Multiple Dimensions of Environmental Justice and Oil and Gas Development in Pennsylvania

Background

Community socioeconomic deprivation (CSD) may be related to higher oil and natural gas development (OGD) exposure. We tested for distributive and benefit-sharing environmental injustice in Pennsylvania's Marcellus Shale by examining (1) whether OGD and waste disposal occurred disproportionately in more deprived communities and (2) discordance between the location of land leased for OGD and where oil and gas rights owners resided.

Materials and Methods

Analyses took place at the county subdivision level and considered OGD wells, waste disposal, and land lease agreement locations from 2005 to 2019. Using 2005-2009 American Community Survey data, we created a CSD index relevant to community vulnerability in suburban/rural areas.

Results

In adjusted regression models accounting for spatial dependence, we observed no association between the CSD index and conventional or unconventional drilled well presence. However, a higher CSD index was linearly associated with odds of a subdivision having an OGD waste disposal site and receiving a larger volume of waste. A higher percentage of oil and gas rights owners lived in the same county subdivision as leased land when the community was least versus most deprived (66% vs. 56% in same county subdivision), suggesting that individuals in more deprived communities were less likely to financially benefit from OGD exposure.

Discussion and Conclusions

We observed distributive environmental injustice with respect to well waste disposal and benefit-sharing environmental injustice related to oil and rights owner's residential locations across Pennsylvania's Marcellus Shale. These results add evidence of a disparity between exposure and benefits resulting from OGD.

Contribution of arsenic and uranium in private wells and community water systems to urinary biomarkers in US adults: The Strong Heart Study and the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Chronic exposure to inorganic arsenic (As) and uranium (U) in the United States (US) occurs from unregulated private wells and federally regulated community water systems (CWSs). The contribution of water to total exposure is assumed to be low when water As and U concentrations are low.

OBJECTIVE

We examined the contribution of water As and U to urinary biomarkers in the Strong Heart Family Study (SHFS), a prospective study of American Indian communities, and the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective study of racially/ethnically diverse urban U.S. communities.

METHODS

We assigned residential zip code-level estimates in CWSs (µg/L) and private wells (90th percentile probability of As >10 µg/L) to up to 1485 and 6722 participants with dietary information and urinary biomarkers in the SHFS (2001-2003) and MESA (2000-2002; 2010-2011), respectively. Urine As was estimated as the sum of inorganic and methylated species, and urine U was total uranium. We used linear mixed-effects models to account for participant clustering and removed the effect of dietary sources via regression adjustment.

RESULTS

The median (interquartile range) urine As was 5.32 (3.29, 8.53) and 6.32 (3.34, 12.48) µg/L for SHFS and MESA, respectively, and urine U was 0.037 (0.014, 0.071) and 0.007 (0.003, 0.018) µg/L. In a meta-analysis across both studies, urine As was 11% (95% CI: 3, 20%) higher and urine U was 35% (5, 73%) higher per twofold higher CWS As and U, respectively. In the SHFS, zip-code level factors such as private well and CWS As contributed 46% of variation in urine As, while in MESA, zip-code level factors, e.g., CWS As and U, contribute 30 and 49% of variation in urine As and U, respectively.

IMPACT STATEMENT

We found that water from unregulated private wells and regulated CWSs is a major contributor to urinary As and U (an estimated measure of internal dose) in both rural, American Indian populations and urban, racially/ethnically diverse populations nationwide, even at levels below the current regulatory standard. Our findings indicate that additional drinking water interventions, regulations, and policies can have a major impact on reducing total exposures to As and U, which are linked to adverse health effects even at low levels.

Epidemiologic roadblocks in studying elongated mineral particles and mesothelioma risk

Elongated mineral particles (EMPs) are a type of both occupational and environmental exposures that have generated interest in the scientific community due to their potential health effects. Their possible association with mesothelioma represents an area of concern. We provide an overview of the current challenges around epidemiological assessments of EMP exposure and mesothelioma risk, including methodological aspects that need to be addressed when designing and analyzing a study on EMP exposure and mesothelioma. Future work is needed to investigate the relationship between EMPs and mesothelioma, focused on an improved definition of EMP exposure and accounting for other concomitant sources of carcinogen exposure.

Geospatial Assessment of Racial/Ethnic Composition, Social Vulnerability, and Lead Water Service Lines in New York City

BACKGROUND

The state of New York expects to receive $ 115  million in 2022 alone from the U.S. Infrastructure Investment and Jobs Act to support the replacement of lead water service lines.

OBJECTIVES

Our objective was to determine the number and proportion of potential lead water service lines across New York City (NYC) and to evaluate the association between census tract-level racial/ethnic composition, housing vulnerability, and child lead exposure vulnerability with service line type (Potential Lead, Unknown) for n = 2,083 NYC tracts.

METHODS

We conducted a descriptive analysis assessing water service line material recorded in the NYC Department of Environmental Protection's Lead Service Line Location Coordinates database. We used conditional autoregressive Bayesian Poisson models to assess the relative risk [RR; median posterior estimates, and 95% credible interval (CrI)] of service line type per 20% higher proportion of residents in a given racial/ethnic group and per higher housing vulnerability and child lead exposure vulnerability index scores corresponding to the interquartile range. We also evaluated the associations in flexible natural cubic spline models.

RESULTS

Out of 854,672 residential service line records, 136,891 (16.0%) were Potential Lead, and 227,443 (26.6%) were Unknown. In fully adjusted models, higher proportions of Hispanic/Latino residents and higher child lead exposure vulnerability were associated with Potential Lead service lines in flexible spline models and linear models [RR = 1.15 (95% CrI: 1.11, 1.21) and RR = 1.11 (95% CrI: 1.02, 1.20), respectively]. Associations were modified by borough; Potential Lead service lines were associated with higher proportions of non-Hispanic White and non-Hispanic Asian residents in the Bronx and Manhattan, and with higher proportions of non-Hispanic Black residents in Queens.

DISCUSSION

NYC has a high number of Potential Lead and Unknown water service lines. Communities with a high proportion of Hispanic/Latino residents and those with children who are already highly vulnerable to lead exposures from numerous sources are disproportionately impacted by Potential Lead service lines. These findings can inform equitable service line replacement across New York state and NYC. https://doi.org/10.1289/EHP12276.

Addressing Public Health Aspects of Cancer Center Catchment Areas

Serving the catchment area has become an integral mission of cancer centers, and examining the geographic extent of cancer coverage is an important component aimed at efficiently maximizing care and reducing the cancer burden. In addition to cancer incidence and mortality, geographic analyses of cancer center coverage must also be measured by the need for reducing the prevalence of risk factors and increasing screening rates within communities. Here, we briefly comment on these additional parameters and their relevance to analyzing cancer coverage across the United States. See related article by Leader et al., p. 955.

The impact of climate change on the prevalence of mental illness symptoms

BACKGROUND

The repercussions of climate change threaten the population with an increased prevalence of extreme climate events. We explored the impact of climate change induced sea level rise (SLR) and tropical cyclone (TC) exposure on mental illness symptom prevalence.

METHODS

Using three datasets, TC exposure scores were calculated for each subject to determine how exposure affects posttraumatic stress disorder (PTSD), anxiety, and major depressive disorder (MDD) symptom prevalence. Inundation mapping of various SLR and storm surge (SS) scenarios were performed for the susceptible region of Miami-Dade and Broward counties to determine the population impact of flooding.

RESULTS

We found an elevated risk of mental illness symptoms from exposure to more high- intensity TCs and identified demographic variables that may contribute to this risk. Furthermore, inundation mapping demonstrated severe and widespread impact of SLR and SS on the mental health of communities.

LIMITATIONS

This study did not include data directly measuring comorbidity, resilience, preparedness, or ability to adapt to climate change. Also, multiple imputation using chained equations may have been imperfect. Furthermore, there is uncertainty in predicting and mapping SLR and TC intensity, which limits complete confidence in our SS predictions.

CONCLUSION

The impacts of climate change have been frequently studied in terms of physical health, natural disaster prevalence, and economic impacts, but rarely on mental health burden. However, it is vital that national, state, and local governments develop and deploy plans to address mental health needs along with expenditures for protecting infrastructure, the economy, and physical health from the combined effects of SLR and climate change-induced natural disasters.

Socioeconomic Disparities in Severe Acute Respiratory Syndrome Coronavirus 2 Serological Testing and Positivity in New York City

Background

We characterized severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody test prevalence and positive test prevalence across New York City (NYC) in order to investigate disparities in testing outcomes by race and socioeconomic status (SES).

Methods

Serologic data were downloaded from the NYC Coronavirus data repository (August 2020–December 2020). Area-level characteristics for NYC neighborhoods were downloaded from United States census data and a socioeconomic vulnerability index was created. Spatial generalized linear mixed models were performed to examine the association between SES and antibody testing and positivity.

Results

The proportion of Hispanic population (posterior median, 0.001 [95% credible interval, 0.0003–0.002]), healthcare workers (0.003 [0.0001–0.006]), essential workers (0.003 [0.001–0.005]), age ≥65 years (0.003 [0.00002–0.006]), and high SES (SES quartile 3 vs 1: 0.034 [0.003–0.062]) were positively associated with antibody tests per 100000 residents. The White proportion (–0.002 [–0.003 to –0.001]), SES index (quartile 3 vs 1, –0.068 [–0.115 to –0.017]; quartile 4 vs 1, –0.077 [–0.134 to –0.018]) and age ≥65 years (–0.005 [–0.009 to –0.002]) were inversely associated with positive test prevalence (%), whereas the Hispanic (0.004 [0.002–0.006]) and essential worker (0.008 [0.003–0.012]) proportions had positive coefficients.

Conclusions

Disparities in serologic testing and seropositivity exist on SES and race/ethnicity across NYC, indicative of excess coronavirus disease burden in vulnerable and marginalized populations.

Mental Health Effects of Hurricane Sandy on Older Adults

OBJECTIVES

To examine whether hurricane exposure, lack of access to medical care (LAMC), and displacement during Hurricane Sandy were associated with PTSD and other mental health (MH) symptoms among older adult New York residents.

METHODS

Participants (N = 411) were ≥60 years old at the time of survey data collection (1-4 years post-Sandy). Outcomes included PTSD, depression, and anxiety symptoms and stress. Hurricane exposure, displacement, and LAMC were primary predictors.

RESULTS

Older adults with greater hurricane exposure had increased PTSD, anxiety, and stress symptoms. LAMC had a strong association (ORadj = 4.11) with PTSD symptoms but was not associated with other MH symptoms. Displacement was not associated with MH outcomes.

DISCUSSION

This is the first study to examine exposure, displacement, and LAMC together and to examine their varying impacts on different MH outcomes among older adults post-hurricane. Findings support the importance of disaster preparedness interventions tailored to the MH needs of community-dwelling older adults.

Analyzing disparities in COVID-19 testing trends according to risk for COVID-19 severity across New York City

BACKGROUND

Given the interplay between race and comorbidities on COVID-19 morbidity and mortality, it is vital that testing be performed in areas of greatest need, where more severe cases are expected. The goal of this analysis is to evaluate COVID-19 testing data in NYC relative to risk factors for COVID-19 disease severity and demographic characteristics of NYC neighborhoods.

METHODS

COVID-19 testing and the racial/ethnic composition of NYC Zip Code Tabulation Areas (ZCTA) were obtained from the NYC Coronavirus data repository and the American Community Survey, respectively. The prevalence of neighborhood-level risk factors for COVID-19 severity according to the Centers for Disease Control and Prevention criteria for risk of severe illness and complications from COVID-19 were used to create a ZCTA-level risk index. Poisson regressions were performed to study the ratio of total tests relative to the total ZCTA population and the proportion of positive tests relative to the total tests performed over time.

RESULTS

From March 2nd-April 6th, the total tests/population (%) was positively associated with the proportion of white residents (IRR_adj: 1.0003, 95% CI: 1.0003-1.0004) and the COVID risk index (IRR_adj: 1.038, 95% CI: 1.029-1.046). The risk index (IRR_adj: 1.017, 95% CI: 0.939-1.101) was not associated with total tests performed from April 6th-May 12th, and inversely associated from May 12th-July 6th (IRR_adj: 0.862, 95% CI: 0.814-0.913). From March 2nd-April 6th the COVID risk index was not statistically associated (IRR_adj: 1.010, 95% CI: 0.987-1.034) with positive tests/total tests. From April 6th-May 12th, the COVID risk index was positively associated (IRR_adj: 1.031, 95% CI: 1.002-1.060), while from May 12th-July 6th, the risk index was inversely associated (IRR_adj: 1.135, 95% CI: 1.042-1.237) with positivity.

CONCLUSIONS

Testing in NYC has suffered from the lack of availability in high-risk populations, and was initially limited as a diagnostic tool for those with severe symptoms, which were mostly concentrated in areas where vulnerable residents live. Subsequent time periods of testing were not targeted in areas according to COVID-19 disease risk, as these areas still experience more positive tests.

Unequal social vulnerability to Hurricane Sandy flood exposure

Disparities exist in post-disaster flooding exposure and vulnerable populations bear a disproportionate impact of this exposure. We describe the unequal burden of flooding in a cohort of New York residents following Hurricane Sandy and assess whether the likelihood of flooding was distributed equally according to socioeconomic demographics, and whether this likelihood differed when analyzing self-reported or FEMA flood exposure measures. Residents of New York City and Long Island completed a self-administered survey 1.5-4.0 years after the storm. Multivariable logistic regressions were performed to determine the relationship between sociodemographic characteristics and flood exposure. Participants (n = 1231) residing in areas of the lowest two quartiles of median household income experienced flooding the most often (FEMA/self-reported: <$40,298: 65.3%/42.0%, $40,298-$67,188: 43.3%/32.1%), and these areas contained the highest proportions of non-White participants (<$40,298: 39.1%, $40,298-$67,188: 36.6%) and those with ≤high school education (<$40,298: 35.5%, $40,298-$67,188: 33.6%). Both self-report (p < 0.05) and FEMA (p < 0.05) flood measures indicated that older participants were more likely to live in a household exposed to flooding, while those living in higher-income areas had decreased likelihood of flooding (p < 0.0001). Socioeconomic and age disparities were present in exposure to flooding during Hurricane Sandy. Future disaster preparedness responses must understand flooding from an environmental justice perspective to create effective strategies that minimize disproportionate exposure and its adverse outcomes.

A risk index for COVID-19 severity is associated with COVID-19 mortality in New York City

BACKGROUND

New York City (NYC) was the epicenter of the COVID-19 pandemic, and is home to underserved populations with higher prevalence of chronic conditions that put them in danger of more serious infection. Little is known about how the presence of chronic risk factors correlates with mortality at the population level. Here we determine the relationship between these factors and COVD-19 mortality in NYC.

METHODS

A cross-sectional study of mortality data obtained from the NYC Coronavirus data repository (03/02/2020-07/06/2020) and the prevalence of neighborhood-level risk factors for COVID-19 severity was performed. A risk index was created based on the CDC criteria for risk of severe illness and complications from COVID-19, and stepwise linear regression was implemented to predict the COVID-19 mortality rate across NYC zip code tabulation areas (ZCTAs) utilizing the risk index, median age, socioeconomic status index, and the racial and Hispanic composition at the ZCTA-level as predictors.

RESULTS

The COVID-19 death rate per 100,000 persons significantly decreased with the increasing proportion of white residents (βadj = - 0.91, SE = 0.31, p = 0.0037), while the increasing proportion of Hispanic residents (βadj = 0.90, SE = 0.38, p = 0.0200), median age (βadj = 3.45, SE = 1.74, p = 0.0489), and COVID-19 severity risk index (βadj = 5.84, SE = 0.82, p <  0.001) were statistically significantly positively associated with death rates.

CONCLUSIONS

Disparities in COVID-19 mortality exist across NYC and these vulnerable areas require increased attention, including repeated and widespread testing, to minimize the threat of serious illness and mortality.

Deferred Action for Childhood Arrivals (DACA) medical students - an examination of their journey and experiences as medical students in limbo

BACKGROUND

Although the value of DACA medical students has been hypothesized, no data are available on their contribution to US healthcare. While the exact number of DACA recipients in medical school is unknown, DACA medical students are projected to represent an increasing proportion of physicians in the future. The current literature on DACA students has not analyzed the experiences of these students.

METHODS

A mixed-methods study on the career intentions and experiences of DACA medical students was performed utilizing survey data and in-depth interviews. The academic performance of a convenience sample of DACA medical students was compared to that of matriculated medical students from corresponding medical schools, national averages, and first-year residents according to specialty.

RESULTS

Thirty-three DACA medical students completed the survey and five participated in a qualitative interview. The average undergraduate GPA (SD) of the DACA medical student sample was 3.7 (0.3), the same as the national GPA of 2017-2018 matriculated medical students. The most common intended residency programs were Internal Medicine (27.2%), Emergency Medicine (15.2%), and Family Medicine (9.1%). In interviews, DACA students discussed their motivation for pursuing medicine, barriers and facilitators that they faced in attending medical school, their experiences as medical students, and their future plans.

CONCLUSIONS

The intent of this sample to pursue medical specialties in which there is a growing need further exemplifies the unique value of these students. It is vital to protect the status of DACA recipients and realize the contributions that DACA physicians provide to US healthcare.

Socioeconomic disparities in incidents at toxic sites during Hurricane Harvey

BACKGROUND

Hurricane Harvey facilitated exposure to various toxic substances and floodwater throughout the greater Houston metropolitan area. Although disparities exist in this exposure and vulnerable populations can bear a disproportionate impact, no research has integrated disparities in exposure to toxic incidents following Hurricane Harvey.

OBJECTIVE

The objective of this study was to analyze the relationship between flooding, socioeconomic status (SES), and toxic site incidents.

METHODS

Data on toxic site locations, reported releases, and flood water depths during Hurricane Harvey in the greater Houston area were compiled from multiple sources. A multivariable logistic regression was performed to predict the odds of a toxic site release by flooding at the site, SES and racial composition of the census tract.

RESULTS

83 out of 1403 toxic sites (5.9%) had reported releases during Hurricane Harvey. The proportion of toxic sites with reported incidents across increasing SES index quintiles were 8.35, 7.67, 5.14, 4.55, and 0.51, respectively. The odds of an incident were lower in the highest SES quintile areas (OR_adj = 0.06, 95% CI: 0.01-0.42) compared to the lowest SES quintile. Flooding was similar at toxic sites with and without incidents, and was distributed similarly and highest at toxic sites located in lower SES quintiles.

SIGNIFICANCE

Despite similar flooding across toxic sites during Hurricane Harvey, areas with lower SES were more likely to have a toxic release during the storm, after accounting for number of toxic sites. Improving quality of maintenance, safety protocols, number of storm-resilient facilities may minimize this disproportionate exposure and its subsequent adverse outcomes among socioeconomically vulnerable populations.

Using Rapid Research Implementation and Collaborations to Assess the Mental Health Impact of the COVID-19 Pandemic Among Community and Clinical Cohorts

A research initiative was launched during the initial coronavirus disease (COVID-19) outbreak by 3 New York metropolitan area institutions. Collaborators recruited community members and patients from previous research studies to examine COVID-19 experiences and mental health symptoms through self-report surveys. The current report descriptively presents findings from the initial survey characterized by both community and clinical cohorts, and discusses challenges encountered with rapid implementation. The clinical cohort exhibited higher rates of symptoms of mental health difficulties (depression, anxiety, and posttraumatic stress disorder [PTSD]) as compared to the community cohort. COVID-19 positivity rates were similar among both groups and lower than the national average. While both groups reported low rates of job loss, community members reported higher rates of financial difficulty resulting from the pandemic. Findings indicate the need for further collaborative research on the mental health impact of COVID-19.

Update on human exposure to glyphosate, with a complete review of exposure in children

BACKGROUND

Glyphosate, a commonly used pesticide, has been the topic of much debate. The effects of exposure to glyphosate remains a contentious topic. This paper provides an update to the existing literature regarding levels of glyphosate exposure in occupationally exposed individuals and focuses or reviewing all the available published literature regarding glyphosate exposure levels in children.

METHODS

A literature review was conducted and any articles reporting quantifiable exposure levels in humans published since January 2019 (the last published review on glyphosate exposure) were reviewed and data extracted and standardized.

RESULTS

A total of five new studies reporting exposure levels in humans were found including 578 subjects. Two of these studies focused on occupationally exposed individuals while three of them focused on glyphosate exposure levels in children. Given the sparse nature of the new data, previously identified studies on exposure to glyphosate in children were included in our analysis of children's exposure. The lowest average level of glyphosate exposure reported was 0.28 μg/L and the highest average exposure levels reported was 4.04 μg/L.

CONCLUSION

The literature on glyphosate exposure levels, especially in children, remains limited. Without more data collected in a standardized way, parsing out the potential relationship between glyphosate exposure and disease will not be possible.

Clinical Course of Cancer Patients With COVID-19: A Retrospective Cohort Study

Background

Complications in cancer patients with coronavirus disease 2019 (COVID-19) have not been examined. This analysis aimed to compare characteristics of COVID-19 patients with and without cancer and assess whether cancer is associated with COVID-19 morbidity or mortality.

Methods

COVID-19-positive patients with an inpatient or emergency encounter at the Mount Sinai Health System between March 1, 2020, and May 27, 2020, were included and compared across cancer status on demographics and clinical characteristics. Multivariable logistic regressions were used to model the associations of cancer with sepsis, venous thromboembolism, acute kidney injury, intensive care unit admission, and all-cause mortality.

Results

There were 5556 COVID-19-positive patients included, 421 (7.6%) with cancer (325 solid, 96 nonsolid). Those with cancer were statistically significantly older, more likely to be non-Hispanic Black and to be admitted to the hospital during their encounter, and had more comorbidities than noncancer COVID-19 patients. Cancer patients were statistically significantly more likely to develop sepsis (adjusted odds ratio [OR_adj] = 1.31, 95% confidence interval [CI] = 1.06 to 1.61) and venous thromboembolism (OR_adj = 1.77, 95% CI = 1.01 to 3.09); there was no statistically significant difference in acute kidney injury (OR_adj = 1.10, 95% CI = 0.87 to 1.39), intensive care unit admissions (OR_adj = 1.04, 95% CI = 0.80 to 1.34), or mortality (OR_adj = 1.02, 95% CI = 0.81 to 1.29).

Conclusions

COVID-19 patients with cancer may have a higher risk for adverse outcomes. Although there was no statistically significant difference in mortality, COVID-19 patients with cancer have statistically significantly higher risk of thromboembolism and sepsis. Further research is warranted into the potential effects of cancer treatments on inflammatory and immune responses to COVID-19 and on the efficacy of anticoagulant therapy in these patients.

Disparities in COVID-19 Testing and Positivity in New York City

INTRODUCTION

Existing socioeconomic and racial disparities in healthcare access in New York City have likely impacted the public health response to COVID-19. An ecological study was performed to determine the spatial distribution of COVID-19 testing by ZIP code Tabulation Area and investigate if testing was associated with race or SES.

METHODS

Data were obtained from the New York City coronavirus data repository and 2018 American Community Survey 5-year estimates. A combined index of SES was created using principal component analysis and incorporated household income, gross rent, poverty, education, working class status, unemployment, and occupants per room. Multivariable Poisson regressions were performed to predict the number of total tests and the ratio of positive tests to total tests performed, using the SES index, racial composition, and Hispanic composition as predictors.

RESULTS

The number of total tests significantly increased with the increasing proportion of white residents (β=0.004, SE=0.001, p=0.0032) but not with increasing Hispanic composition or SES index score. The ratio of positive tests to total tests significantly decreased with the increasing proportion of white residents in the ZIP code Tabulation Area (β= -0.003, SE=0.000 6, p<0.001) and with increasing SES index score (β= -0.001 6, SE=0.0007, p=0.0159).

CONCLUSIONS

In New York City, COVID-19 testing has not been proportional to need; existing socioeconomic and racial disparities in healthcare access have likely impacted public health response. There is urgent need for widespread testing and public health outreach for the most vulnerable communities in New York City.

Three months of informational trends in COVID-19 across New York City

In the midst of widespread community transmission of coronavirus disease 2019 (COVID-19) in New York, residents have sought information about COVID-19. We analyzed trends in New York State (NYS) and New York City (NYC) data to quantify the extent of COVID-19-related queries. Data on the number of 311 calls in NYC, Google Trend data on the search term 'Coronavirus' and information about trends in COVID-19 cases in NYS and the USA were compiled from multiple sources. There were 1228 994 total calls to 311 between 22 January 2020 and 22 April 2020, with 50 845 calls specific to COVID-19 in the study period. The proportion of 311 calls related to COVID-19 increased over time, while the 'interest over time' of the search term 'Coronavirus' has exponentially increased since the end of February 2020. It is vital that public health officials provide clear and up-to-date information about protective measures and crucial communications to respond to information-seeking behavior across NYC.

PD-L1 as a prognostic biomarker in surgically resectable non-small cell lung cancer: a meta-analysis

Background

PD-L1 tumor expression has been associated with poor prognosis in a variety of solid tumors, including lung cancer, and represents a validated target for immune checkpoint inhibition in advanced malignances. It remains unknown, however, if PD-L1 can be used to predict survival in early stage, surgically treated cancers. This meta-analysis compares PD-L1 tumor expression and long term survival after surgical resection in early non-small cell lung cancer (NSCLC).

Methods

PubMed was searched to identify eligible studies that compared survival of surgically resected stage I–III NSCLC patients according to PD-L1 tumor expression. Included studies were grouped according to measurement criteria of PD-L1 expression: 1%, 5%, 50% cutoffs or H-score. Meta-analysis was performed using a linear mixed-effects model to determine overall survival (OS). I² was used as a measure of heterogeneity.

Results

There were 40 eligible studies, including 10,380 patients. Regardless of cut-off used, higher PD-L1 tumor expression was associated with worse OS [hazard ratio (HR)_1%: 1.59, 95% confidence interval (CI), 1.17–2.17; HR_5%: 1.44, 95% CI, 1.03–2.00; HR_50%: 1.52, 95% CI, 1.02–2.25, HR_H-score: 1.34, 95% CI, 1.04–1.73]. Study heterogeneity was low and not statistically significant under all PD-L1 cutoffs.

Conclusions

PD-L1 expression is consistently associated with worse survival, regardless of how it is quantified. In addition to acting as a prognostic biomarker, PD-L1 may also be used in future as a predictive biomarker for patients most likely to benefit from adjuvant immunotherapy.

Effect of Insurance Type on Stage at Presentation, Surgical Approach, Tumor Recurrence and Cancer-Specific Survival in Resectable Non-Small Lung Cancer Patients

Purpose

The aim of this study was to identify the association between Thailand’s insurance types and stage at presentation, surgical approach, tumor recurrence and cancer-specific survival in resectable non-small cell lung cancer (NSCLC) patients in northern Thailand.

Patients and Methods

Medical records of patients with NSCLC who underwent pulmonary resection at Chiang Mai University Hospital from January 2007 through December 2015 were retrospectively reviewed. Patients were divided into two groups: patients with the Universal Coverage Scheme (UCS) or Social Security Scheme (SSS) and patients with the Civil Servant Medical Benefit Scheme (CSMBS) or private insurance (PI). Patient characteristics were assessed. The primary outcome was cancer-specific survival while the secondary outcome was tumor recurrence. Cox’s regression and matching propensity score analysis was used to analyze data.

Results

This study included 583 patients: 344 with UCS or SSS and 239 with CSMBS or PI. Patients with UCS or SSS were more likely to be active smokers, have a lower percent predicted FEV1, present with higher-stage tumors and worse differentiated tumors, present with tumor necrosis, and undergo an open surgical approach than those with CSMBS or PI. At multivariable analysis of all patients cohort, there were no significant differences in terms of early stage at presentation (adjusted odds ratio (OR_adj) = 0.94, 95% confidence interval (CI) = 0.65–1.37), undergoing lobectomy (OR_adj = 0.59, 95% CI = 0.24–1.46), and recurrent-free survival (adjusted hazard ratio (HR_adj) =1.20, 95% CI = 0.88–1.65) between groups (UCS/SSS versus CSMBS/PI). However, patients with UCS or SSS had shorter cancer-specific survival (HR_adj = 1.61, 95% CI = 1.22–2.15). The results from the propensity score matched patient cohort were not different from those analyses on the full patient cohort.

Conclusion

Thai insurance types have an effect on cancer-specific survival. The Thai government should recognize the importance of these differences, and further multi-center studies with a larger sample size are warranted to confirm this result.

Prognostic value of immune cells in the tumor microenvironment of early-stage lung cancer: a meta-analysis

BACKGROUND

Early-stage non-small cell lung cancer (NSCLC) patients carry significant risk of recurrence post-surgery. In-depth characterization of the immune tumor microenvironment (TME) can have prognostic value. This study aimed to evaluate the association of individual immune cell types in the TME with clinical outcomes in surgically resected, early-stage NSCLC.

METHODS

We performed a systematic literature search of the National Library of Medicine database through November 2019, investigating predefined biomarkers (CD3+ T cells, CD4+ T helper cells, CD8+ cytotoxic T cells, CD20+ B cells, CD56+ & CD57+ Natural Killer (NK) cells, CD68+ Tissue Associated Macrophages (TAMS), FoxP3+ T regulatory cells, and Mast Cells (MC)), and their association with survival following PRISMA guidelines.

RESULTS

Studies that adjusted for important clinical covariates (such as stage and age) showed that higher levels of CD8+ cytotoxic T cells were associated with improved OS (HR = 0.68; 95% CI, 0.50-0.93) and DFS (HR = 0.60; 95% CI, 0.41-0.87), while increased CD20+ B cells (HR = 0.16; 95% CI, 0.04-0.64) and CD 56/57+ NK cells (HR = 0.50; 95% CI, 0.26-0.95) were associated with improved OS; lung cancers with increased FoxP3+ T regulatory cells (HR = 2.22; 95% CI, 1.47-3.34) had worse OS.

CONCLUSIONS

Immune cell components of the TME have prognostic value in early-stage, surgically resected NSCLC, and may reveal which patients are more likely to need additional systemic treatment, including immunotherapy. Clinical covariates need to be considered when evaluating the prognostic value of immune cells in the TME.

Complementary biobank of rodent tissue samples to study the effect of World Trade Center exposure on cancer development

World Trade Center (WTC) responders were exposed to mixture of dust, smoke, chemicals and carcinogens. New York University (NYU) and Mount Sinai have recreated WTC exposure in rodents to observe the resulting systemic and local biological responses. These experiments aid in the interpretation of epidemiological observations and are useful for understanding the carcinogenesis process in the exposed human WTC cohort. Here we describe the implementation of a tissue bank system for the rodents experimentally exposed to WTC dust. NYU samples were experimentally exposed to WTC dust via intratracheal inhalation that mimicked conditions in the immediate aftermath of the disaster. Tissue from Mount Sinai was derived from genetically modified mice exposed to WTC dust via nasal instillation. All processed tissues include annotations of the experimental design, WTC dust concentration/dose, exposure route and duration, genetic background of the rodent, and method of tissue isolation/storage. A biobank of tissue from rodents exposed to WTC dust has been compiled representing an important resource for the scientific community. The biobank remains available as a scientific resource for future research through established mechanisms for samples request and utilization. Studies using the WTC tissue bank would benefit from confirming their findings in corresponding tissues from organs of animals experimentally exposed to WTC dust. Studies on rodent tissues will advance the understanding of the biology of the tumors developed by WTC responders and ultimately impact the modalities of treatment, and the probability of success and survival of WTC cancer patients.

Examining Associations Between Hurricane Sandy Exposure and Posttraumatic Stress Disorder by Community of Residence

Exposure to 2012's Hurricane Sandy differed by community across New York City and nearby Long Island, and the differential impact of exposure on mental health concerns must be studied to enhance resilience in vulnerable communities. We assessed the association between self-reported Hurricane Sandy exposure and subsequent posttraumatic stress disorder (PTSD) symptoms, obtained through validated questionnaires completed by residents of lower Manhattan (n = 1,134), Queens/Long Island (LI)/Staten Island (SI; n = 622), and the Rockaways (n = 1,011); mean assessment times were 7, 14, and 32 months post-Sandy, respectively. The median number of hurricane exposures was similar for all communities; however, Rockaways residents had a higher proportion of likely PTSD symptoms (18.8%) compared to lower Manhattan (8.0%) and Queens/LI/SI residents (5.8%). Regarding likely PTSD, there was significant interaction between total hurricane exposure and community, p = .002, and flooding and community, p = .040. Number of hurricane exposures was associated with higher odds of likely PTSD in Queens/LI/SI, AOR = 1.61, 95% CI [1.34, 1.94]; lower Manhattan, AOR = 1.43, 95% CI [1.28, 1.59]; and the Rockaways, AOR = 1.25, 95% CI [1.16, 1.35]. Flooding was associated with increased odds of likely PTSD in the Rockaways, AOR = 1.65, 95% CI [1.01, 2.69]; and Queens/LI/SI, AOR = 3.29, 95% CI [1.08, 10.00]. This study emphasizes the differential impact of hurricane exposure on subsequent PTSD symptoms in three communities affected by Hurricane Sandy. Future preparedness and recovery efforts must understand community correlates of mental health concerns to promote resilience in vulnerable communities.

Increased Incidence of Thyroid Cancer among World Trade Center First Responders: A Descriptive Epidemiological Assessment

An increased incidence of thyroid cancer among 9/11 rescue workers has been reported, the etiology of which remains unclear but which may, at least partly, be the result of the increased medical surveillance this group undergoes. This study aimed to investigate thyroid cancer in World Trade Center (WTC) responders by looking at the demographic data and questionnaire responses of thyroid cancer cases from the Mount Sinai WTC Health Program (WTCHP). WTCHP thyroid cancer tumors were of a similar size (p = 0.4), and were diagnosed at a similar age (p = 0.2) compared to a subset of thyroid cancer cases treated at Mount Sinai without WTC exposure. These results do not support the surveillance bias hypothesis, under which smaller tumors are expected to be diagnosed at earlier ages. WTCHP thyroid cancer cases also reported a past history of radiation exposure and a family history of thyroid conditions at lower rates than expected, with higher than expected rates of previous cancer diagnoses, family histories of other cancers, and high Body Mass Indexes (BMIs). Further research is needed to better understand the underlying risk factors that may play a role in the development of thyroid cancer in this group.

Spectroscopy can predict key leaf traits associated with source-sink balance and carbon-nitrogen status

Approaches that enable high-throughput, non-destructive measurement of plant traits are essential for programs seeking to improve crop yields through physiological breeding. However, many key traits still require measurement using slow, labor-intensive, and destructive approaches. We investigated the potential to retrieve key traits associated with leaf source-sink balance and carbon-nitrogen status from leaf optical properties. Structural and biochemical traits and leaf reflectance (500-2400 nm) of eight crop species were measured and used to develop predictive 'spectra-trait' models using partial least squares regression. Independent validation data demonstrated that the models achieved very high predictive power for C, N, C:N ratio, leaf mass per area, water content, and protein content (R2>0.85), good predictive capability for starch, sucrose, glucose, and free amino acids (R2=0.58-0.80), and some predictive capability for nitrate (R2=0.51) and fructose (R2=0.44). Our spectra-trait models were developed to cover the trait space associated with food or biofuel crop plants and can therefore be applied in a broad range of phenotyping studies.

Systematic review of quality of life following pleurectomy decortication and extrapleural pneumonectomy for malignant pleural mesothelioma

BACKGROUND

Few studies have focused on quality of life (QoL) after treatment of malignant pleural mesothelioma (MPM). There are still questions as to which surgical procedure, extrapleural pneumonectomy (EPP) or pleurectomy decortication (P/D) is most effective and results in better survival outcomes, involves fewer complications, and results in better QoL. Here we performed a literature review on MPM patients to assess and compare QoL changes after P/D and EPP.

METHODS

Research articles concerning QoL after mesothelioma surgery were identified through May 2018 in Medline. For inclusion, studies were 1) cohort or randomized controlled trials (RCT) design, 2) included standardized QoL instruments, 3) reported QoL measurement after surgery, 4) described the type of surgery performed (EPP or P/D), 5) were written in English. Measures of lung function (FEV1, FVC) and measures from the EORTC-C30 were compared 6 months following surgery with preoperative values.

RESULTS

QoL data was extracted from 17 articles (14 datasets), encompassing 659 patients (102 EPP, 432 P/D); the available evidence was of low quality. While two studies directly compared QoL between the two surgical procedures, additional data was available from one arm of two RCTs, as the RCTs were not comparing EPP and P/D. The remaining data was reported from observational studies. While QoL was still compromised 6 months following surgery, from the limited and low quality data available it would appear that P/D patients had better QoL than EPP patients across all measures. Physical function, social function and global health were better at follow-up for P/D than for EPP, while other indicators such as pain and cough were similar. Forced Expiratory Volume (FEV1) and Forced Vital Capacity (FVC) were reported in one study only, and were higher at follow-up for P/D compared to EPP.

CONCLUSIONS

Although the existing evidence is limited and of low quality, it suggests that P/D patients have better QoL than EPP patients following surgery. QoL outcomes should be factored into the choice of surgical procedure for MPM patients, and the possible effects on lung function and QoL should be discussed with patients when presenting surgical treatment options.

The development of a Biobank of cancer tissue samples from World Trade Center responders

Background

World Trade Center (WTC) responders were exposed to mixture of dust, smoke, chemicals and carcinogens. Studies of cancer incidence in this population have reported elevated risks of cancer compared to the general population. There is a need to supplement current epidemiologic cancer follow-up with a cancer tissue bank in order to better elucidate a possible connection between each cancer and past WTC exposure. This work describes the implementation of a tissue bank system for the WTC newly diagnosed cancers, focused on advancing the understanding of the biology of these tumors. This will ultimately impact the modalities of treatment, and the probability of success and survival of these patients.

Methods

WTC Responders who participated (as employees or volunteers) in the rescue, recovery and cleanup efforts at the WTC sites have been enrolled at Mount Sinai in the World Trade Center Health Program. Responders with cancer identified and validated through linkages with New York, New Jersey, Pennsylvania, and Connecticut cancer registries were eligible to participate in this biobank. Potential participants were contacted through letters, phone calls, and emails to explain the research study, consent process, and to obtain the location where their cancer procedure was performed. Pathology departments were contacted to identify and request tissue samples.

Results

All the 866 solid cancer cases confirmed by the Data Center at Mount Sinai have been contacted and consent was requested for retrieval and storage of the tissue samples from their cancer. Hospitals and doctors’ offices were then contacted to locate and identify the correct tissue block for each patient. The majority of these cases consist of archival paraffin blocks from surgical patients treated from 2002 to 2015. At the time of manuscript writing, this resulted in 280 cancer samples stored in the biobank.

Conclusions

A biobank of cancer tissue from WTC responders has been compiled with 280 specimens in storage to date. This tissue bank represents an important resource for the scientific community allowing for high impact studies on environmental exposures and cancer etiology, cancer outcome, and gene-environment interaction in the unique population of WTC responders.

Early stage lung cancer survival after wedge resection and stereotactic body radiation

BACKGROUND

The comparative effectiveness of stereotactic body radiation therapy (SBRT) and wedge resection in the treatment of early stage lung cancer is still under debate. This meta-analysis compares the 5-year overall survival (OS) of wedge resection and SBRT in patients with stage I non-small cell lung cancer (NSCLC).

METHODS

Original research articles published between 1995 and 2017 were identified through the National Library of Medicine and National Institutes of Health PubMed database and through the reference lists of reviewed articles. Data were processed and analyzed in R (version 3.4.2) and a summary estimate that accounted for the sample size of each study was calculated. The combined percent survival was calculated using random effect models. Funnel plots were used to assess publication bias. Heterogeneity was tested using the Q statistic and the I2 statistic.

RESULTS

There were 16 studies totaling 1,984 patients with stage I NSCLC treated with wedge resection. The meta-estimate was 74% (95% CI, 66-81%), with significant heterogeneity across studies (Q =172.46, P<0.0001; I2=91.30%). Thirty-six studies including 3,309 patients with stage I NSCLC treated with SBRT/SABR produced a meta-estimate of 44% (95% CI, 38-50%), with significant heterogeneity (Q =423.55, P<0.0001; I2=91.74%). Two articles directly comparing stage I NSCLC patients treated with wedge resection to patients treated with SBRT both reported higher 5-year OS after wedge resection.

CONCLUSIONS

SBRT is a treatment option reserved to medically inoperable patients, but could be an alternative to surgery in medically operable patients who prefer a less invasive treatment. More standardized methods for data collection and reporting are necessary to allow better comparisons across published studies.

Examining posttraumatic growth and mental health difficulties in the aftermath of Hurricane Sandy

OBJECTIVE

Hurricane Sandy continues to affect the mental health of New York residents. This study examined associations between Posttraumatic Growth (PTG) and mental health difficulties (MHD) including symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD).

METHOD

Participants (N = 1,356) recruited from the New York metropolitan area completed questionnaires regarding their PTG, demographics, MHD, and hurricane experiences. A weighted least squares regression assessed the association between MHD and PTG. A post hoc analysis determined whether anxiety or depression moderated the effect of PTSD on PTG.

RESULTS

All MHD were crudely associated with greater PTG. After adjustment, an increased PTSD score was significantly associated with a 0.20 unit increase in PTG (t = 6.05, p < .001); this did not hold for depression or anxiety symptoms. Higher PTG was associated with being non-White (B = 5.90, t = 6.49, p < .001), Hispanic (B = 3.38, t = 2.89, p = .004), a smoker (B = 3.18, t = 3.28, p = .001), and greater Hurricane Sandy exposure (t = 7.11, p < .001). The positive association between PTSD symptoms and PTG was weaker among participants with probable depression.

CONCLUSION

Results suggest that participants with higher PTSD symptoms were more likely to grow from the impact of the storm, indicating resilience. Highly exposed participants were more likely to experience PTG. A decrease in PTG was found among those with both PTSD and depression symptoms. The development and implementation of interventions fostering PTG could be beneficial in clinical disaster response work. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mental health challenges and experiences in displaced populations following Hurricane Sandy and Hurricane Harvey: the need for more comprehensive interventions in temporary shelters

Hurricane exposure can have a profound impact on mental health, leading to increased symptoms of stress, anxiety, depression and post-traumatic stress disorder that are still present years after the storm. Those displaced following a hurricane are particularly vulnerable to adverse mental health outcomes, especially if displaced to temporary shelters. The current work highlights the experiences and mental health challenges of displaced populations following Hurricane Sandy and Hurricane Harvey, as well as describing barriers to conducting research in the immediate aftermath of Hurricane Harvey and the need for more comprehensive interventions in these vulnerable populations.

Displacement during Hurricane Sandy: The impact on mental health

OBJECTIVE

To assess the effect of displacement due to Hurricane Sandy on mental health outcomes among residents of the greater New York City (NYC) area.

DESIGN

Prospective, cross sectional.

SETTING

NYC area residents, including Queens, Staten Island, and Long Island.

PARTICIPANTS

In a 4.25 year period (June 2012 to September 2016), a convenience sample of 1,615 adult residents from the greater NYC area completed validated measures of hurricane exposure (including displacement), perceived stress, depression, anxiety, and post-traumatic stress disorder (PTSD) symptoms as well as indicators of alcohol, illicit substance, and tobacco use.

MAIN OUTCOME MEASURES

Perceived stress, depression, anxiety and PTSD symptoms and alcohol, illicit substance, and tobacco use.

RESULTS

Multivariable analyses indicated that displaced participants were more likely to have PTSD (adjusted odds ratio [AOR]: 2.21, 95% CI: 1.73-2.82), depression (AOR: 1.37, 95% CI: 1.05-1.79) and anxiety symptoms (AOR: 1.30, 95% CI: 1.01-1.67) and had a 1.16 unit increase in perceived stress score (SE = 0.38) compared to nondisplaced participants. Staying with friends/family versus at a shelter was significantly associated with a 48 percent decreased odds of having PTSD symptoms (AOR: 0.52, 95% CI: 0.31-0.88) and of being a current tobacco user (AOR: 0.52, 95% CI: 0.30-0.92).

CONCLUSIONS

Displacement is associated with negative mental health outcomes, particularly displacement to shelters. Disaster preparedness efforts should involve increasing mental health resources to those who are displaced and providing support services within the shelter setting.

Longitudinal Impact of Hurricane Sandy Exposure on Mental Health Symptoms

Hurricane Sandy hit the eastern coast of the United States in October 2012, causing billions of dollars in damage and acute physical and mental health problems. The long-term mental health consequences of the storm and their predictors have not been studied. New York City and Long Island residents completed questionnaires regarding their initial Hurricane Sandy exposure and mental health symptoms at baseline and 1 year later (N = 130). There were statistically significant decreases in anxiety scores (mean difference = -0.33, p < 0.01) and post-traumatic stress disorder (PTSD) scores (mean difference = -1.98, p = 0.001) between baseline and follow-up. Experiencing a combination of personal and property damage was positively associated with long-term PTSD symptoms (OR_adj 1.2, 95% CI [1.1-1.4]) but not with anxiety or depression. Having anxiety, depression, or PTSD at baseline was a significant predictor of persistent anxiety (OR_adj 2.8 95% CI [1.1-6.8], depression (OR_adj 7.4 95% CI [2.3-24.1) and PTSD (OR_adj 4.1 95% CI [1.1-14.6]) at follow-up. Exposure to Hurricane Sandy has an impact on PTSD symptoms that persists over time. Given the likelihood of more frequent and intense hurricanes due to climate change, future hurricane recovery efforts must consider the long-term effects of hurricane exposure on mental health, especially on PTSD, when providing appropriate assistance and treatment.

Quality of Life after Open or Minimally Invasive Esophagectomy in Patients With Esophageal Cancer-A Systematic Review

Although esophageal cancer is rare in the United States, 5-year survival and quality of life (QoL) are poor following esophageal cancer surgery. Although esophageal cancer has been surgically treated with esophagectomy through thoracotomy, an open procedure, minimally invasive surgical procedures have been recently introduced to decrease the risk of complications and improve QoL after surgery. The current study is a systematic review of the published literature to assess differences in QoL after traditional (open) or minimally invasive esophagectomy. We hypothesized that QoL is consistently better in patients treated with minimally invasive surgery than in those treated with a more traditional and invasive approach. Although global health, social function, and emotional function improved more commonly after minimally invasive surgery compared with open surgery, physical function and role function, as well as symptoms including choking, dysphagia, eating problems, and trouble swallowing saliva, declined for both surgery types. Cognitive function was equivocal across both groups. The potential small benefits in global and mental health status among those who experience minimally invasive surgery should be considered with caution given the possibility of publication and selection bias.

Personal and hospital factors associated with limited surgical resection for lung cancer, in-hospital mortality and complications in New York State

BACKGROUND AND OBJECTIVES

Early stage lung cancer is generally treated with surgical resection. The objective of the study was to identify patient and hospital characteristics associated with the type of lung cancer surgical approach utilized in New York State (NYS), and to assess in-hospital adverse events.

METHODS

A total of 33 960 lung cancer patients who underwent limited resection (LR) or lobectomy (L) were selected from the NYS Statewide Planning and Research Cooperative System database (1995-2012).

RESULTS

LR patients were more likely to be older (adjusted odds ratio OR_adj and [95% confidence interval]: 1.01 [1.01-1.02]), female (OR_adj : 1.11 [1.06-1.16]), Black (OR_adj : 1.17 [1.08-1.27]), with comorbidities (OR_adj : 1.08 [1.03-1.14]), and treated in more recent years than L patients. Length of stay and complications were significantly less after LR than L (OR_adj : 0.56 [0.53-0.58] and 0.65 [0.62-0.69]); in-hospital mortality was similar (OR_adj : 0.93 [0.81-1.07]), and was positively associated with age and urgent/emergency admission, but inversely associated with female gender, private insurance, recent admission year, and surgery volume.

CONCLUSIONS

There was a growing trend toward LR, which was more likely to be performed in older patients with comorbidities. In-hospital outcomes were better after LR than L, and were affected by patient and hospital characteristics.

Temporal trends in centralization and racial disparities in utilization of high-volume hospitals for lung cancer surgery

Racial disparities have been suggested in hospital utilization and outcome for lung cancer surgery, but the effect of hospital centralization on closing this gap is unknown. We hypothesized that centralization has increased the utilization of high- or very-high-volume (HV/VHV) hospitals, a proxy for access to high-quality care, over the study period independently from race.Inpatient records were extracted from the New York Statewide Planning and Research Cooperative System database (1995-2012) according to Clinical Modification of the International Classification of Diseases, 9th Revision diagnosis codes 162.* and 165.* and surgical procedure codes 32.2-32.6 (n = 31,931). Patients treated exclusively with surgery of black or white race with a valid zip code were included. Logistic models were performed to determine factors associated with utilization of HV/VHV or low- or very-low-volume (LV/VLV) hospitals; these models were subsequently stratified by race.The percentage of both black and white patients utilizing HV/VHV hospitals increased over the study period (+22.7% and 13.9%, respectively). The distance to the nearest HV/VHV hospital and patient-hospital distance were significantly lower in black compared to white patients, however, blacks were consistently less likely to use HV/VHV than whites (odds ratioadj: 0.26; 95% confidence interval: 0.23-0.29), and were significantly more likely to utilize urban, teaching, and lower volume hospitals than whites. Likelihood of HV/VHV utilization decreased with an increasing distance from a HV/VHV hospital, overall and separately for black and white patients.Although centralization has increased the utilization of HV/VHV for both black and white patients, racial differences in access and utilization of HV hospitals persisted.

Self-Reported and FEMA Flood Exposure Assessment after Hurricane Sandy: Association with Mental Health Outcomes

Hurricane Sandy caused extensive physical and economic damage; the long-term mental health consequences are unknown. Flooding is a central component of hurricane exposure, influencing mental health through multiple pathways that unfold over months after flooding recedes. Here we assess the concordance in self-reported and Federal Emergency Management (FEMA) flood exposure after Hurricane Sandy and determine the associations between flooding and anxiety, depression, and post-traumatic stress disorder (PTSD). Self-reported flood data and mental health symptoms were obtained through validated questionnaires from New York City and Long Island residents (N = 1231) following Sandy. Self-reported flood data was compared to FEMA data obtained from the FEMA Modeling Task Force Hurricane Sandy Impact Analysis. Multivariable logistic regressions were performed to determine the relationship between flooding exposure and mental health outcomes. There were significant discrepancies between self-reported and FEMA flood exposure data. Self-reported dichotomous flooding was positively associated with anxiety (ORadj: 1.5 [95% CI: 1.1-1.9]), depression (ORadj: 1.7 [1.3-2.2]), and PTSD (ORadj: 2.5 [1.8-3.4]), while self-reported continuous flooding was associated with depression (ORadj: 1.1 [1.01-1.12]) and PTSD (ORadj: 1.2 [1.1-1.2]). Models with FEMA dichotomous flooding (ORadj: 2.1 [1.5-2.8]) or FEMA continuous flooding (ORadj: 1.1 [1.1-1.2]) were only significantly associated with PTSD. Associations between mental health and flooding vary according to type of flood exposure measure utilized. Future hurricane preparedness and recovery efforts must integrate micro and macro-level flood exposures in order to accurately determine flood exposure risk during storms and realize the long-term importance of flooding on these three mental health symptoms.