden of heatwave-related deaths.

CONCLUSIONS

We found strong evidence of heatwave impacts on daily mortality. Longer and more intense heatwaves were linked to an increased mortality risk, however, resulted in a lower burden of heatwave-related deaths. Both definitions and the burden associated with each heatwave definition should be incorporated into planning and decision-making processes for policymakers.

Validation of a neighborhood sentiment and safety index derived from existing data repositories

BACKGROUND

The communities we live in are central to our health. Neighborhood disadvantage is associated with worse physical and mental health and even early mortality, while resident sense of safety and positive neighborhood sentiment has been repeatedly linked to better physical and mental health outcomes. Therefore, understanding where negative neighborhood sentiment and safety are salient concerns can help inform public health interventions and as a result, improve health outcomes. To date, fear of crime and neighborhood sentiment data or indices have largely been based on the administration of time consuming and costly standardized surveys.

OBJECTIVE

The current study aims to develop a Neighborhood Sentiment and Safety Index (NSSI) at the census tract level, building on publicly available data repositories, including the US Census and ACS surveys, Data Axle, and ESRI repositories.

METHODS

The NSSI was created using Principal Component Analysis. Mineigen and minimum loading values were 1 and 0.3, respectively. Throughout the step-wise PCA process, variables were excluded if their loading value was below 0.3 or if variables loaded into multiple components.

RESULTS

The novel index was validated against standardized survey items from a longitudinal cohort study in the Northeastern United States characterizing experiences of (1) Neighborhood Characteristics with a Pearson correlation of -0.34 (p < 0.001) and, (2) Neighborhood Behavior Impact with a Pearson correlation of -0.33 (p < 0.001). It also accurately predicted the Share Care Community Well Being Index (Spearman correlation = 0.46) and the neighborhood deprivation index (NDI) (Spearman correlation = -0.75).

SIGNIFICANCE

Our NSSI can serve as a predictor of neighborhood experience where data is either unavailable or too resource consuming to practically implement in planned studies.

IMPACT STATEMENT

To date, fear of crime and neighborhood sentiment data or indices have largely been based on the administration of time consuming and costly standardized surveys. The current study aims to develop a Neighborhood Sentiment and Safety Index (NSSI) at the census tract level, building on publicly available data repositories, including the US Census and ACS surveys, Data Axle, and ESRI repositories. The NSSI was validated against four separate measures and can serve as a predictor of neighborhood experience where data is either unavailable or too resource consuming to practically implement in planned studies.

Deep Ensemble Learning for Retinal Image Classification

Purpose

Vision impairment affects 2.2 billion people worldwide, half of which is preventable with early detection and treatment. Currently, automatic screening of ocular pathologies using convolutional neural networks (CNNs) on retinal fundus photographs is limited to a few pathologies. Simultaneous detection of multiple ophthalmic pathologies would increase clinical usability and uptake.

Methods

Two thousand five hundred sixty images were used from the Retinal Fundus Multi-Disease Image Dataset (RFMiD). Models were trained (n = 1920) and validated (n = 640). Five selected CNN architectures were trained to predict the presence of any pathology and categorize the 28 pathologies. All models were trained to minimize asymmetric loss, a modified form of binary cross-entropy. Individual model predictions were averaged to obtain a final ensembled model and assessed for mean area under the receiver-operator characteristic curve (AUROC) for disease screening (healthy versus pathologic image) and classification (AUROC for each class).

Results

The ensemble network achieved a disease screening (healthy versus pathologic) AUROC score of 0.9613. The highest single network score was 0.9586 using the SE-ResNeXt architecture. For individual disease classification, the average AUROC score for each class was 0.9295.

Conclusions

Retinal fundus images analyzed by an ensemble of CNNs trained to minimize asymmetric loss were effective in detection and classification of ocular pathologies than individual models. External validation is needed to translate machine learning models to diverse clinical contexts.

Translational Relevance

This study demonstrates the potential benefit of ensemble-based deep learning methods on improving automatic screening and diagnosis of multiple ocular pathologies from fundoscopy imaging.

Changes in Ultrafine Particle Concentrations near a Major Airport Following Reduced Transportation Activity during the COVID-19 Pandemic

Mobility reductions following the COVID-19 pandemic in the United States were higher, and sustained longer, for aviation than ground transportation activity. We evaluate changes in ultrafine particle (UFP, Dp < 100 nm, a marker of fuel-combustion emissions) concentrations at a site near Logan Airport (Boston, Massachusetts) in relation to mobility reductions. Several years of particle number concentration (PNC) data prepandemic [1/2017-9/2018] and during the state-of-emergency (SOE) phase of the pandemic [4/2020-6/2021] were analyzed to assess the emissions reduction impact on PNC, controlling for season and wind direction. Mean PNC was 48% lower during the first three months of the SOE than prepandemic, consistent with 74% lower flight activity and 39% (local)-51% (highway) lower traffic volume. Traffic volume and mean PNC for all wind directions returned to prepandemic levels by 6/2021; however, when the site was downwind from Logan Airport, PNC remained lower than prepandemic levels (by 23%), consistent with lower-than-normal flight activity (44% below prepandemic levels). Our study shows the effect of pandemic-related mobility changes on PNC in a near-airport community, and it distinguishes aviation-related and ground transportation source contributions.

983 LEARNING FROM THE EXPERIENCES OF NURSES IN CARE HOMES DURING COVID-19 (THRIVE STUDY): STEERING THE SHIP THROUGH THE STORM

Background

Nurses practising in older people’s care homes are often the only trained nurse on shift, undertaking leadership roles while also supporting residents with complex clinical needs. The study aimed to explore Nursing and Midwifery Council (NMC)-registered nurses’ experiences of working in older people’s care homes during the COVID-19 pandemic.

Method

Recruitment used direct contact with care homes, social media and links provided by national partners, then purposive sampling for age, gender, type of care home and location. Data collected through one-to-one on-line interviews using a topic guide developed collaboratively with care home nurses, focusing on how COVID-19 impacted on nurses’ resilience and mental well-being. Data were analysed thematically.

Results

18 nurses interviewed between March–July 2021: female 16, majority aged between 46–55 years; mean time registered with NMC 19 years (range 18 months-45 years); one had not nursed residents with COVID-19. Preliminary findings indicate that nurses developed enhanced clinical skills, which increased their professional standing. Many nurses were in leadership roles responsible for processing and sharing rapidly-changing guidance, making judgements on how to manage infection risk within the home. Nurses reported balancing information-assimilation and reporting with providing direct care due to staff shortages. All nurses provided emotional support to other staff. They sought support from their peers, namely nurses inside and outside their workplace. As leaders, many of the nurses spoke about the emotional impact of having to manage relatives’ expectations and make decisions on whether a relative could be with a dying resident.

Conclusion

Understanding the types of support that might best increase resilience and well-being for nurses in care homes now and in the future is essential to maintain a healthy, stable workforce. Support for nurses will likely benefit other care workers either directly through wider roll-out, or indirectly through improved well-being of the nurse leaders.

Benefits of Increasing Greenness on All-Cause Mortality in the Largest Metropolitan Areas of the United States Within the Past Two Decades

Across the United States, cities are creating sustainability and climate action plans (CAPs) that call to increase local vegetation. These greening initiatives have the potential to not only benefit the environment but also human health. In epidemiologic literature, greenness has a protective effect on mortality through various direct and indirect pathways. We aimed to assess how an increase in greenness could decrease mortality in the largest urban areas in the United States. We conducted a nationwide quantitative health impact assessment to estimate the predicted reduction in mortality associated with an increase in greenness across two decades (2000, 2010, and 2019). Using a recently published exposure-response function, Landsat 30 m 16-day satellite imagery from April to September, and publicly available county-level mortality data from the CDC, we calculated the age-adjusted reduction in all-cause mortality for those 65 years and older within 35 of the most populated metropolitan areas. We estimated that between 34,000 and 38,000 all-cause deaths could have been reduced in 2000, 2010, and 2019 with a local increase in green vegetation by 0.1 unit across the most populated metropolitan areas. We found that overall greenness increased across time with a 2.86% increase from 2000 to 2010 to 11.11% from 2010 to 2019. These results can be used to support CAPs by providing a quantitative assessment to the impact local greening initiatives can have on mortality. Urban planners and local governments can use these findings to calculate the co-benefits of local CAPs through a public health lens and support policy development.

Trends in cesarean section rates in private and public facilities in rural eastern Maharashtra, India from 2010-2017

INTRODUCTION

Rates of cesarean sections (CS) have increased dramatically over the past two decades in India. This increase has been disproportionately high in private facilities, but little is known about the drivers of the CS rate increase and how they vary over time and geographically.

METHODS

Women enrolled in the Nagpur, India site of the Global Network for Women's and Children's Health Research Maternal and Neonatal Health Registry, who delivered in a health facility with CS capability were included in this study. The trend in CS rates from 2010 to 2017 in public and private facilities were assessed and displayed by subdistrict. Multivariable generalized estimating equations models were used to assess the association of delivering in private versus public facilities with having a CS, adjusting for known risk factors.

RESULTS

CS rates increased substantially between 2010 and 2017 at both public and private facilities. The odds of having a CS at a private facility were 40% higher than at a public facility after adjusting for other known risk factors. CS rates had unequal spatial distributions at the subdistrict level.

DISCUSSION

Our study findings contribute to the knowledge of increasing CS rates in both public and private facilities in India. Maps of the spatial distribution of subdistrict-based CS rates are helpful in understanding patterns of CS deliveries, but more investigation as to why clusters of high CS rates have formed in warranted.

Building capacity for air pollution epidemiology in India

Air pollution represents a major public health threat in India affecting 19% of the world's population at extreme levels. Despite this, research in India lags behind in large part due to a lack of comprehensive air pollution exposure assessment that can be used in conjunction with health data to investigate health effects. Our vision is to provide a consortium to rapidly expand the evidence base of the multiple effects of ambient air pollution. We intend to leapfrog current limitations of exposure assessment by developing a machine-learned satellite-informed spatiotemporal model to estimate daily levels of ambient fine particulate matter measuring less than 2.5 µm (PM2.5) at a fine spatial scale across all of India. To catalyze health effects research on an unprecedented scale, we will make the output from this model publicly available. In addition, we will also apply these PM2.5 estimates to study the health outcomes of greatest public health importance in India, including cardiovascular diseases, chronic obstructive pulmonary disease, pregnancy (and birth) outcomes, and cognitive development and/or decline. Thus, our efforts will directly generate actionable new evidence on the myriad effects of air pollution on health that can inform policy decisions, while providing a comprehensive and publicly available resource for future studies on both exposure and health effects. In this commentary, we discuss the motivation, rationale, and vision for our consortium and a path forward for reducing the enormous burden of disease from air pollution in India.

Abstract P3-01-16: Micro-cavity array system for size-based enrichment of circulating tumor cells and circulating cancer associated fibroblasts from blood of patients with breast cancer

Background:Circulating Tumor Cells(CTCs) have prognostic implications in patients with metastatic breast cancer(MBC).During the Epithelial Mesenchymal Transition(EMT), CTCs acquire a more mesenchymal phenotype. Hence, methodologies such as the Cell search that rely on the expression of an epithelial marker EpCAM in CTCs fail to capture a subset of CTCs undergoing the process of EMT and therefore do not adequately represent the true circulatory metastatic load. Hitachi chemicals has invented a size based micro cavity array (MCA) system that allows for the isolation of tumor cells based on the differences in size and deformability between tumor and blood cells. Photolithography and the metal plating can precisely control the filter pore size of our system. Our platform is more sensitive than the Cell Search method in detecting CTCs in Lung Cancer. Cancer Associated Fibroblasts (CAFs) are a major component of the breast tumor microenvironment. Using a micro filter capture technique, our co-authors have demonstrated that CAFs can be enumerated as circulating CAFs (cCAFs). Hitachi's Micro cavity Array System has not been evaluated in the detection of CTCs and cCAFs in patients with Breast Cancer. The purpose of this study is to demonstrate that CTCs and cCAFs can be enumerated using our platform and the cCAFs can serve as biomarkers of metastasis simultaneously with CTCs.

Method:We undertook a Pilot study of 20 patients each with breast cancer across Stage I, Stage II, Stage III and Stage IV. A total of 10ml of peripheral blood was obtained from each patient. Enumeration of CTCs and cCAFs was carried out by the size based mircocavity array system invented by Hitachi Chemicals. Identification of these cells was done by a triple Immunofluorescence staining for pan-CK (cytokeratin), FAP (Fibroblast Activated Protein) and CD45. CTCs were identified as CK+, CD45-, FAP- cells and cCAFs were identified as FAP+, CK- and CD 45 negative cells.

Result:Our method had a high cell recovery rate (90%or higher) and efficient white blood cells depletion rate (99.99%). We present the data from a total of 13 patients in this abstract, (two with stage III and eleven with stage IV breast cancer) . Data from rest of the subjects will be presented at the actual meeting. We detected the presence of CTCs in 11/11(100%) in patients with stage IV(mean of 44) and in 2 out of 2 (100%) patients with Stage III Breast Cancer. We detected the presence of cCAFs in 1 out of 2 patients( 50%) with stage III and in 8 of 11(81.8%) (mean of 9)patients with stage IV breast cancer( Fisher's exact test p-value= 0.42). The number of CTCs and cCAFs was significantly elevated in patients with MBC and the number was clinically associated with a high metastatic burden.

Conclusions:CTCs and cCAFs can be enumerated using a size based size based micro cavity array invented by Hitachi Chemicals that does not rely on the expression of epithelial markers in CTCs. CTCs and cCAFs can be detected in patients with stage III and stage IV breast cancer. CTCs and cCAFs were associated with high metastatic burden and their numbers were significantly elevated in patients with MBC. cCAFs could serve as biomarkers alongside of CTCs in MBC.

Citation Format: Parajuli R, Ly R, Ziogas A, Eapen A, Lane K, Chen J, Lin E, Mehta R, Tsai A. Micro-cavity array system for size-based enrichment of circulating tumor cells and circulating cancer associated fibroblasts from blood of patients with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-01-16.

Relationship of Time-Activity-Adjusted Particle Number Concentration with Blood Pressure

Emerging evidence suggests long-term exposure to ultrafine particulate matter (UFP, aerodynamic diameter < 0.1 µm) is associated with adverse cardiovascular outcomes. We investigated whether annual average UFP exposure was associated with measured systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and hypertension prevalence among 409 adults participating in the cross-sectional Community Assessment of Freeway Exposure and Health (CAFEH) study. We used measurements of particle number concentration (PNC, a proxy for UFP) obtained from mobile monitoring campaigns in three near-highway and three urban background areas in and near Boston, Massachusetts to develop PNC regression models (20-m spatial and hourly temporal resolution). Individual modeled estimates were adjusted for time spent in different micro-environments (time-activity-adjusted PNC, TAA-PNC). Mean TAA-PNC was 22,000 particles/cm³ (sd = 6500). In linear models (logistic for hypertension) adjusted for the minimally sufficient set of covariates indicated by a directed acyclic graph (DAG), we found positive, non-significant associations between natural log-transformed TAA-PNC and SBP (β = 5.23, 95%CI: −0.68, 11.14 mmHg), PP (β = 4.27, 95%CI: −0.79, 9.32 mmHg), and hypertension (OR = 1.81, 95%CI: 0.94, 3.48), but not DBP (β = 0.96, 95%CI: −2.08, 4.00 mmHg). Associations were stronger among non-Hispanic white participants and among diabetics in analyses stratified by race/ethnicity and, separately, by health status.

Refining the Maritime Foundations of Andean Civilization: How Plant Fiber Technology Drove Social Complexity During the Preceramic Period

Moseley's (1975) Maritime Foundations of Andean Civilization hypothesis challenges, in one of humanity's few pristine hearths of civilization, the axiom that agriculture is necessary for the rise of complex societies. We revisit that hypothesis by setting new findings from La Yerba II (7571-6674 Cal bp) and III (6485-5893 Cal bp), Río Ica estuary, alongside the wider archaeological record for the end of the Middle Preceramic Period on the Peruvian coast. The La Yerba record evinces increasing population, sedentism, and "Broad Spectrum Revolution" features, including early horticulture of Phaseolus and Canavalia beans. Yet unlike further north, these changes failed to presage the florescence of monumental civilization during the subsequent Late Preceramic Period. Instead, the south coast saw a profound "archaeological silence." These contrasting trajectories had little to do with any relative differences in marine resources, but rather to restrictions on the terrestrial resources that determined a society's capacity to intensify exploitation of those marine resources. We explain this apparent miscarriage of the Maritime Foundations of Andean Civilization (MFAC) hypothesis on the south coast of Peru by proposing more explicit links than hitherto, between the detailed technological aspects of marine exploitation using plant fibers to make fishing nets and the emergence of social complexity on the coast of Peru. Rather than because of any significant advantages in quality, it was the potential for increased quantities of production, inherent in the shift from gathered wild Asclepias bast fibers to cultivated cotton, that inadvertently precipitated revolutionary social change. Thereby refined, the MFAC hypothesis duly emerges more persuasive than ever.

Human Elimination of Organochlorine Pesticides: Blood, Urine, and Sweat Study

Background. Many individuals have been exposed to organochlorinated pesticides (OCPs) through food, water, air, dermal exposure, and/or vertical transmission. Due to enterohepatic reabsorption and affinity to adipose tissue, OCPs are not efficiently eliminated from the human body and may accrue in tissues. Many epidemiological studies demonstrate significant exposure-disease relationships suggesting OCPs can alter metabolic function and potentially lead to illness. There is limited study of interventions to facilitate OCP elimination from the human body. This study explored the efficacy of induced perspiration as a means to eliminate OCPs. Methods. Blood, urine, and sweat (BUS) were collected from 20 individuals. Analysis of 23 OCPs was performed using dual-column gas chromatography with electron-capture detectors. Results. Various OCPs and metabolites, including DDT, DDE, methoxychlor, endrin, and endosulfan sulfate, were excreted into perspiration. Generally, sweat samples showed more frequent OCP detection than serum or urine analysis. Many OCPs were not readily detected in blood testing while still being excreted and identified in sweat. No direct correlation was found among OCP concentrations in the blood, urine, or sweat compartments. Conclusions. Sweat analysis may be useful in detecting some accrued OCPs not found in regular serum testing. Induced perspiration may be a viable clinical tool for eliminating some OCPs.

Implementation and evaluation of a transit dosimetry system for treatment verification

PURPOSE

To evaluate a formalism for transit dosimetry using a phantom study and prospectively evaluate the protocol on a patient population undergoing 3D conformal radiotherapy.

METHODS

Amorphous silicon EPIDs were calibrated for dose and used to acquire images of delivered fields. The measured EPID dose map was back-projected using the planning CT images to calculate dose at pre-specified points within the patient using commercially available software, EPIgray (DOSIsoft, France). This software compared computed back-projected dose with treatment planning system dose. A series of tests were performed on solid water phantoms (linearity, field size effects, off-axis effects). 37 patients were enrolled in the prospective study.

RESULTS

The EPID dose response was stable and linear with dose. For all tested field sizes the agreement was good between EPID-derived and treatment planning system dose in the central axis, with performance stability up to a measured depth of 18cm (agreement within -0.5% at 10cm depth on the central axis and within -1.4% at 2cm off-axis). 126 transit images were analysed of 37 3D-conformal patients. Patient results demonstrated the potential of EPIgray with 91% of all delivered fields achieved the initial set tolerance level of ΔD of 0±5-cGy or %ΔD of 0±5%.

CONCLUSIONS

The in vivo dose verification method was simple to implement, with very few commissioning measurements needed. The system required no extra dose to the patient, and importantly was able to detect patient position errors that impacted on dose delivery in two of cases.

"FIND Technology": investigating the feasibility, efficacy and safety of controller-free interactive digital rehabilitation technology in an inpatient stroke population: study protocol for a randomized controlled trial

Background

Stroke results in significant disability, which can be reduced by physical rehabilitation. High levels of repetition and activity are required in rehabilitation, but patients are typically sedentary. Using clinically relevant and fun computer games may be one way to achieve increased activity in rehabilitation.

Methods/design

A single-blind randomized controlled trial will be conducted to evaluate the feasibility, efficacy and safety of novel stroke-specific rehabilitation software. This software uses controller-free client interaction and inertial motion sensors. Elements of feasibility include recruitment into the trial, ongoing participation (adherence and dropout), perceived benefit, enjoyment and ease of use of the games. Efficacy will be determined by measuring activity and using upper-limb tasks as well as measures of balance and mobility. The hypothesis that the intervention group will have increased levels of physical activity within rehabilitation and improved physical outcomes compared with the control group will be tested.

Discussion

Results from this study will provide a basis for discussion of feasibility of this interactive video technological solution in an inpatient situation. Differences in activity levels between groups will be the primary measure of efficacy. It will also provide data on measures of upper-limb function, balance and mobility.

Trial registration

ACTRN12614000427673. Prospectively registered 17 April 2014.

Hepatitis E virus in patients with decompensated chronic liver disease: a prospective UK/French study

BACKGROUND

In developed countries, hepatitis E is a porcine zoonosis caused by hepatitis E virus (HEV) genotype 3. In developing countries, hepatitis E is mainly caused by genotype 1, and causes increased mortality in patients with pre-existing chronic liver disease (CLD).

AIM

To determine the role of HEV in patients with decompensated CLD.

METHODS

Prospective HEV testing of 343 patients with decompensated CLD at three UK centres and Toulouse France, with follow-up for 6 months or death. IgG seroprevalence was compared with 911 controls.

RESULTS

11/343 patients (3.2%) had acute hepatitis E infection, and three died. There were no differences in mortality (27% vs. 26%, OR 1.1, 95% CI 0.28-4.1), age (P = 0.9), bilirubin (P = 0.5), alanine aminotransferase (P = 0.06) albumin (P = 0.5) or international normalised ratio (P = 0.6) in patients with and without hepatitis E infection. Five cases were polymerase chain reaction (PCR) positive (genotype 3). Hepatitis E was more common in Toulouse (7.9%) compared to the UK cohort (1.2%, P = 0.003). HEV IgG seroprevalence was higher in Toulouse (OR 17, 95% CI 9.2-30) and Truro (OR 2.5, 95% CI 1.4-4.6) than in Glasgow, but lower in cases, compared to controls (OR 0.59, 95% CI 0.41-0.86).

CONCLUSIONS

Hepatitis E occurs in a minority of patients with decompensated chronic liver disease. The mortality is no different to the mortality in patients without hepatitis E infection. The diagnosis can only be established by a combination of serology and PCR, the yield and utility of which vary by geographical location.

Mapping the vertical distribution of population and particulate air pollution in a near-highway urban neighborhood: implications for exposure assessment

Owing to data collection challenges, the vertical variation in population in cities and particulate air pollution are typically not accounted for in exposure assessments, which may lead to misclassification of exposures based on elevation of residency. To better assess this misclassification, the vertical distribution of the potentially highly exposed population (PHEP), defined as all residents within the 100-m buffer zone of above-ground highways or the 200-m buffer zone of a highway-tunnel exit, was estimated for four floor categories in Boston's Chinatown (MA, USA) using the three-dimensional digital geography methodology. Vertical profiles of particle number concentration (7-3000 nm; PNC) and particulate matter (PM2.5) mass concentration were measured by hoisting instruments up the vertical face of an 11-story (35-m) building near the study area throughout the day on multiple days. The concentrations from all the profiles (n=23) were averaged together for each floor category. As measurement elevation increased from 0 to 35 m PNC decreased by 7.7%, compared with 3.6% for PM2.5. PHEP was multiplied by the average PNC for each floor category to assess exposures for near-highway populations. The results show that adding temporally-averaged vertical air pollution data had a small effect on residential ambient exposures for our study population; however, greater effects were observed when individual days were considered (e.g., winds were off the highways).

Abstract 551: In a South Asian Population, Urbanization is an Independent Predictor of Arterial Stiffness in Men

Background: Rapid urbanization is driving economies of South Asian countries. Here we use satellite based land cover data and distance to urban center (UC) to measure of the impact of urban environment on arterial stiffness (AS) in a population based study in South India.

Methods: In a cross-sectional analysis, after exclusion of people with previous history of diabetes and hypertension, 6746 subjects (mean age 42 years; 54% women) spread over 78 kms from the UC constituted the study sample. MODIS satellite derived land cover data at a 1 km x 1 km resolution was obtained and joined to each participant's geolocated residential position in ArcGIS to assign urban and rural designations. The study included carotid-femoral pulse wave velocity (PWV) measurement using a high-fidelity applanation tonometry, blood pressure (BP), anthropometric, psychosocial, high sensitive C-reactive protein (HsCRP) and other biomarkers assessments.

Results: Based on land cover analysis, participants in urban locations had a mean (SD) PWV (m/s) of 7.74 (1.65) compared to 7.6 (1.62) in rural locations (p= 0.002) [Fig 1], while there was no significant difference in HsCRP levels. In multiple regression analyses adjusting for age, smoking, BMI, BP, blood glucose, LDL, socioeconomic, anxiety and stress levels, distance from UC was independently associated with PWV in men (β = -0.007, p <0.001), but not in women. Standardized effect-estimates in the multi-linear regression model indicated that distance from UC had the third largest effect on PWV after age and BP. After multivariable adjustments, the largest effect of distance from UC on PWV was on non-smoking men age 46-75 years. Residing every 1 km further away from the UC corresponded with a -0.012 m/s (95%CI: -0.020, -0.003) decrease in PWV.

Conclusions: Urbanization is an independent predictor of AS in men, more so in non-smoking older men. Further research will elucidate components in the urban environment that may be contributing to higher AS.

Highway proximity associated with cardiovascular disease risk: the influence of individual-level confounders and exposure misclassification

BACKGROUND

Elevated cardiovascular disease risk has been reported with proximity to highways or busy roadways, but proximity measures can be challenging to interpret given potential confounders and exposure error.

METHODS

We conducted a cross sectional analysis of plasma levels of C-Reactive Protein (hsCRP), Interleukin-6 (IL-6), Tumor Necrosis Factor alpha receptor II (TNF-RII) and fibrinogen with distance of residence to a highway in and around Boston, Massachusetts. Distance was assigned using ortho-photo corrected parcel matching, as well as less precise approaches such as simple parcel matching and geocoding addresses to street networks. We used a combined random and convenience sample of 260 adults >40 years old. We screened a large number of individual-level variables including some infrequently collected for assessment of highway proximity, and included a subset in our final regression models. We monitored ultrafine particle (UFP) levels in the study areas to help interpret proximity measures.

RESULTS

Using the orthophoto corrected geocoding, in a fully adjusted model, hsCRP and IL-6 differed by distance category relative to urban background: 43% (-16%,141%) and 49% (6%,110%) increase for 0-50 m; 7% (-39%,45%) and 41% (6%,86%) for 50-150 m; 54% (-2%,142%) and 18% (-11%,57%) for 150-250 m, and 49% (-4%, 131%) and 42% (6%, 89%) for 250-450 m. There was little evidence for association for TNF-RII or fibrinogen. Ortho-photo corrected geocoding resulted in stronger associations than traditional methods which introduced differential misclassification. Restricted analysis found the effect of proximity on biomarkers was mostly downwind from the highway or upwind where there was considerable local street traffic, consistent with patterns of monitored UFP levels.

CONCLUSION

We found associations between highway proximity and both hsCRP and IL-6, with non-monotonic patterns explained partly by individual-level factors and differences between proximity and UFP concentrations. Our analyses emphasize the importance of controlling for the risk of differential exposure misclassification from geocoding error.

Indoor and outdoor measurements of particle number concentration in near-highway homes

Exposure to high levels of traffic-generated particles may pose risks to human health; however, limited measurement has been conducted at homes near highways. The purpose of this study was to characterize differences between indoor and outdoor particle number concentration (PNC) in homes near to and distant from a highway and to identify factors that may affect infiltration. We monitored indoor and outdoor PNC (6-3000 nm) for 1-3 weeks at 18 homes located <1500 m from Interstate-93 (I-93) in Somerville, MA (USA). Median hourly indoor and outdoor PNC pooled over all homes were 5.2 × 10(3) and 5.9 × 10(3) particles/cm(3), respectively; the median ratio of indoor-to-outdoor PNC was 0.95 (5(th)/95th percentile: 0.42/1.75). Homes <100 m from I-93 (n=4) had higher indoor and outdoor PNC compared with homes >1000 m away (n=3). In regression models, a 10% increase in outdoor PNC was associated with an approximately equal (10.8%) increase in indoor PNC. Wind speed and direction, temperature, time of day and weekday were also associated with indoor PNC. Average mean indoor PNC was lower for homes with air conditioners compared with homes without air conditioning. These results may have significance for estimating indoor, personal exposures to traffic-related air pollution.

A community participatory study of cardiovascular health and exposure to near-highway air pollution: study design and methods

Current literature is insufficient to make causal inferences or establish dose-response relationships for traffic-related ultrafine particles (UFPs) and cardiovascular (CV) health. The Community Assessment of Freeway Exposure and Health (CAFEH) is a cross-sectional study of the relationship between UFP and biomarkers of CV risk. CAFEH uses a community-based participatory research framework that partners university researchers with community groups and residents. Our central hypothesis is that chronic exposure to UFP is associated with changes in biomarkers. The study enrolled more than 700 residents from three near-highway neighborhoods in the Boston metropolitan area in Massachusetts, USA. All participants completed an in-home questionnaire and a subset (440+) completed an additional supplemental questionnaire and provided biomarkers. Air pollution monitoring was conducted by a mobile laboratory equipped with fast-response instruments, at fixed sites, and inside the homes of selected study participants. We seek to develop improved estimates of UFP exposure by combining spatiotemporal models of ambient UFP with data on participant time-activity and housing characteristics. Exposure estimates will then be compared with biomarker levels to ascertain associations. This article describes our study design and methods and presents preliminary findings from east Somerville, one of the three study communities.

The importance of an independent oversight committee to preserve treatment fidelity, ensure protocol compliance, and adjudicate safety endpoints in the ATACH II trial

In response to growing trends and accepted U.S. Food and Drug Administration (FDA) guidance, the ATACH II trial leadership developed the independent oversight committee (IOC) as a mechanism to adjudicate the trial safety endpoints and to evaluate treatment fidelity and protocol compliance. To accomplish these tasks, the IOC reviews the first three subjects enrolled at each study center and all serious adverse events that occur across all study centers. The IOC makes recommendations to the steering committee regarding the aggregation of, or trend in, adverse events at particular sites and discusses homogeneity, or lack thereof, in the principles and intensity of the overall care. Based on the IOC findings, the steering committee will contact individual sites, as needed, to discuss potential remedial measures.

Abstract LB-420: Long circulating 18F-labeled liposomes for PET imaging

Liposomes are lipid nanoparticles comprised of phospholipid bilayers with an aqueous interior. They have emerged as promising multi-modality imaging agents and engender significant interest as drug delivery vehicles, e.g. doxorubicin liposomes. Although a number of methods for radiolabeling liposomes with various radionuclides have been developed, 18F is the most useful for PET imaging. In this study, preformed maleimide-PEG functionalized liposomes with a mean diameter of 70 nm were obtained by sonication of a lipid mixture consisting of DPPC, cholesterol, and DSPE-PEG2000-Mal (61:30:9) in acetate buffer (pH 6.5) followed by extrusion. 18F labeled 2-(2-(2-(2-fluoroethoxy)ethoxy)ethoxy)ethanethiol was prepared, followed by conjugation with the maleimide-PEG functionalized liposome in 0.1M acetate buffer (0.1% EDTA), pH 6.5-8.0. Liposome sizes did not differ significantly before and after the 18F labeling. The overall radiochemical yield of the reaction was 10-25% (n= 12, uncorrected) in a 180 minute radiolabeling time. Micro PET imaging of rats was done at various times, up to 4 hrs, following IV injection of the 18F liposomes and their bio-distribution was also investigated. Our imaging studies with 18F liposomes appear comparable to images from previously described labeling methods with 18F liposomes remaining in the blood pool at 4 hrs. Our results indicate that this will allow the ready availability of 18F liposomes for vascular imaging and also potentially for cancer imaging. Research Support: This study was funded by the intramural program of the National Institutes of Health.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr LB-420. doi:1538-7445.AM2012-LB-420

Preliminary results from a comparative effectiveness study of breast cancer survivorship care: A University of California (UC) ATHENA Breast Health Network project

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Background: The ATHENA Breast Health Network collaboration is a large scale, UC system-wide project initiated with the intent to drive innovation in breast cancer prevention, screening and treatment. An IRB approved research protocol was developed to examine survivorship care across Network sites, which includes key informant interviews at each site and patient/survivor surveys. This abstract presents preliminary analyses from the key informant interviews.

Methods: Investigators at each site conducted semi-structured interviews with oncology specialists and primary care providers (PCPs). Interviews used case study examples and open and closed-ended questions on the delivery of post-treatment breast cancer care. Informant responses were manually recorded by the interviewer, compiled in a database, then coded and analyzed using NVIVO9 software.

Results: There were 39 key informants across five participating UC sites: 14 medical oncologists, 7 radiation oncologists, 11 surgeons, 3 oncology nurses, and 4 PCPs. Care coordination is a major unprompted theme identified in the interviews. 85% of all participants reported using shared care coordination between PCP and oncology for post-treatment follow-up. 49% report the need for greater care coordination in general, and 28% report the need for greater care coordination within oncology, particularly to help avoid duplication of follow-up care and services. The responses demonstrate wide variability among provider types and institutions (Table). Additional analyses from this study will be updated in our presentation.

Conclusions: These preliminary results identify the need for focus on care coordination during the post-treatment phase of breast cancer care within the UC system.

[Table: see text]

Effect of airplane travel on women treated for breast cancer

Abstract #1119

Background: Many patient materials promulgate lifestyle adaptations purported to minimize risk of lymphedema. One factor often mentioned is development or exacerbation of lymphedema due to airplane travel. The aim of this study was to describe prospectively the effect of airplane travel on women treated for breast cancer, traveling to Caloundra, Qld., Australia to attend a dragon boat regatta.&#x2028; Methods: Pre and post data were obtained from 63 women traveling from Canada to Australia, and from 12 women traveling within Australia. 54% were treated for breast cancer on their dominant side, 63% underwent mastectomy with or without reconstruction, 77% underwent axillary node dissection, and 21% wore a compression sleeve during flight; 94% trained at a moderate to vigorous intensity for the regatta. Single frequency bioimpedance analysis (BIA; XCA; Impedimed Inc.®) was used to determine the inter-limb difference in upper limb extracellular fluid. BIA is highly reliable and has high sensitivity and specificity for increased extracellular fluid accumulation. Change in ratio &gt;0.05 for women without lymphoedema is of clinical significance. Women were measured within 2 weeks of their flight to Caloundra, immediately on arrival in Caloundra, and for 46 women, within 6 weeks of return to Canada.&#x2028; Results: Airplane travel did not have a significant effect on the upper limb BIA ratio, either between the pre and post flight (t75= -0.355; p=0.72) or between the pre and follow-up measures (t44=.241; p=0.811).&#x2028; &#x2028; Overall, the BIA post ratio increased from the pre measure by ≤0.02 in 48 women; 0.02 to &lt;0.05 in 12 women; 0.05 to &lt;0.10 in 10 women; and &gt;0.10 in 5 women (Fig 1). In Figure 1, symbols in grey-shaded area represents women who did not have lymphedema prior to flight but presented with it post flight and the dashed lines indicate previously established cut-offs for criteria for detection of lymphedema. Dotted line on each graph is the line of agreement. The 6 symbols in the grey shaded area (Fig 1) represent women from the international group; their change in BIA ranged from 0.05 to 0.28. Follow-up measures were available on 5 of these women, and indicated that 4 were below the cut-offs for lymphedema. All 6 women had undergone mastectomy and axillary clearance of their lymph nodes and for 5, surgery was on their dominant side. Only 3 of the women wore a compressive sleeve on the plane.&#x2028; Discussion: For the majority of women who undertake moderate to vigorous upper limb exercise, airplane travel did not have a significant impact on extracellular fluid ratio. Acknowledgment: Impedimed for funding and equipment.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1119.

Association between the serum anion gap and blood pressure among patients at Harvard Vanguard Medical Associates

Animal and human data suggest a link between endogenous acid production with elevations in blood pressure and the development of hypertension; increases in endogenous organic acid production can lead to a higher anion gap. We studied the cross-sectional association between the serum anion gap and blood pressure among 1057 non-diabetic patients who were not taking antihypertensive drugs, and who received their care at a multisite, multispecialty group practice in eastern Massachusetts. Using linear regression controlling for age, sex, race, BMI, estimated GFR and presence of impaired fasting glucose, every 1 mEq l(-1) higher serum anion gap was associated with a 0.27 mm Hg (P=0.08) higher systolic, 0.20 mm Hg (P=0.05) higher diastolic and 0.22 mm Hg (P=0.04) higher mean arterial pressure; these results suggest that endogenous acid production may raise the risk of hypertension.