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Background: Black women in the United States (US) have the highest risk of preterm birth (PTB) and small for gestational age (SGA) births, compared to women of other racial groups. Among Black women, there are disparities by nativity whereby foreign‐born women have a lower risk of PTB and SGA compared to US‐born women. Differential exposure to racism may confer nativity‐based differences in adverse perinatal outcomes between US‐ and foreign‐born Black women. This remains unexplored among US‐ and African‐born women in California. Objectives: Evaluate the relationship between structural racism, nativity, PTB and SGA among US‐ and African‐born Black women in California. Methods: We conducted a population‐based study of singleton births to US‐ and African‐born Black women in California from 2011 to 2017 (n = 131,424). We examined the risk of PTB and SGA by nativity and neighbourhoods with differing levels of structural racism, as measured by the Index of Concentration at the Extremes. We fit crude and age‐adjusted Poisson regression models, estimated using generalized estimating equations, with risk ratios (RR) and 95% confidence intervals (CI) as the effect measure. Results: The proportions of PTB and SGA were 9.7% and 14.5%, respectively, for US‐born women, while 5.6% and 8.3% for African‐born women. US‐born women (n = 24,782; 20.8%) were more likely to live in neighbourhoods with high structural racism compared to African‐born women (n = 1474; 11.6%). Structural racism was associated with an elevated risk of PTB (RR 1.19, 95% CI 1.12, 1.26) and SGA (RR 1.19, 95% CI 1.13, 1.25) for all Black women, however, there was heterogeneity by nativity, with US‐born women experiencing a higher magnitude of effect than African‐born women. Conclusions: Among Black women in California, exposure to structural racism and the impacts of structural racism on the risk of PTB and SGA varied by nativity. [ABSTRACT FROM AUTHOR]

Background We evaluated the impact of a brief peer-led intervention on COVID-19 vaccination among people who inject drugs (PWID) presenting at syringe services program (SSP) locations in San Diego County, California. Methods Between March and July 2022, PWID aged ≥18 years without recent voluntary COVID-19 testing who were not up to date on COVID-19 vaccinations received a single-session motivational interviewing intervention (LinkUP) or an attention-matched didactic control condition from trained peer counselors at SSP sites randomized by week. Following either 30-minute session, counselors offered referrals to local vaccination services. Multivariable log binomial regression via generalized estimating equations assessed LinkUP effects on (1) acceptance of COVID-19 vaccination referrals immediately postintervention and (2) COVID-19 vaccine uptake at 6-month follow-up. Results COVID-19 vaccination outcomes were obtained on 135 (90.6%) of 149 participants. In multivariable analysis, participants receiving LinkUP had greater acceptance of COVID-19 vaccination referrals than controls (adjusted relative risk, 3.50; 95% CI, 1.01–12.2) and were marginally more likely to report receiving a new COVID-19 vaccine dose (adjusted relative risk, 1.57; 95% CI,.99–2.48). After 6 months, 20% reported receiving a new vaccine dose; however, if COVID-19 vaccine had been available at SSPs, this proportion could have been as high as 34.3% (45.3% LinkUP vs 24.3% control; P =.01). Conclusions A brief peer-led SSP-based intervention significantly improved COVID-19 vaccination among PWID. Further improvements could likely be obtained by supporting SSPs to offer COVID-19 vaccination on-site instead of relying on referrals. Clinical Trials Registration ClinicalTrials.gov NCT05181657. [ABSTRACT FROM AUTHOR]

Purpose: The Supplemental Nutrition Assistance Program (SNAP) Online Purchasing Pilot (OPP) allows for the online purchase of groceries using SNAP benefits. First implemented in California in late April 2020, little is known about program usage. This study assessed initial implementation of SNAP Online in California using SNAP OPP transaction data from April - October 2020. Insights can identify usage differences by demographics, store availability, and rurality to help inform future pilot programs and nutrition initiatives. Design: Using generalized estimating equations, we modeled county-level associations between transactions and county-level demographics, rurality, and retailer availability. Setting: Transaction data from California's Department of Social Services (CDSS) was linked with publicly-available, county-level demographics. Subjects: Anonymized county-level data on SNAP Online transactions and CalFresh households. Measures: The primary outcome was successful SNAP Online food transactions per county. Analysis: Generalized estimating equation models with clustering by county was used. Results: During the first 7 months, median SNAP Online transactions per county per month was 665; 2.7% of total SNAP redemptions were from SNAP Online. Counties with more female-led, disabled, Latino, or Asian CalFresh households had fewer Amazon transactions. Each additional Walmart per county corresponded to 260.7 more Walmart transactions (P <.001). Each percent increase in county zip codes covered by Amazon Fresh corresponded to 45.4 fewer Walmart transactions (P <.05) and 37.3 more Amazon transactions (P <.001). Conclusion: Number of stores per county was associated with greater online grocery transactions, whereas rurality was not. County-level SNAP demographics correlated with transactions at particular retailers. [ABSTRACT FROM AUTHOR]

Background: Individuals globally were affected by the COVID-19 pandemic in myriad of ways, including social isolation and economic hardship, resulting in negative impacts on mental health and substance use. Young adults have been subjected to extraordinary challenges such as job loss, virtual school, or childcare issues, but have received limited attention from research so far. Methods: Using electronic health record data from a large integrated healthcare system in Northern California, this longitudinal observational study examined changes in the prevalence of unhealthy alcohol use (identified via systematic alcohol screening in adult primary care) from pre-(3/1/2019-12/31/2019) to post-COVID onset (3/1/2020-12/31/2020) among young adults (18-34 years). Among the 663,111 and 627,095 young adults who utilized primary care in the pre- and post-COVID onset periods, 342,889 (51.9%) and 186,711 (29.8%) received alcohol screening, respectively. We fit generalized estimating equation Poisson models to estimate the change in prevalence of unhealthy alcohol use from pre- to post-COVID onset among those who were screened, while using inverse probability weighting to account for potential selection bias of receiving alcohol screening. Heterogeneity in the change of prevalence by patient characteristics was also examined. Results: Overall, the unadjusted prevalence of unhealthy alcohol use slightly decreased from 9.2% pre-COVID to 9.0% post-COVID onset. After adjusting for patient covariates, the prevalence of unhealthy alcohol use decreased by about 2% [adjusted prevalence ratio (aPR) = 0.98, 95% CI = 0.96, 1.00]. The prevalence of unhealthy alcohol use increased among women by 8% (aPR = 1.08, 95% CI = 1.06, 1.11), patients 18-20 years by 7% (aPR = 1.07, 95% CI = 1.00, 1.15), and Latino/Hispanic patients by 7% (aPR = 1.07, 95% CI = 1.03, 1.11). While the prevalence of unhealthy alcohol use decreased among men by 12% (aPR = 0.88, 95% CI = 0.86, 0.90), patients 21-34 years by 2% (aPR = 0.98, 95% CI = 0.96, 0.99), White patients by 3% (95% CI = 0.95, 1.00), and patients living in neighborhoods with the lowest deprivation indices by 9% (aPR = 0.91, 95% CI = 0.88, 0.94), their unadjusted prevalence remained higher than their counterparts post-COVID onset. There was no variation in the change of prevalence by comorbid mental health conditions or drug use disorders. Conclusions: While changes in unhealthy alcohol use prevalence among young adults were small, findings raise concerns over increased drinking among women, those younger than the U.S. legal drinking age, and Latino/Hispanic patients. [ABSTRACT FROM AUTHOR]

Background: Low socioeconomic status (SES) has been associated with a higher risk of aggressive breast cancer (BC) subtypes, but few studies have examined the independent effects of both neighborhood‐level socioeconomic status (nSES) and individual‐level SES measures. Methods: This study included 5547 women from the Pathways and Life After Cancer Epidemiology cohorts who were diagnosed with invasive BC. Generalized estimating equation models were used to examine associations of nSES (a composite score based on income, poverty, education, occupation, employment, rent, and house value) and individual‐level SES (income and education) with BC subtypes: luminal B (LumB), Her2‐enriched (Her2‐e), and triple‐negative breast cancer (TNBC) relative to luminal A (LumA). Models controlled for age, race, nativity, stage, days from diagnosis to survey, and study cohort and simultaneously for nSES and individual‐level SES. Results: In fully adjusted models, low nSES was significantly associated with the LumB (odds ratio for quartile 1 vs quartile 4 [ORQ1vQ4], 1.31; 95% confidence interval [CI], 1.11‐1.54; P for trend =.005) and TNBC subtypes (ORQ1vQ4, 1.32; 95% CI, 1.02‐1.71; P for trend =.037) relative to LumA. Conversely, individual education was significantly associated with only the Her2‐e subtype (odds ratio for high school degree or less vs postgraduate, 1.68; 95% CI, 1.03‐2.75; P for trend =.030) relative to LumA. Individual income was not significantly associated with any BC subtype. Conclusions: nSES and individual‐level SES are independently associated with different BC subtypes; specifically, low nSES and individual‐level education are independent predictors of more aggressive BC subtypes relative to LumA. Low neighborhood‐level socioeconomic status and individual‐level education are independent predictors of more aggressive breast cancer subtypes relative to luminal A. [ABSTRACT FROM AUTHOR]

Background: Most U.S. states have legalized cannabis for medical and/or recreational use. In a 6-month prospective observational study, we examined changes in adult cannabis use patterns and health perceptions following broadened legalization of cannabis use from medical to recreational purposes in California.Methods: Respondents were part of Stanford University's WELL for Life registry, an online adult cohort concentrated in Northern California. Surveys were administered online in the 10 days prior to state legalization of recreational use (1/1/18) and 1-month (2/1/18-2/15/18) and 6-months (7/1/2018-7/15/18) following the change in state policy. Online surveys assessed self-reported past 30-day cannabis use, exposure to others' cannabis use, and health perceptions of cannabis use. Logistic regression models and generalized estimating equations (GEE) examined associations between participant characteristics and cannabis use pre- to 1-month and 6-months post-legalization.Results: The sample (N = 429, 51% female, 55% non-Hispanic White, age mean = 56 ± 14.6) voted 58% in favor of state legalization of recreational cannabis use, with 26% opposed, and 16% abstained. Cannabis use in the past 30-days significantly increased from pre-legalization (17%) to 1-month post-legalization (21%; odds ratio (OR) = 1.28, p-value (p) = .01) and stayed elevated over pre-legalization levels at 6-months post-legalization (20%; OR = 1.28, p = .01). Exposure to others' cannabis use in the past 30 days did not change significantly over time: 41% pre-legalization, 44% 1-month post-legalization (OR = 1.18, p = .11), and 42% 6-months post-legalization (OR = 1.08, p = .61). Perceptions of health benefits of cannabis use increased from pre-legalization to 6-months post-legalization (OR = 1.19, p = .02). Younger adults, those with fewer years of education, and those reporting histories of depression were more likely to report recent cannabis use pre- and post-legalization. Other mental illness was associated with cannabis use at post-legalization only. In a multivariate GEE adjusted for sociodemographic characteristics and diagnoses, favoring legalization and the interaction of time and positive health perceptions were associated with a greater likelihood of using cannabis.Conclusions: Legalized recreational cannabis use was associated with greater self-reported past 30-day use post-legalization, and with more-positive health perceptions of cannabis use. Future research is needed to examine longer-term perceptions and behavioral patterns following legalization of recreational cannabis use, especially among those with mental illness. [ABSTRACT FROM AUTHOR]

Background: Idiopathic pulmonary fibrosis (IPF) is a rare, chronic lung disease associated with substantial symptom burden, morbidity, and cost. Delivery of high-quality effective care in IPF requires understanding health-care resource utilization (HRU) patterns; however, longitudinal data from real-world populations are limited.Research Question: This study aimed to define HRU attributable to IPF by evaluating a longitudinal cohort of community patients with IPF compared with matched control subjects.Study Design and Methods: Incident IPF cases were identified in the Kaiser Permanente Northern California electronic health records (2000-2015) using case-validated code-based algorithms. IPF cases were compared with matched control subjects by age, sex, and length of enrollment. Annual rates of HRU measures were assessed during the 5 years pre- and postdiagnosis. Poisson generalized estimating equations were used to estimate adjusted case-control differences in HRU. IPF treatment trends were assessed before and after the availability of IPF-specific medications.Results: A total of 691 IPF cases were identified and matched with 3,452 control subjects. Adjusted rates of all diagnostic procedures were significantly increased (P < .001) for IPF cases compared with control subjects in both the pre- and postindex periods, including chest CT scans (pre-relative risk [RR], 80.35; post-RR, 32.79), 6-min walk tests (pre-RR, 20.81; post-RR, 34.49), and pulmonary function tests (pre-RR, 9.50; post-RR, 13.24). All-cause hospitalizations (pre-RR, 1.42; post-RR, 2.33) and outpatient visits (pre-RR, 1.22; post-RR, 1.80) were significantly higher among cases compared with control subjects during both the preindex (P < .05) and postindex (P < .001) periods. We observed use of immunosuppressive and IPF-specific therapies prior to diagnosis, and high rates of corticosteroid use before and after diagnosis.Interpretation: This study defines a marked increase in HRU in patients with IPF compared with control subjects, with accelerated use beginning at least 1 year prediagnosis and elevated use sustained over the following 5 years. To our knowledge, this is the first study to evaluate longitudinal medication trends in IPF. Collectively, this information is foundational to advancing IPF care delivery models and supporting clinical decision-making. [ABSTRACT FROM AUTHOR]

Wildfires have been increasing in frequency in the western United States (US) with the 2017 and 2018 fire seasons experiencing some of the worst wildfires in terms of suppression costs and air pollution that the western US has seen. Although growing evidence suggests respiratory exacerbations from elevated fine particulate matter (PM 2.5) during wildfires, significantly less is known about the impacts on human health of ozone (O 3) that may also be increased due to wildfires. Using machine learning, we created daily surface concentration maps for PM 2.5 and O 3 during an intense wildfire in California in 2008. We then linked these daily exposures to counts of respiratory hospitalizations and emergency department visits at the ZIP code level. We calculated relative risks of respiratory health outcomes using Poisson generalized estimating equations models for each exposure in separate and mutually-adjusted models, additionally adjusted for pertinent covariates. During the active fire periods, PM 2.5 was significantly associated with exacerbations of asthma and chronic obstructive pulmonary disease (COPD) and these effects remained after controlling for O 3. Effect estimates of O 3 during the fire period were non-significant for respiratory hospitalizations but were significant for ED visits for asthma (RR = 1.05 and 95% CI = (1.022, 1.078) for a 10 ppb increase in O 3). In mutually-adjusted models, the significant findings for PM 2.5 remained whereas the associations with O 3 were confounded. Adjusted for O 3 , the RR for asthma ED visits associated with a 10 μg/m3 increase in PM 2.5 was 1.112 and 95% CI = (1.087, 1.138). The significant findings for PM 2.5 but not for O 3 in mutually-adjusted models is likely due to the fact that PM 2.5 levels during these fires exceeded the 24-hour National Ambient Air Quality Standard (NAAQS) of 35 μg/m3 for 4976 ZIP-code days and reached levels up to 6.073 times the NAAQS, whereas our estimated O 3 levels during the fire period only occasionally exceeded the NAAQS of 70 ppb with low exceedance levels. Future studies should continue to investigate the combined role of O 3 and PM 2.5 during wildfires to get a more comprehensive assessment of the cumulative burden on health from wildfire smoke. • Ozone was associated with respiratory ED visits during a wildfire, but associations disappeared when adjusted for PM 2.5 • PM 2.5 was associated with respiratory ED visits and hospitalizations during a wildfire period even when adjusted for ozone. • Our findings may be context specific; other wildfire-health studies should examine other air pollutants besides PM 2.5 [ABSTRACT FROM AUTHOR]

Thirty-day readmission after congenital heart surgery (CHS) is an important outcome given the vulnerability of pediatric patients. We hypothesized that readmissions after pediatric CHS are common and identifiable risk factors exist. We obtained State Inpatient Databases for Washington, New York, Florida, and California and selected CHS admissions age < 19 years. The main outcome was readmission defined as non-elective hospitalization < 31 days of discharge from index CHS admission. In multivariable analyses using generalized estimating equations, we examined associations of patient-level characteristics (age, sex, race, household income, insurance status, genetic syndromes, co-morbidities, RACHS-1 surgical risk category and complication) and admission characteristics [weekend admission, urgent/emergent admission, and high resource use (HRU)] with 30-day pediatric readmission after adjusting for case mix. Among 8585 index admissions we identified 967 readmissions (11.3%). Median length of stay for readmissions was 5 days, median total charge of $31,973, and mortality rate 1.8%. Among readmissions, 1.7% underwent another CHS of which 44% were HRU, complication rate 88% and mortality 6.25%. In multivariable analysis, age 1 month–1 year AOR 1.3 p = 0.01; Hispanic ethnicity AOR 1.2 p = 0.03; government-insurance AOR 1.3 p = 0.01; RACHS-1 3 complexity AOR 2.4 p < 0.001; RACHS-1 4 + complexity 2.0 p = 0.001; HRU AOR 1.4 p = 0.02; complications AOR 1.1 p = 0.04; and emergent index admission AOR 2.0 p < 0.001 were risk factors for readmission. Over 11% of pediatric CHS admissions result in an unplanned readmission. Hispanic ethnicity, government insurance, HRU admissions, higher case complexity, complications, and emergent index admission are risk factors for readmission. [ABSTRACT FROM AUTHOR]

Traffic related air pollution (TRAP) is associated with a complex and diverse array of health effects. It is unknown whether these effects may be reflected by higher health care costs. Evaluate the association between TRAP exposure and direct health care costs in an elderly population. This multi-ethnic population-based cohort of 25,684 elderly subjects, served by Kaiser Permanente Northern California (KPNC), were followed between 2013 and 2017. Hyperlocal long-term pollutant concentrations for nitrogen dioxide [NO 2 ], nitric oxide [NO], and black carbon [BC] were measured at a resolution of 30 m using repeated street-level mobile measurements and linked to residential addresses. Health care utilization and costs were derived from KPNC databases and were used to calculate individual annual total health care, inpatient, outpatient, and emergency room (ER) and pharmacy costs. The associations between TRAP exposures and health care costs were evaluated using generalized estimating equation models adjusted for age, sex, race, BMI, smoking, SES and comorbidities. Subgroup analyses and interaction models were used to assess differences among specific susceptible population subgroups. An IQR difference (10.1 ppb vs 4.2 ppb) in NO 2 concentration was associated with a 3% (95% CI: -1%, 6%), 22% (95% CI:11%, 35%), and 5% (95% CI:1%, 8%) increase in annual total health care, ER and outpatient costs in the baseline model. Associations with black carbon showed similar patterns but were smaller in magnitude. Among those with cardiovascular diseases, an IQR increase in NO 2 was associated with a 7% (95% CI: 1%, 13%) increase in total annual health care cost and 23% (95% CI: 17%, 29%) increase in ER costs. Higher long-term TRAP exposure was associated with higher direct annual health care cost in this elderly cohort. Those with existing cardiovascular disease had particularly strong associations between TRAP exposure and direct annual health care costs. • Traffic related air pollution was associated with health care costs. • The strongest associations were between nitrogen dioxide and emergency room costs. • Effects were more pronounced among those with existing cardiovascular disease. [ABSTRACT FROM AUTHOR]

Background: Although multiple professional organizations encourage minimally invasive surgical approaches whenever feasible, nationally, fewer than half of myomectomies are performed via minimally invasive routes. Black women are less likely than their non-Black counterparts to have minimally invasive surgery.Objective: This study aimed to assess the trends in surgical approach among women who underwent minimally invasive myomectomies for uterine leiomyomas within a large integrated healthcare system as initiatives were implemented to encourage minimally invasive surgery, particularly evaluating differences in the proportion of minimally invasive surgery performed in Black vs non-Black women.Study Design: We conducted a retrospective cohort study of women, aged ≥18 years, who underwent a myomectomy for a uterine leiomyoma within Kaiser Permanente Northern California between 2009 and 2019. Generalized estimating equations and Cochran-Armitage testing were used to assess myomectomy incidence and linear trend in the proportions of myomectomy by surgical route-abdominal myomectomy and minimally invasive myomectomy. Multivariable logistic regression analyses were used to assess the associations between surgical route and (1) race and ethnicity and (2) complications, controlling for patient demographic, clinical, and surgical characteristics.Results: A total of 4033 adult women underwent a myomectomy during the study period. Myomectomy incidence doubled from 0.12 (95% confidence interval, 0.12-0.13) per 1000 women in 2009 to 0.25 (95% confidence interval, 0.24-0.25) per 1000 women in 2019 (P<.001). During the 11-year study period, the proportion of minimally invasive myomectomy increased from 6.0% to 89.5% (a 15-fold increase). The proportion of minimally invasive myomectomy in Black women remained lower than in non-Black women (54.5% vs 64.7%; P<.001). Black women undergoing myomectomy were younger (36.4±5.6 vs 37.4±5.8 years; P<.001), had a higher mean fibroid weight (436.0±505.0 vs 324.7±346.1 g; P<.001), and had a higher mean body mass index (30.8±7.3 vs 26.6±5.9 kg/m2; P<.001) than their non-Black counterparts. In addition to patient race, surgery performed between 2016 and 2019 compared with surgery performed between 2009 and 2012 and higher surgeon volume compared with low surgeon volume were associated with an increased proportion of minimally invasive myomectomy (adjusted relative risks, 12.58 [95% confidence interval, 9.96-15.90] and 6.63 [95% confidence interval, 5.35-8.21], respectively). Black race and fibroid weight of >500 g each independently conferred lower rates of minimally invasive myomectomy. In addition, there was an interaction between race and fibroid weight such that Black women with a fibroid weight of ≤500 g or >500 g were both less likely to have minimally invasive myomectomy than non-Black women with a fibroid weight of ≤500 g (adjusted relative risks, 0.74 [95% confidence interval, 0.58-0.95] and 0.26 [95% confidence interval, 0.18-0.36], respectively). Operative, perioperative, and medical complications were low during the 11-year study period. In regression analyses, after controlling for race, age, fibroid weight, parity, low-income residence, body mass index, surgeon volume, and year of myomectomy, the risk of complications was not markedly different comparing abdominal myomectomy with minimally invasive myomectomy. Similar results were found comparing laparoscopic minimally invasive myomectomy with robotic-assisted minimally invasive myomectomy except for women who underwent laparoscopic minimally invasive myomectomy had a lower risk of experiencing any medical complications than those who underwent robotic-assisted minimally invasive myomectomy (adjusted relative risk, 0.27; 95% confidence interval, 0.09-0.83; P=.02).Conclusion: Within an integrated healthcare delivery system, although initiatives to encourage minimally invasive surgery were associated with a marked increase in the proportion of minimally invasive myomectomy, Black women continued to be less likely to undergo minimally invasive myomectomy than their non-Black counterparts. Race and fibroid weight alone did not explain the disparities in minimally invasive myomectomy. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Using statewide data, we evaluated whether the changing incidence of penile anomalies and hypospadias is reflected in the diverse California population of newborn males over the past 20 years. Methods: Discharge data from all California hospitals, prepared by the OSHPD (Sacramento, CA) was reviewed for the years 1985–2006 for male infant births with an ICD-9 code (752.6) for hypospadias, epispadias or other penile anomalies. Trends were examined by Generalized Estimation Equations for Poisson regression. Results: From 1985 to 2006, the birth incidence of newborn penile anomalies increased in California from 47 to 57 cases per 10,000 newborn discharges, yet the trend for hypospadias alone appears stable from 1997. The rates for penile anomalies in newborns increased 1.4% annually (p < 0.001). All racial/ethnic groups analyzed showed this increase (p < 0.001 for each). During the study period there was a 2% increase per year in plural births (p < 0.001). Interestingly, the rate of change in penile anomaly incidence was greater in males of plural births compared to their singleton cohorts (2% vs 1% annually) (p < 0.001). The birth incidence of cleft palate, another congenital anomaly known to be stable over time, remained unchanged over this period. Conclusions: From 1985 to 2006 in California the incidence of penile anomalies increased in a statistically significant manner, but the incidence of hypospadias appears stable for the last decade. Our data support the notion that different racial/ethnic groups have distinct incidences of penile anomaly formation and that an association with plural births appears to be present. [Copyright &y& Elsevier]

Abstract: California residents may experience the highest polybrominated diphenyl ether (PBDE) flame retardant exposures in the United States, the nation with the highest body burdens worldwide. It is hypothesized that Californians'' high exposures are due to the state''s strict furniture flammability standards. Ingestion of PBDE-contaminated dust, to which children may be particularly susceptible, is a dominant exposure pathway. Low-income populations may also face disparately high exposures due to the presence of older, deteriorated or poorly manufactured furniture treated with PBDEs. We collected up to two dust samples per home (54 samples total), several days apart, from low-income California households in the urban community of Oakland (n=13 homes) and the agricultural community of Salinas (n=15 homes). We measured BDE-47, BDE-99 and BDE-100, the major constituents of the penta-PBDE flame retardant formulation commonly used in furniture. All three PBDE congeners were detected in every sample with concentrations (loadings) ranging from 185 to 126,000ng/g (621–264,000ng/m2), 367–220,000ng/g (1550–457,000ng/m2), and 84–41,100ng/g (257–85,700ng/m2) for BDE-47, BDE-99 and BDE-100, respectively. Median concentrations (loadings) observed in Salinas homes for BDE-47, BDE-99 and BDE-100 were 3100ng/g (10,800ng/m2), 5480ng/g (19,500ng/m2), and 1060ng/g (3810ng/m2), respectively, and in Oakland homes 2780ng/g (10,700ng/m2), 4450ng/g (19,100ng/m2), and 1050ng/g (4000ng/m2), respectively. Maximum concentrations for BDE-47 and BDE-99 are the highest reported to date. Indoor concentrations and loadings did not significantly differ between communities; concentrations and loadings were strongly correlated between collections for all three congeners (Spearman rho=0.79–0.97, p<0.002). We estimated non-dietary ingestion of each congener for one child in each home (n=28 children) and found that estimated intake for BDE-47 and BDE-99 exceeded the U.S. Environmental Protection Agency''s recommended chronic reference dose for three and five children, respectively. Children''s estimated intake via dust ranged from 1.0 to 599ng/kg/day, 2.0–1065ng/kg/day and 0.5–196ng/kg/day for BDE-47, BDE-99 and BDE-100, respectively. In order to mitigate these exposures, future research must address the factors that contribute to PBDE exposures in low-income homes. [Copyright &y& Elsevier]

There are many determinants of children's dental caries. We hypothesized that a mother's untreated caries was associated with increased likelihood of her children's untreated caries, after controlling for other factors. This population-based study was conducted in a rural, primarily Hispanic, California community. Interview and dental examination data for mother-child (children < 18 yrs old) dyads were analyzed. In a Generalized Estimation Equation (GEE) logit model for mothers (n = 179) and children (n = 387), maternal untreated caries was a statistically significant correlate of children's untreated caries, odds ratio (OR) = 1.76 (95%CI: 1.10, 2.70), adjusted for demographic factors. This relationship did not change when behavioral and dental utilization factors were added to the model, OR = 1.85 (95%CI: 1.12, 3.07). Maternal untreated caries almost doubled the odds of children's untreated caries and significantly increased child's caries severity by about 3 surfaces. Caries prevention and dental utilization programs for mothers and their children should be increased. [ABSTRACT FROM AUTHOR]

The empirical impact of housing costs on commuting is still relatively poorly understood. This impact is especially salient in California given the state's notoriously high housing costs, which have forced many lower- and middle-class households to move inland in search of affordable housing at the cost of longer commutes. To investigate this linkage, we relied on Generalized Structural Equation Modeling and analyzed 2012 CHTS data for Los Angeles County – the most populous county in the U.S. Our model, which jointly explains commuting distance and time, accounts for residential self-selection and car use endogeneity, while controlling for household characteristics and land use around residences and workplaces. We find that households who can afford more expensive neighborhoods have shorter commute distances (−2.3% and − 3.1% per additional $100 k to median home values around workplaces and residences respectively). Job density, distance to the CBD, and land-use diversity around workplaces have a relatively greater impact on commuting than the corresponding variables around commuters' residences. Compared to non-Hispanics, Hispanic workers commute longer distances (+3.5%), and so do African American (+5.1%) and Asian (+2.0%) workers compared to Caucasians, while college educated workers have shorter (−2.6% to −3.6%) commutes. Furthermore, commuters in the top income brackets tend to have faster commutes than lower income workers. Finally, women's commutes are ~41% shorter than men's, possibly because they are balancing work with domestic responsibilities. Better understanding the determinants of commuting is critical to inform housing and transportation policy, improve the health of commuters, reduce air pollution, and achieve climate goals. • We jointly analyze the impact on commuting time and distance of housing costs. • Our data come from the 2012 CHTS for Los Angeles County, the largest in the US. • We estimate a generalized structural equations model. • Households who reside in expensive neighborhoods have shorter commuting distances. • Hispanics, African Americans, and Asian have longer commutes than Whites. [ABSTRACT FROM AUTHOR]

Objective: To examine trends and correlates of frequency of self-reported alcohol and nicotine use among pregnant women.Methods: Cross-sectional study of 363,240 pregnancies from 2009 to 2017 screened for self-reported substance use at their first prenatal visit in Kaiser Permanente Northern California. Poisson regression with a log link function was used to estimate the annual prevalences of self-reported daily, weekly, and ≤ monthly alcohol and nicotine use, adjusting for socio-demographics. Generalized estimating equation models were used to estimate the adjusted odds ratios (aOR) of any self-reported prenatal alcohol or nicotine use among those who self-reported use in the year prior to pregnancy, by frequency of pre-pregnancy substance use and socio-demographics.Results: The sample was 64 % non-White [mean (SD) age = 30.1 (5.6)]. From 2009-2017, alcohol use before pregnancy increased from 63.4%-65.9% (trend p-value = .008), and prenatal alcohol use decreased from 11.6%-8.8% (trend p-value<.0001). Nicotine use before pregnancy decreased from 12.7 % to 7.7 % (trend p-value<.0001), and prenatal use decreased from 4.3 % to 2.0 % (trend p-value<.0001). Trends by use frequency were similar to overall trends. The odds of continued use of alcohol and nicotine during pregnancy were higher among those who used daily or weekly (versus monthly or less) in the year before pregnancy and varied with socio-demographics.Discussion: Prenatal alcohol and nicotine use decreased from 2009 to 2017. More frequent pre-pregnancy use predicted higher odds of prenatal use. Results suggest that interventions and education about the harms of prenatal substance use for frequent users prior to conception may reduce substance use during pregnancy. [ABSTRACT FROM AUTHOR]

Background: Eliminating persistent racial/ethnic disparities in maternal mortality and morbidity is a public health priority. National strategies to improve maternal outcomes are increasingly focused on quality improvement collaboratives. However, the effectiveness of quality collaboratives for reducing racial disparities in maternity care is understudied.Objective: To evaluate the impact of a hemorrhage quality-improvement collaborative on racial disparities in severe maternal morbidity from hemorrhage.Study Design: We conducted a cross-sectional study from 2011 to 2016 among 99 hospitals that participated in a hemorrhage quality improvement collaborative in California. The focus of the quality collaborative was to implement the national maternal hemorrhage safety bundle consisting of 17 evidence-based recommendations for practice and care processes known to improve outcomes. This analysis included 54,311 women from the baseline period (January 2011 through December 2014) and 19,165 women from the postintervention period (October 2015 through December 2016) with a diagnosis of obstetric hemorrhage during delivery hospitalization. We examined whether racial/ethnic-specific severe maternal morbidity rates in these women with obstetric hemorrhage were reduced from the baseline to the postintervention period. In addition, we conducted Poisson Generalized Estimating Equation models to estimate relative risks and 95% confidence intervals for severe maternal morbidity comparing each racial/ethnic group with white.Results: During the baseline period, the rate of severe maternal morbidity among women with hemorrhage was 22.1% (12,002/54,311) with the greatest rate observed among black women (28.6%, 973/3404), and the lowest among white women (19.8%, 3124/15,775). The overall rate fell to 18.5% (3553/19,165) in the postintervention period. Both black and white mothers benefited from the intervention, but the benefit among black women exceeded that of white women (9.0% vs 2.1% absolute rate reduction). The baseline risk of severe maternal morbidity was 1.34 times greater among black mothers compared with white mothers (relative risk, 1.34; 95% confidence interval, 1.27-1.42), and it was reduced to 1.22 (1.05-1.40) in the postintervention period. Sociodemographic and clinical factors explained a part of the black-white differences. After controlling for these factors, the black-white relative risk was 1.22 (95% confidence interval, 1.15-1.30) at baseline and narrowed to 1.07 (1.92-1.24) in the postintervention period. Results were similar when excluding severe maternal morbidity cases with transfusion alone. After accounting for maternal risk factors, the black-white relative risk for severe maternal morbidity excluding transfusion alone was reduced from a baseline of 1.33 (95% confidence interval, 1.16-1.52) to 0.99 (0.76-1.29) in the postintervention period. The most important clinical risk factor for disparate black rates for both severe maternal morbidity and severe maternal morbidity excluding transfusion alone was cesarean delivery, potentially providing another opportunity for quality improvement.Conclusion: A large-scale quality improvement collaborative reduced rates of severe maternal morbidity due to hemorrhage in all races and reduced the performance gap between black and white women. Improving access to highly effective treatments has the potential to decrease disparities for care-sensitive acute hospital-focused morbidities. [ABSTRACT FROM AUTHOR]

Background: Data from controlled laboratory experiments in adults indicate that the subjective effects of cannabis vary by administration method (e.g., combustible, vaporized). Whether the subjective effects of cannabis experienced in the natural ecology and among adolescents differ by cannabis administration method is unknown. In this observational study, adolescents' retrospective reports of subjective effects after combustible, edible, and vaporized cannabis use were examined.Methods: Students from ten public schools in Los Angeles, CA, USA (M[SD] age = 16.1 [.43] years) who reported past 6-month use of combustible, edible, or vaporized cannabis (N = 584) were surveyed on subjective effects experienced after use (yes/no). They were provided with a 12 item self-report checklist of six positive (e.g., relaxed, energetic) and six negative (e.g., drowsy, lazy) subjective effects. For each method of administration, affirmative responses were summed in positive (range: 0-6) and negative (range: 0-6) effect composite scores.Results: Generalized estimating equations adjusted for demographics and recent cannabis use revealed a graded pattern of differences in positive subjective effects across products, with highest scores for combustible (M[SD] = 3.98[1.76]), followed by edible (M[SD] = 3.58 [2.04]) and vaporized (M[SD] = 3.11 [2.21]) cannabis (all pairwise cross-product contrasts p < .01). Mean negative effect score was highest for edible (M[SD] = 2.27 [1.95]), followed by combustible (M[SD] = 1.94 [1.66]), and vaporized (M[SD] = 1.34 [1.73]) cannabis, respectively (all pairwise contrasts p < .02).Conclusion: Adolescents' reports of subjective effects varied across cannabis administration methods. Combustible cannabis' more desirable subjective effects profile might be indicative of higher abuse liability. [ABSTRACT FROM AUTHOR]

Methods for multiple informants help to estimate the marginal effect of each multiple source predictor and formally compare the strength of their association with an outcome. We extend multiple informant methods to the case of hierarchical data structures to account for within cluster correlation. We apply the proposed method to examine the relationship between features of the food environment near schools and children's body mass index z-scores (BMIz). Specifically, we compare the associations between two different features of the food environment (fast food restaurants and convenience stores) with BMIz and investigate how the association between the number of fast food restaurants or convenience stores and child's BMIz varies across distance from a school. The newly developed methodology enhances the types of research questions that can be asked by investigators studying effects of environment on childhood obesity and can be applied to other fields., (Copyright © 2013 John Wiley & Sons, Ltd.)