All Publications

  • Association of Early-, Middle-, and Late-Life Depression With Incident Dementia in a Danish Cohort. JAMA neurology Elser, H., Horváth-Puhó, E., Gradus, J. L., Smith, M. L., Lash, T. L., Glymour, M. M., Sørensen, H. T., Henderson, V. W. 2023


    Late-life depressive symptoms are associated with subsequent dementia diagnosis and may be an early symptom or response to preclinical disease. Evaluating associations with early- and middle-life depression will help clarify whether depression influences dementia risk.To examine associations of early-, middle-, and late-life depression with incident dementia.This was a nationwide, population-based, cohort study conducted from April 2020 to March 2023. Participants included Danish citizens from the general population with depression diagnoses who were matched by sex and birth year to individuals with no depression diagnosis. Participants were followed up from 1977 to 2018. Excluded from analyses were individuals followed for less than 1 year, those younger than 18 years, or those with baseline dementia.Depression was defined using diagnostic codes from the International Classification of Diseases (ICD) within the Danish National Patient Registry (DNPR) and Danish Psychiatric Central Research Register (DPCRR).Incident dementia was defined using ICD diagnostic codes within the DPCRR and DNPR. Cox proportional hazards regression was used to examine associations between depression and dementia adjusting for education, income, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, anxiety disorders, stress disorders, substance use disorders, and bipolar disorder. Analyses were stratified by age at depression diagnosis, years since index date, and sex.There were 246 499 individuals (median [IQR] age, 50.8 [34.7-70.7] years; 159 421 women [64.7%]) with diagnosed depression and 1 190 302 individuals (median [IQR] age, 50.4 [34.6-70.0] years; 768 876 women [64.6%]) without depression. Approximately two-thirds of those diagnosed with depression were diagnosed before the age of 60 years (684 974 [67.7%]). The hazard of dementia among those diagnosed with depression was 2.41 times that of the comparison cohort (95% CI, 2.35-2.47). This association persisted when the time elapsed from the index date was longer than 20 to 39 years (hazard ratio [HR], 1.79; 95% CI, 1.58-2.04) and among those diagnosed with depression in early, middle, or late life (18-44 years: HR, 3.08; 95% CI, 2.64-3.58; 45-59 years: HR, 2.95; 95% CI, 2.75-3.17; ≥60 years: HR, 2.31; 95% CI, 2.25-2.38). The overall HR was greater for men (HR, 2.98; 95% CI, 2.84-3.12) than for women (HR, 2.21; 95% CI, 2.15-2.27).Results suggest that the risk of dementia was more than doubled for both men and women with diagnosed depression. The persistent association between dementia and depression diagnosed in early and middle life suggests that depression may increase dementia risk.

    View details for DOI 10.1001/jamaneurol.2023.2309

    View details for PubMedID 37486689

  • Wildfire smoke exposure and emergency department visits for headache: A case-crossover analysis in California, 2006-2020. Headache Elser, H., Rowland, S. T., Marek, M. S., Kiang, M. V., Shea, B., Do, V., Benmarhnia, T., Schneider, A. L., Casey, J. A. 2023


    OBJECTIVE: To evaluate the association of short-term exposure to overall fine particulate matter of <2.5mum (PM2.5 ) and wildfire-specific PM2.5 with emergency department (ED) visits for headache.BACKGROUND: Studies have reported associations between PM2.5 exposure and headache risk. As climate change drives longer and more intense wildfire seasons, wildfire PM2.5 may contribute to more frequent headaches.METHODS: Our study included adult Californian members (aged ≥18years) of a large de-identified commercial and Medicare Advantage claims database from 2006 to 2020. We identified ED visits for primary headache disorders (subtypes: tension-type headache, migraine headache, cluster headache, and "other" primary headache). Claims included member age, sex, and residential zip code. We linked daily overall and wildfire-specific PM2.5 to residential zip code and conducted a time-stratified case-crossover analysis considering 7-day average PM2.5 concentrations, first for primary headache disorders combined, and then by headache subtype.RESULTS: Among 9898 unique individuals we identified 13,623 ED encounters for primary headache disorders. Migraine was the most frequently diagnosed headache (N=5534/13,623 [47.6%]) followed by "other" primary headache (N=6489/13,623 [40.6%]). For all primary headache ED diagnoses, we observed an association of 7-day average wildfire PM2.5 (odds ratio [OR] 1.17, 95% confidence interval [CI] 0.95-1.44 per 10mug/m3 increase) and by subtype we observed increased odds of ED visits associated with 7-day average wildfire PM2.5 for tension-type headache (OR 1.42, 95% CI 0.91-2.22), "other" primary headache (OR 1.40, 95% CI 0.96-2.05), and cluster headache (OR 1.29, 95% CI 0.71-2.35), although these findings were not statistically significant under traditional null hypothesis testing. Overall PM2.5 was associated with tension-type headache (OR 1.29, 95% CI 1.03-1.62), but not migraine, cluster, or "other" primary headaches.CONCLUSIONS: Although imprecise, these results suggest short-term wildfire PM2.5 exposure may be associated with ED visits for headache. Patients, healthcare providers, and systems may need to respond to increased headache-related healthcare needs in the wake of wildfires and on poor air quality days.

    View details for DOI 10.1111/head.14442

    View details for PubMedID 36651537

  • State Cannabis Legalization and Psychosis-Related Health Care Utilization. JAMA network open Elser, H., Humphreys, K., Kiang, M. V., Mehta, S., Yoon, J. H., Faustman, W. O., Matthay, E. C. 2023; 6 (1): e2252689


    Psychosis is a hypothesized consequence of cannabis use. Legalization of cannabis could therefore be associated with an increase in rates of health care utilization for psychosis.To evaluate the association of state medical and recreational cannabis laws and commercialization with rates of psychosis-related health care utilization.Retrospective cohort design using state-level panel fixed effects to model within-state changes in monthly rates of psychosis-related health care claims as a function of state cannabis policy level, adjusting for time-varying state-level characteristics and state, year, and month fixed effects. Commercial and Medicare Advantage claims data for beneficiaries aged 16 years and older in all 50 US states and the District of Columbia, 2003 to 2017 were used. Data were analyzed from April 2021 to October 2022.State cannabis legalization policies were measured for each state and month based on law type (medical or recreational) and degree of commercialization (presence or absence of retail outlets).Outcomes were rates of psychosis-related diagnoses and prescribed antipsychotics.This study included 63 680 589 beneficiaries followed for 2 015 189 706 person-months. Women accounted for 51.8% of follow-up time with the majority of person-months recorded for those aged 65 years and older (77.3%) and among White beneficiaries (64.6%). Results from fully-adjusted models showed that, compared with no legalization policy, states with legalization policies experienced no statistically significant increase in rates of psychosis-related diagnoses (medical, no retail outlets: rate ratio [RR], 1.13; 95% CI, 0.97-1.36; medical, retail outlets: RR, 1.24; 95% CI, 0.96-1.61; recreational, no retail outlets: RR, 1.38; 95% CI, 0.93-2.04; recreational, retail outlets: RR, 1.39; 95% CI, 0.98-1.97) or prescribed antipsychotics (medical, no retail outlets RR, 1.00; 95% CI, 0.88-1.13; medical, retail outlets: RR, 1.01; 95% CI, 0.87-1.19; recreational, no retail outlets: RR, 1.13; 95% CI, 0.84-1.51; recreational, retail outlets: RR, 1.14; 95% CI, 0.89-1.45). In exploratory secondary analyses, rates of psychosis-related diagnoses increased significantly among men, people aged 55 to 64 years, and Asian beneficiaries in states with recreational policies compared with no policy.In this retrospective cohort study of commercial and Medicare Advantage claims data, state medical and recreational cannabis policies were not associated with a statistically significant increase in rates of psychosis-related health outcomes. As states continue to introduce new cannabis policies, continued evaluation of psychosis as a potential consequence of state cannabis legalization may be informative.

    View details for DOI 10.1001/jamanetworkopen.2022.52689

    View details for PubMedID 36696111

  • Trends and inequities in the diagnosis and treatment of poststroke depression: a retrospective cohort study of privately insured patients in the USA, 2003-2020. Journal of neurology, neurosurgery, and psychiatry Elser, H., Caunca, M., Rehkopf, D. H., Andres, W., Gottesman, R. F., Kasner, S. E., Yaffe, K., Schneider, A. L. 2022


    BACKGROUND: Depression is a common neuropsychiatric consequence of stroke, but there is little empiric evidence regarding clinical diagnosis and management of poststroke depression.METHODS: Retrospective cohort study among 831 471 privately insured patients with first stroke in the USA from 2003 to 2020. We identified diagnoses of poststroke depression using codes from the International Classification of Diseases. We identified treatment based on prescriptions for antidepressants. We used Cox proportional hazards regression analysis to examine rates of poststroke depression diagnosis by gender, age and race/ethnicity. Among individuals who received a diagnosis of poststroke depression, we estimated treatment rates by gender, race/ethnicity and age using negative binomial regression analysis.RESULTS: Annual diagnosis and treatment rates for poststroke depression increased from 2003 to 2020 (both p for trend<0.001). Diagnosis rates were higher in women than men (HR 1.53, 95% CI 1.51 to 1.55), lower among members of racial/ethnic minorities (vs white patients: Asian HR 0.63, 95% CI 0.60 to 0.66; Black HR 0.76, 95% CI 0.74 to 0.78; Hispanic HR 0.88, 95% CI 0.86 to 0.90) and varied by age. Among individuals diagnosed with poststroke depression, 69.8% were prescribed an antidepressant. Rates of treatment were higher in women vs men (rate ratio, RR=1.19, 95% CI: 1.17 to 1.21), lower among members of racial/ethnic minorities (vs white patients: Asian RR 0.85, 95% CI 0.80 to 0.90; Black RR 0.92, 95% CI 0.89 to 0.94; Hispanic RR 0.96, 95% CI 0.93 to 0.99) and higher among older patients.CONCLUSIONS: In this insured population, we identify potential inequities in clinical management of poststroke depression by gender, race/ethnicity and age that may reflect barriers other than access to healthcare.

    View details for DOI 10.1136/jnnp-2022-330179

    View details for PubMedID 36400454

  • Metalworking Fluid Exposure and Stroke Mortality Among U.S. Autoworkers. American journal of epidemiology Elser, H., Chen, K. T., Arteaga, D., Reimer, R., Picciotto, S., Costello, S., Eisen, E. A. 1800


    Although Air pollution is an important risk factor for stroke, few studies have considered the impact of workplace exposure to particulate matter (PM). We examined implications of exposure to PM composed of metalworking fluids (MWF) for stroke mortality in the United Autoworkers-General Motors cohort. Cox proportional hazards models with age as the timescale were used to estimate the association of cumulative straight, soluble, and synthetic MWF exposure with stroke mortality controlling for sex, race, plant, calendar year, and hire year. Among 38,553 autoworkers followed 1941-1995, we identified 114 ischemic stroke deaths and 113 hemorrhagic stroke deaths. Overall stroke mortality risk was increased among workers in the middle exposure category for straight MWF (HR: 1.31, 95% CI: 0.87-1.98), and workers in the highest exposure category for synthetic MWF (1.94, 1.13-3.16) compared to workers with no direct exposure. Ischemic stroke mortality risk was increased among workers in the highest exposure categories for straight MWF (1.45, 0.83-2.53) and synthetic MWF (2.50, 1.39-4.50). We observed no clear relationship between MWF exposure and hemorrhagic stroke mortality. Our results support a potentially important role for occupational PM exposures in stroke mortality and indicate the need for further studies of PM exposure and stroke in varied occupational settings.

    View details for DOI 10.1093/aje/kwac002

    View details for PubMedID 35029630

  • Anomalously warm weather and acute care visits in patients with multiple sclerosis: A retrospective study of privately insured individuals in the US. PLoS medicine Elser, H., Parks, R. M., Moghavem, N., Kiang, M. V., Bozinov, N., Henderson, V. W., Rehkopf, D. H., Casey, J. A. 2021; 18 (4): e1003580


    BACKGROUND: As the global climate changes in response to anthropogenic greenhouse gas emissions, weather and temperature are expected to become increasingly variable. Although heat sensitivity is a recognized clinical feature of multiple sclerosis (MS), a chronic demyelinating disorder of the central nervous system, few studies have examined the implications of climate change for patients with this disease.METHODS AND FINDINGS: We conducted a retrospective cohort study of individuals with MS ages 18-64 years in a nationwide United States patient-level commercial and Medicare Advantage claims database from 2003 to 2017. We defined anomalously warm weather as any month in which local average temperatures exceeded the long-term average by ≥1.5°C. We estimated the association between anomalously warm weather and MS-related inpatient, outpatient, and emergency department visits using generalized log-linear models. From 75,395,334 individuals, we identified 106,225 with MS. The majority were women (76.6%) aged 36-55 years (59.0%). Anomalously warm weather was associated with increased risk for emergency department visits (risk ratio [RR] = 1.043, 95% CI: 1.025-1.063) and inpatient visits (RR = 1.032, 95% CI: 1.010-1.054). There was limited evidence of an association between anomalously warm weather and MS-related outpatient visits (RR = 1.010, 95% CI: 1.005-1.015). Estimates were similar for men and women, strongest among older individuals, and exhibited substantial variation by season, region, and climate zone. Limitations of the present study include the absence of key individual-level measures of socioeconomic position (i.e., race/ethnicity, occupational status, and housing quality) that may determine where individuals live-and therefore the extent of their exposure to anomalously warm weather-as well as their propensity to seek treatment for neurologic symptoms.CONCLUSIONS: Our findings suggest that as global temperatures rise, individuals with MS may represent a particularly susceptible subpopulation, a finding with implications for both healthcare providers and systems.

    View details for DOI 10.1371/journal.pmed.1003580

    View details for PubMedID 33901187

  • Air pollution, methane super-emitters, and oil and gas wells in Northern California: the relationship with migraine headache prevalence and exacerbation. Environmental health : a global access science source Elser, H., Morello-Frosch, R., Jacobson, A., Pressman, A., Kioumourtzoglou, M., Reimer, R., Casey, J. A. 2021; 20 (1): 45


    BACKGROUND: Migraine-an episodic disorder characterized by severe headache that can lead to disability-affects over 1 billion people worldwide. Prior studies have found that short-term exposure to fine particulate matter (PM2.5), nitrogen dioxide (NO2), and ozone increases risk of migraine-related emergency department (ED) visits. Our objective was to characterize the association between long-term exposure to sources of harmful emissions and common air pollutants with both migraine headache and, among patients with migraine, headache severity.METHODS: From the Sutter Health electronic health record database, we identified 89,575 prevalent migraine cases between 2014 and 2018 using a migraine probability algorithm (MPA) score and 270,564 frequency-matched controls. Sutter Health delivers care to 3.5 million patients annually in Northern California. Exposures included 2015 annual average block group-level PM2.5 and NO2 concentrations, inverse-distance weighted (IDW) methane emissions from 60 super-emitters located within 10km of participant residence between 2016 and 2018, and IDW active oil and gas wells in 2015 within 10km of each participant. We used logistic and negative binomial mixed models to evaluate the association between environmental exposures and (1) migraine case status; and (2) migraine severity (i.e., MPA score>100, triptan prescriptions, neurology visits, urgent care migraine visits, and ED migraine visits per person-year). Models controlled for age, sex, race/ethnicity, Medicaid use, primary care visits, and block group-level population density and poverty.RESULTS: In adjusted analyses, for each 5ppb increase in NO2, we observed 2% increased odds of migraine case status (95% CI: 1.00, 1.05) and for each 100,000kg/hour increase in IDW methane emissions, the odds of case status also increased (OR=1.04, 95% CI: 1.00, 1.08). We found no association between PM2.5 or oil and gas wells and migraine case status. PM2.5 was linearly associated with neurology visits, migraine-specific urgent care visits, and MPA score>100, but not triptans or ED visits. NO2 was associated with migraine-specific urgent care and ED visits, but not other severity measures. We observed limited or null associations between continuous measures of methane emissions and proximity to oil and gas wells and migraine severity.CONCLUSIONS: Our findings illustrate the potential role of long-term exposure to multiple ambient air pollutants for prevalent migraine and migraine severity.

    View details for DOI 10.1186/s12940-021-00727-w

    View details for PubMedID 33865403

  • Seasonal patterns of relapse and disability in Danish MS patients: A population-based cohort study. Multiple sclerosis and related disorders Elser, H. C., Koch-Henriksen, N. n., Magyari, M. n. 2021; 49: 102739


    The importance of environmental risk factors in the onset of multiple sclerosis (MS) has been studied extensively. Similarly, a growing number of studies address the importance of environmental factors, including seasonality, for ongoing activity of established disease. Specifically, past research demonstrates higher rates of relapse activity in summer months among individuals with MS. Our study adds to the existing literature on seasonality of disease relapse by analysing a large population-based and virtually complete cohort of patient with relapsing and remitting MS (RRMS) in an area of temperate climate.The Danish Multiple Sclerosis Registry includes follow-up for all patients receiving disease modifying treatment from 1996-2020, with near-complete registration of all relapses and their dates. We compared the observed and expected numbers of relapses for each calendar month and calculated month-specific annualized relapse rates (ARR) using Poisson regression. In addition, we analysed seasonal variation in disability as measured by the Expanded Disability Status Scale (EDSS).From 1996 to 2020 we followed 13,575 MS patients treated with disease modifying therapy (4165 men and 9410 women) for a total of 82,187 person years and 134,593 control visits. The mean age at entry was 41.1 years with standard deviation 10.9 years. We recorded 16,083 relapses throughout the observation period, and for 15,728 of the relapses the date of onset was known. Relapses were unevenly distributed by calendar month (p < 0.00001). The most prominent deviation was a paucity of relapses in July in which the ARR was 0.166 compared with mean of 0.191 for the whole year. Otherwise, the ARR formed a plateau slightly above mean during the spring months. Mean EDSS was slightly higher in autumn (2.78) than in spring (2.74), but there was no difference between winter and summer; p < 0.0001.In contrast with previous studies, we observed a nadir of relapses in July among Danish patients with RRMS. This finding may be related to increased exposure to sunlight in the summer, particularly during vacation when outdoor recreational activities are more frequent and potential exposure to infections is decreased. Confirmation of this in future studies is warranted.

    View details for DOI 10.1016/j.msard.2021.102739

    View details for PubMedID 33450501

  • Petro-riskscapes and environmental distress in West Texas: Community perceptions of environmental degradation, threats, and loss. Energy research & social science Elser, H., Goldman-Mellor, S., Morello-Frosch, R., Deziel, N. C., Ranjbar, K., Casey, J. A. 2020; 70


    Unconventional oil and gas development (UOGD) expanded rapidly in the United States between 2004-2019 with resultant industrial change to landscapes and new environmental exposures. By 2019, West Texas' Permian Basin accounted for 35% of domestic oil production. We conducted an online survey of 566 Texans in 2019 to examine the implications of UOGD using three measures from the Environmental Distress Scale (EDS): perceived threat of environmental issues, felt impact of environmental change, and loss of solace when valued environments are transformed ("solastalgia"). We found increased levels of environmental distress among respondents living in counties in the Permian Basin who reported a 2.75% increase in perceived threat of environmental issues (95% CI = -1.14, 6.65) and a 4.21% increase in solastalgia (95% CI = 0.03, 8.40). In our subgroup analysis of women, we found higher EDS subscale scores among respondents in Permian Basin counties for perceived threat of environmental issues (4.08%, 95% CI= -0.12, 8.37) and solastalgia (7.09%, 95% CI= 2.44, 11.88). In analysis restricted to Permian Basin counties, we found exposure to at least one earthquake of magnitude ≥ 3 was associated with increases in perceived threat of environmental issues (4.69%, 95% CI = 0.15, 9.23), and that county-level exposure to oil and gas injection wells was associated with increases in felt impact (4.38%, 95% CI = -1.77, 10.54) and solastalgia (4.06%, 95% CI = 3.02, 11.14). Our results indicate increased environmental distress in response to UOGD-related environmental degradation among Texans and highlight the importance of considering susceptible sub-groups.

    View details for DOI 10.1016/j.erss.2020.101798

    View details for PubMedID 33072520

  • Suicide, overdose and worker exit in a cohort of Michigan autoworkers. Journal of epidemiology and community health Eisen, E. A., Chen, K. T., Elser, H., Picciotto, S., Riddell, C. A., Combs, M. A., Dufault, S. M., Goldman-Mellor, S., Cohen, J. 2020


    BACKGROUND: In recent decades, suicide and fatal overdose rates have increased in the US, particularly for working-age adults with no college education. The coincident decline in manufacturing has limited stable employment options for this population. Erosion of the Michigan automobile industry provides a striking case study.METHODS: We used individual-level data from a retrospective cohort study of 26804 autoworkers in the United Autoworkers-General Motors cohort, using employment records from 1970 to 1994 and mortality follow-up from 1970 to 2015. We estimated HRs for suicide or fatal overdose in relation to leaving work, measured as active or inactive employment status and age at worker exit.RESULTS: There were 257 deaths due to either suicide (n=202) or overdose (n=55); all but 21 events occurred after leaving work. The hazard rate for suicide was 16.1 times higher for inactive versus active workers (95% CI 9.8 to 26.5). HRs for suicide were elevated for all younger age groups relative to those leaving work after age 55. Those 30-39years old at exit had the highest HR for suicide, 1.9 (95% CI 1.2 to 3.0). When overdose was included, the rate increased by twofold for both 19- to 29-year-olds and 30- to 39-year-olds at exit. Risks remained elevated when follow-up was restricted to 5 years after exit.CONCLUSIONS: Autoworkers who left work had a higher risk of suicide or overdose than active employees. Those who left before retirement age had higher rates than those who left after, suggesting that leaving work early may increase the risk.

    View details for DOI 10.1136/jech-2020-214117

    View details for PubMedID 32641405

  • Gender, Depression, and Blue-collar Work: A Retrospective Cohort Study of US Aluminum Manufacturers. Epidemiology (Cambridge, Mass.) Elser, H., Rehkopf, D. H., Meausoone, V., Jewell, N. P., Eisen, E. A., Cullen, M. R. 2019; 30 (3): 435–44


    BACKGROUND: Industrial blue-collar workers face multiple work-related stressors, but evidence regarding the burden of mental illness among today's blue-collar men and women remains limited.METHODS: In this retrospective cohort study, we examined health and employment records for 37,183 blue- and white-collar workers employed by a single US aluminum manufacturer from 2003 to 2013. Using Cox proportional hazards regression, we modeled time to first episode of treated depression by gender and occupational class. Among cases, we modeled rates of depression-related service utilization with generalized gamma regression.RESULTS: Compared with their white-collar counterparts, blue-collar men were more likely to be treated for depression (hazard ratio [HR] = 1.3; 95% confidence interval [CI] = 1.1, 1.4) as were blue-collar women (HR = 1.4; 1.2, 1.6). Blue-collar women were most likely to be treated for depression as compared with white-collar men (HR = 3.2; 95% CI = 2.1, 5.0). However, blue-collar workers used depression-related services less frequently than their white-collar counterparts among both men (rate ratio = 0.91; 95% CI = 0.84, 0.98) and women (rate ratio = 0.82; 95% CI = 0.77, 0.88).CONCLUSIONS: Blue-collar women were more likely to be treated for depression than white-collar workers, and blue-collar women were most likely to be treated for depression compared with white-collar men. However, blue-collar men and women used depression-related healthcare services less frequently than white-collar workers. These findings underscore that blue-collar women may be uniquely susceptible to depression, and suggest that blue-collar workers may encounter barriers to care-seeking related mental illness other than their insurance status.

    View details for PubMedID 30964814

  • Gender, Depression, and Blue-collar Work A Retrospective Cohort Study of US Aluminum Manufacturers EPIDEMIOLOGY Elser, H., Rehkopf, D. H., Meausoone, V., Jewell, N. R., Eisen, E. A., Cullen, M. R. 2019; 30 (3): 435–44
  • Manmade earthquakes and healthcare visits for anxiety disorders in Oklahoma, 2010-2019 ENVIRONMENTAL EPIDEMIOLOGY Elser, H., Kempinsky, A., Goldman-Mellor, S., Li, M., Catalano, R., Rehkopf, D. H., Casey, J. A. 2023; 7 (1)
  • Manmade earthquakes and healthcare visits for anxiety disorders in Oklahoma, 2010-2019. Environmental epidemiology (Philadelphia, Pa.) Elser, H., Kempinsky, A., Goldman-Mellor, S., Li, M., Catalano, R., Rehkopf, D. H., Casey, J. A. 2023; 7 (1): e232


    Since 2010, seismicity in Oklahoma has increased from wastewater injection. It remains unknown if these earthquakes have resulted in increased treatment seeking for mental healthcare services.Using data from a nationwide United States patient-level commercial and Medicare Advantage claims database from 2010 to 2019, we identified healthcare encounters for anxiety disorders using diagnostic codes and subclassified them as adjustment reaction; anxiety-related disorders; physical symptoms of anxiety; and stress disorders. With U.S. Geological Survey Advanced National Seismic System data, we generated county-level 6-month rolling counts of felt earthquakes (≥M 4) and linked them to patient residential county at the time of the healthcare visit. In this repeated measures, individual-level analysis we used generalized estimating equations to estimate the odds of monthly anxiety-related healthcare visits as a function of the frequency of ≥M 4 earthquakes in the previous 6 months.We identified 4,594 individuals in Oklahoma observed from 2010 to 2019. For every additional five ≥M 4 earthquakes in the preceding 6 months, the odds of healthcare visits for stress disorders increased (odds ratio [OR] = 1.27; 95% confidence interval [CI] = 1.03, 1.57). We found no evidence of an association with adjustment reaction (OR = 1.05; 95% CI = 0.89, 1.23), anxiety-related disorders (OR = 0.96; 95% CI = 0.90, 1.03), or physical symptoms of anxiety (OR = 1.03; 95% CI = 0.98, 1.09).We report an association between increased frequency of felt earthquakes and treatment seeking for stress disorders. This finding should motivate ongoing study of the potential consequences of the oil and gas industry for mental health outcomes including anxiety disorders.

    View details for DOI 10.1097/EE9.0000000000000232

    View details for PubMedID 36777522

    View details for PubMedCentralID PMC9916016

  • Extended Delay to Treatment for Stage III-IV Non-Small-Cell Lung Cancer and Survival: Balancing Risks During the COVID-19 Pandemic. Clinical lung cancer Mayne, N. R., Bajaj, S. S., Powell, J., Elser, H. C., Civiello, B. S., Fintelmann, F. J., Li, X., Yang, C. J. 2022


    BACKGROUND: Due to the coronavirus disease 2019 (COVID-19) pandemic, patients may encounter lung cancer care delays. Here, we sought to examine the impact of extended treatment delay for stage III-IV non-small-cell lung cancer on patient survival.MATERIALS AND METHODS: Using National Lung Screening Trial (NLST) and National Cancer Data Base (NCDB) data, Cox regression analysis with penalized smoothing splines was performed to examine the association between treatment delay and all-cause mortality for stage III-IV lung adenocarcinoma and squamous cell carcinoma. In the NCDB, propensity score-matched analysis was used to compare cumulative survival in patients who received "early" versus "delayed" treatment (ie, 0-30 vs. 90-120 days following diagnosis).RESULTS: Cox regression analysis of the NLST (n=392) and NCDB (n=275,198) cohorts showed a decrease in hazard ratio the longer treatment was delayed. In propensity score-matched analysis, no significant differences in survival were found between early and delayed treatment for patients with stage IIIA, IIIB (T3-4,N2,M0), IIIC, and IV (M1B-C) adenocarcinoma and patients with IIIA, IIIB, IIIC, and IV squamous cell carcinoma (all log-rank P > .05). For patients with stage IIIB (T1-2,N3,M0) and stage IV (M1A) adenocarcinoma, delayed treatment was associated with improved survival (log-rank P=.03, P=.02). The findings were consistent in sensitivity analysis accounting for wait time bias.CONCLUSION: In this national analysis, for patients with stage III-IV adenocarcinoma and squamous cell carcinoma, an extended treatment delay by 3 to 4 months was not associated with significantly decreased overall survival compared to prompt treatment. These findings can be used to guide decision-making during the ongoing COVID-19 pandemic.

    View details for DOI 10.1016/j.cllc.2022.05.001

    View details for PubMedID 35660355

  • Cancer risk in patients with migraine: A population-based cohort study in Denmark. Headache Elser, H., Skajaa, N., Ehrenstein, V., Fuglsang, C. H., Farkas, D. K., Sorensen, H. T. 1800; 62 (1): 57-64


    OBJECTIVE: The purpose of this study was to examine overall and site-specific cancer risk among individuals diagnosed with migraine compared with the general population.BACKGROUND: Current evidence regarding migraine and risk of cancer is sparse and inconclusive.METHODS: We conducted a nationwide population-based cohort study with data collected routinely and prospectively from Danish population-based registries from 1995 to 2017. We computed the age- and sex-standardized incidence ratio (SIR) as the ratio of observed to expected cancers among patients diagnosed with migraine in the study population overall, and by encounter type of first diagnosis (inpatient, outpatient specialty clinic, and emergency department). Site-specific cancers were grouped according to etiology.RESULTS: We identified 72,826 patients with a first-time hospital migraine diagnosis. There were 3090 observed overall cancer cases among individuals diagnosed with migraine as compared with 3108 expected cases (SIR 0.99, 95% confidence interval [CI]: 0.96-1.03). The cumulative incidence of all cancers combined from 1995 to 2017 among those with a first-time migraine diagnosis was 9.47% (95% CI: 9.08-9.87). The SIRs for most cancers were consistent with absence of an association: 1.00 (95% CI: 0.94-1.06) for hormone-related cancers, 0.96 (95% CI: 0.88-1.03) for smoking-related cancers, 1.10 (95% CI: 0.98-1.24) for hematologic cancers, and 0.95 (95% CI: 0.85-1.06) for immune-related cancers. Exceptions were SIRs for gastrointestinal cancers (0.78, 95% CI: 0.70-0.87) and for cancers of neurological origin (1.57, 95% CI: 1.40-1.76).CONCLUSIONS: For most cancer groups, our results did not support an association with migraine. The exceptions were an increased risk for cancers of neurological origin and a decreased risk for gastrointestinal cancers. These findings may reflect a true difference in risk among individuals with migraine, or more plausibly they reflect other forces, such as differences in medication use, detection bias and reverse causation, or shared risk factors.

    View details for DOI 10.1111/head.14251

    View details for PubMedID 35041219

  • A US State Index of Successful Aging: Differences Between States and Over Time. The Milbank quarterly Rehkopf, D. H., Furstenberg, F. F., Elser, H., Jackson, C., Levy, N., Rowe, J. W., AGING SOCIETY RESEARCH NETWORK 2021


    Policy Points The focus of successful aging is on the social contexts that enable individuals to be productively engaged and secure, with an emphasis on equity. There is currently no index to measure progress towards this goal at the US state level. We developed an empirical index for the evaluation of US state adaptation to societal aging across five critical domains that support successful population aging: (1) productivity and engagement, (2) security, (3) equity, (4) cohesion, and (5) well-being. Our index shows substantial variability over time and is not overly influenced by the performance of an individual domain. This suggests that it can be used to monitor state progress over time toward the goal of supporting successful aging. Rather than a major national trend, there are large between-state differences and changes in our index over time. This suggests individual US state policies and programs, as well as local economic conditions, may have a substantial impact on adaptations to societal aging.CONTEXT: Although it is recognized that aspects of US state environments impact the likelihood that older adults age successfully, there is currently no reliable and comprehensive measure of contexts that best support successful aging at a state level. The current project adapts a multidimensional index previously used to assess adaptation to successful aging in developed countries and applies it to the 50 US states and the District of Columbia.METHODS: We obtained data from multiple sources for all 50 US states and the District of Columbia from 2003 to 2017 in order to measure five distinct domains that define successful population aging: (1) productivity and engagement, (2) security, (3) equity, (4) cohesion, and (5) well-being. We created a ranking of states for the year 2017 based on these domains, and also examined how individual US state rankings changed over time from 2003 to 2017.FINDINGS: The level of adaptation to successful aging varied substantially between states and over time. The highest-ranked states in 2017 were Vermont, Hawaii, Iowa, Colorado, and New Hampshire, and the lowest-ranked states were Louisiana, Arkansas, Kentucky, West Virginia, and Mississippi. Mississippi, South Carolina, Iowa, Arizona, and Delaware had the greatest improvement in their ranking over the period of 2003 to 2017. Our findings were generally robust to the weighting scheme used and were not overly influenced by any particular domain.CONCLUSIONS: The US State Index of Successful Aging can be used to monitor US state progress in promoting the well-being and health of aging populations. Factors driving the changes in the index remain to be elucidated.

    View details for DOI 10.1111/1468-0009.12542

    View details for PubMedID 34812519

  • The Impact of Extended Delayed Surgery for Indolent Lung Cancer or Part-solid Ground Glass Nodules. The Annals of thoracic surgery Mayne, N. R., Elser, H., Lin, B. K., Raman, V., Liou, D., Li, X., D'Amico, T. A., Yang, C. J. 2021


    BACKGROUND: During the COVID-19 pandemic, patients with lung cancer may experience treatment delays. The objective of this study was to evaluate the impact of extended treatment delays on survival among patients with stage I typical bronchopulmonary carcinoid (BC), lepidic predominant adenocarcinoma (LPA) or invasive adenocarcinoma with a lepidic component (ADL).METHODS: Using National Cancer Data Base data (2004-2015), multivariable Cox regression analysis with penalized smoothing splines was performed to examine the association between treatment delay and all-cause mortality for stage I BC, LPA and ADL. Propensity score-matched analyses compared the overall survival in patients who received "early" versus "delayed" surgery (i.e. 0-30 versus 90-120 days following diagnosis) across the different histologic subtypes.RESULTS: During the study period, patients with stage I BC (n=4,947), LPA (n=5,340) and ADL (n=6,816) underwent surgery. Cox regression analysis of these cohorts showed a gradual steady increase in the hazard ratio the longer treatment is delayed. However, in propensity score-matched analyses which created cohorts of patients who underwent early and delayed surgery that were well-balanced in patient characteristics, no significant differences in 5-year survival were found between early and delayed surgery for stage I BC (87% [95% CI:77-93] vs 89% [95% CI:80-94]), stage I LPA (73% [95% CI:64-80] vs 77% [95% CI:68-83]) and stage I ADL (71% [95% CI:64-76] vs 69% [95% CI:60-76]).CONCLUSIONS: During the COVID-19 pandemic, for early-stage indolent lung tumors and part-solid ground glass lung nodules, a delay of surgery by 3-4 months following diagnosis can be considered.

    View details for DOI 10.1016/j.athoracsur.2021.05.099

    View details for PubMedID 34329603

  • Correction to: Air pollution, methane super-emitters, and oil and gas wells in Northern California: the relationship with migraine headache prevalence and exacerbation. Environmental health : a global access science source Elser, H., Morello-Frosch, R., Jacobson, A., Pressman, A., Kioumourtzoglou, M., Reimer, R., Casey, J. A. 2021; 20 (1): 57

    View details for DOI 10.1186/s12940-021-00745-8

    View details for PubMedID 33971885

  • Air pollution, methane super-emitters, and oil and gas wells in Northern California: the relationship with migraine headache prevalence and exacerbation Elser, H., Morello-Frosch, R., Jacobson, A., Pressman, A., Kioumourtzoglou, M., Reimer, R., Casey, J. LIPPINCOTT WILLIAMS & WILKINS. 2021
  • E-Cigarette Use among Current Smokers Experiencing Homelessness INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH Durazo, A., Hartman-Filson, M., Elser, H., Alizaga, N. M., Vijayaraghavan, M. 2021; 18 (7)


    Two-thirds of cigarette smokers experiencing homelessness report using alternative tobacco products, including blunts, cigarillos (little cigars) or roll-your-own tobacco or electronic nicotine delivery systems such as e-cigarettes. We examined attitudes toward e-cigarette use and explored whether e-cigarette use patterns were associated with past-year cigarette quit attempts among current smokers experiencing homelessness. Among the 470 current cigarette smokers recruited from homeless service sites in San Francisco, 22.1% (n = 65) reported the use of e-cigarettes in the past 30 days ('dual users'). Compared to cigarette-only smokers, dual users considered e-cigarettes to be safer than cigarettes. Patterns of e-cigarette use, including the number of times used per day, duration of use during the day, manner of use and nicotine concentration were not associated with past-year cigarette quit attempts. Studies that examine the motivations for use of e-cigarettes, particularly for their use as smoking cessation aids, could inform interventions for tobacco use among people experiencing homelessness.

    View details for DOI 10.3390/ijerph18073691

    View details for Web of Science ID 000638482800001

    View details for PubMedID 33916203

  • African American Unemployment and the Disparity in Periviable Births. Journal of racial and ethnic health disparities Catalano, R., Karasek, D., Bruckner, T., Casey, J. A., Saxton, K., Ncube, C. N., Shaw, G. M., Elser, H., Gemmill, A. 2021


    Periviable infants (i.e., born before 26 complete weeks of gestation) represent fewer than .5% of births in the US but account for 40% of infant mortality and 20% of billed hospital obstetric costs. African American women contribute about 14% of live births in the US, but these include nearly a third of the country's periviable births. Consistent with theory and with periviable births among other race/ethnicity groups, males predominate among African American periviable births in stressed populations. We test the hypothesis that the disparity in periviable male births among African American and non-Hispanic white populations responds to the African American unemployment rate because that indicator not only traces, but also contributes to, the prevalence of stress in the population. We use time-series methods that control for autocorrelation including secular trends, seasonality, and the tendency to remain elevated or depressed after high or low values. The racial disparity in male periviable birth increases by 4.45% for each percentage point increase in the unemployment rate of African Americans above its expected value. We infer that unemployment-a population stressor over which our institutions exercise considerable control-affects the disparity between African American and non-Hispanic white periviable births in the US.

    View details for DOI 10.1007/s40615-021-01022-7

    View details for PubMedID 33783756

  • Evaluation of State Cannabis Laws and Rates of Self-harm and Assault JAMA NETWORK OPEN Matthay, E. C., Kiang, M., Elser, H., Schmidt, L., Humphreys, K. 2021; 4 (3): e211955


    State cannabis laws are changing rapidly. Research is inconclusive about their association with rates of self-harm and assault. Existing studies have not considered variations in cannabis commercialization across states over time.To evaluate the association of state medical and recreational cannabis laws with self-harm and assault, overall and by age and sex, while considering varying degrees of commercialization.Using a cohort design with panel fixed-effects analysis, within-state changes in claims for self-harm and assault injuries before and after changes in cannabis laws were quantified in all 50 US states and the District of Columbia. Comprehensive claims data on commercial and Medicare Advantage health plan beneficiaries from January 1, 2003, to December 31, 2017, grouped by state and month, were evaluated. Data analysis was conducted from January 31, 2020, to January 21, 2021.Categorical variable that indexed the degree of cannabis legalization in each state and month based on law type (medical or recreational) and operational status of dispensaries (commercialization).Claims for self-harm and assault injuries based on International Classification of Diseases codes.The analysis included 75 395 344 beneficiaries (mean [SD] age, 47 [22] years; 50% female; and median follow-up, 17 months [interquartile range, 8-36 months]). During the study period, 29 states permitted use of medical cannabis and 11 permitted recreational cannabis. Point estimates for populationwide rates of self-harm and assault injuries were higher in states legalizing recreational cannabis compared with states with no cannabis laws, but these results were not statistically significant (adjusted rate ratio [aRR] assault, recreational dispensaries: 1.27; 95% CI, 0.79-2.03;self-harm, recreational dispensaries aRR: 1.15; 95% CI, 0.89-1.50). Results varied by age and sex with no associations found except for states with recreational policies and self-harm among males younger than 40 years (aRR <21 years, recreational without dispensaries: 1.70; 95% CI, 1.11-2.61; aRR aged 21-39 years, recreational dispensaries: 1.46; 95% CI, 1.01-2.12). Medical cannabis was generally not associated with self-harm or assault injuries populationwide or among age and sex subgroups.Recreational cannabis legalization appears to be associated with relative increases in rates of claims for self-harm among male health plan beneficiaries younger than 40 years. There was no association between cannabis legalization and self-harm or assault, for any other age and sex group or for medical cannabis. States that legalize but still constrain commercialization may be better positioned to protect younger male populations from unintended harms.

    View details for DOI 10.1001/jamanetworkopen.2021.1955

    View details for Web of Science ID 000630467900006

    View details for PubMedID 33734416

  • Estimating the Impact of Extended Delay to Surgery for Stage I Non-Small-Cell Lung Cancer on Survival: Lessons for the COVID-19 Pandemic. Annals of surgery Mayne, N. R., Elser, H., Darling, A. J., Raman, V., Liou, D., Colson, Y., D'Amico, T. A., Yang, C. J. 2021


    OBJECTIVE.: The purpose of this study is to evaluate the impact of extended delay to surgery for stage I non-small-cell lung cancer (NSCLC).SUMMARY BACKGROUND DATA.: During the COVID-19 pandemic, patients with NSCLC may experience delays in care, and some national guidelines recommend delays in surgery by >3 months for early NSCLC.METHODS.: Using data from the National Lung Screening Trial (NLST), a multi-center randomized trial, and the National Cancer Data Base (NCDB), a multi-institutional oncology registry, the impact of "early" versus "delayed" surgery (surgery received 0-30 versus 90-120 days following diagnosis) for stage I lung adenocarcinoma and squamous cell carcinoma was assessed using multivariable Cox regression analysis with penalized smoothing spline functions and propensity score-matched analyses.RESULTS.: In Cox regression analysis of the NLST (n = 452) and NCDB (n = 80,086) cohorts, an increase in the hazard ratio (HR) was seen the longer surgery was delayed. In propensity score-matched analysis, no differences in survival were found between early and delayed surgery for stage IA1 adenocarcinoma and IA1-IA3 squamous cell carcinoma (all P > 0.13). For stage IA2-IB adenocarcinoma and IB squamous cell carcinoma, delayed surgery was associated with worse survival (all P < 0.004).CONCLUSIONS.: The mortality risk associated with an extended delay to surgery differs across patient subgroups, and decisions to delay care during the COVID pandemic should take substage and histologic subtype into consideration. For stage IA1 adenocarcinoma and IA squamous cell carcinoma, delaying surgery may be considered; however, for IA2-IB adenocarcinoma and IB squamous cell carcinoma, early surgery-when feasible-should be encouraged.

    View details for DOI 10.1097/SLA.0000000000004811

    View details for PubMedID 33630435

  • Wildfire particulate matter in Shasta County, California and respiratory and circulatory disease-related emergency department visits and mortality, 2013-2018. Environmental epidemiology (Philadelphia, Pa.) Casey, J. A., Kioumourtzoglou, M., Elser, H., Walker, D., Taylor, S., Adams, S., Aguilera, R., Benmarhnia, T., Catalano, R. 2021; 5 (1): e124


    Wildfire smoke harms health. We add to this literature by evaluating the health effects of California's 2018 Carr Fire and preceding wildfire seasons in Shasta County.Methods: With data from the Shasta County Health and Human Services Agency, we examined the link between weekly wildfire fine particulate matter (PM2.5) exposure estimated using a spatiotemporal multiple imputation approach and emergency department (ED) visits and mortality using time-series models that controlled for temporal trends and temperature.Results: Between 2013 and 2018, Shasta County experienced 19 weeks with average wildfire PM2.5 ≥5.5 mug/m3 (hereafter, "high wildfire PM2.5 concentration"). Among all Shasta County Zip Code Tabulation Areas (ZCTAs; n = 36), we detected no association between high wildfire PM2.5 concentrations and respiratory or circulatory disease-related ED visits or mortality. Subsequent analyses were confined to valley ZCTAs (n = 11, lower elevation, majority of population, worse air quality in general). In valley ZCTAs, high wildfire PM2.5 was associated with a 14.6% (95% confidence interval [CI] = 4.2, 24.9) increase in same-week respiratory disease-related ED visits but no increase in the subsequent 2 weeks nor on circulatory disease-related mortality or ED visits or all-cause mortality. Two weeks after high wildfire PM2.5 weeks, respiratory disease-related deaths decreased (-31.5%, 95% CI = -64.4, 1.5). The 2018 Carr Fire appeared to increase respiratory disease-related ED visits by 27.0% (95% CI = 4.0, 50.0) over expectation and possibly reduce circulatory disease-related deaths (-18.2%, 95% CI = -39.4, 2.9).Conclusions: As climate change fuels wildfire seasons, studies must continue to evaluate their health effects, particularly in highly exposed populations.

    View details for DOI 10.1097/EE9.0000000000000124

    View details for PubMedID 33778357

  • The Impact of the first COVID-19 shelter-in-place announcement on social distancing, difficulty in daily activities, and levels of concern in the San Francisco Bay Area: A cross-sectional social media survey. PloS one Elser, H. n., Kiang, M. V., John, E. M., Simard, J. F., Bondy, M. n., Nelson, L. M., Chen, W. T., Linos, E. n. 2021; 16 (1): e0244819


    The U.S. has experienced an unprecedented number of orders to shelter in place throughout the ongoing COVID-19 pandemic. We aimed to ascertain whether social distancing; difficulty with daily activities; and levels of concern regarding COVID-19 changed after the March 16, 2020 announcement of the nation's first shelter-in-place orders (SIPO) among individuals living in the seven affected counties in the San Francisco Bay Area.We conducted an online, cross-sectional social media survey from March 14 -April 1, 2020. We measured changes in social distancing behavior; experienced difficulties with daily activities (i.e., access to healthcare, childcare, obtaining essential food and medications); and level of concern regarding COVID-19 after the March 16 shelter-in-place announcement in the San Francisco Bay Area versus elsewhere in the U.S.In this non-representative sample, the percentage of respondents social distancing all of the time increased following the shelter-in-place announcement in the Bay Area (9.2%, 95% CI: 6.6, 11.9) and elsewhere in the U.S. (3.4%, 95% CI: 2.0, 5.0). Respondents also reported increased difficulty obtaining hand sanitizer, medications, and in particular respondents reported increased difficulty obtaining food in the Bay Area (13.3%, 95% CI: 10.4, 16.3) and elsewhere (8.2%, 95% CI: 6.6, 9.7). We found limited evidence that level of concern regarding the COVID-19 crisis changed following the announcement.This study characterizes early changes in attitudes, behaviors, and difficulties. As states and localities implement, rollback, and reinstate shelter-in-place orders, ongoing efforts to more fully examine the social, economic, and health impacts of COVID-19, especially among vulnerable populations, are urgently needed.

    View details for DOI 10.1371/journal.pone.0244819

    View details for PubMedID 33444363

  • Does the Implementation of Reference Pricing Result in Reduced Utilization? Evidence From Inpatient and Outpatient Procedures MEDICAL CARE RESEARCH AND REVIEW Elser, H., Lin, W., Catalano, R. A., Brown, T. T. 2020: 1077558720971117


    Reference pricing (RP) is an insurance design that can be used to incentivize patients to use low-price settings. While RP is not intended to affect overall utilization, it could unintentionally reduce utilization. We examined whether utilization was reduced when a large employer adopted RP for selected elective surgeries, including inpatient joint replacement surgery and outpatient cataract surgery, colonoscopy, and arthroscopic surgery. Data included a treatment group subject to RP implementation and a comparison group that was not. We applied autoregressive integrated moving average analysis as comparison-population interrupted time-series analysis to determine whether there were procedure reductions following RP implementation. We find no evidence of short-term decreases (within 3 months of RP implementation). However, we find very modest declines of approximately 14 (20%) fewer arthroscopic knee surgeries 6 months after RP implementation and 129 (17.2%) fewer colonoscopies 8 months after RP implementation. There were no declines in the other procedures examined.

    View details for DOI 10.1177/1077558720971117

    View details for Web of Science ID 000626207800001

    View details for PubMedID 33174511

  • Developing Tobacco Control Interventions in Permanent Supportive Housing for Formerly Homeless Adults HEALTH PROMOTION PRACTICE Alizaga, N. M., Nguyen, T., Petersen, A., Elser, H., Vijayaraghavan, M. 2020; 21 (6): 972–82
  • Among Low-Income Women In San Francisco, Low Awareness Of Paid Parental Leave Benefits Inhibits Take-Up. Health affairs (Project Hope) Goodman, J. M., Elser, H., Dow, W. H. 2020; 39 (7): 1157–65


    Paid family leave policies have the potential to reduce health disparities, yet access to paid leave remains limited and unevenly distributed in the United States. Using California administrative claims data, we examined the impact of the San Francisco Paid Parental Leave Ordinance, the first in the US to provide parental leave with full pay. We found that the law increased parental leave uptake in San Francisco by 13percent among fathers, but there was little change in leave among mothers. Data from a survey of mothers suggest that the limited impact may be partly a result of low understanding of benefits. Lower-income mothers reported even less knowledge of their maternity leave benefits than other mothers, and fewer than 2percent of lower-income mothers had accurate information about the policy. The San Francisco policy also excludes small employers, which further limits its reach among low-income workers. A simpler universal policy may be more effective in expanding parental leave among vulnerable workers.

    View details for DOI 10.1377/hlthaff.2020.00157

    View details for PubMedID 32634354

  • Collective Optimism and Selection Against Male Twins in Utero TWIN RESEARCH AND HUMAN GENETICS Catalano, R. A., Goldman-Mellor, S., Karasek, D. A., Gemmill, A., Casey, J. A., Elser, H., Bruckner, T. A., Hartig, T. 2020; 23 (1): 45–50


    Scholarly literature claims that health declines in populations when optimism about investing in the future wanes. This claim leads us to describe collective optimism as a predictor of selection in utero. Based on the literature, we argue that the incidence of suicide gauges collective optimism in a population and therefore willingness to invest in the future. Using monthly data from Sweden for the years 1973-2016, we test the hypothesis that the incidence of suicide among women of child-bearing age correlates inversely with male twin births, an indicator of biological investment in high-risk gestations. We find that, as predicted by our theory, the incidence of suicide at month t varies inversely with the ratio of twin to singleton male births at month t + 3. Our results illustrate the likely sensitivity of selection in utero to change in the social environment and so the potential for viewing collective optimism as a component of public health infrastructure.

    View details for DOI 10.1017/thg.2020.2

    View details for Web of Science ID 000530316700007

    View details for PubMedID 31983362

  • Implications of the COVID-19 San Francisco Bay Area Shelter-in-Place Announcement: A Cross-Sectional Social Media Survey. medRxiv : the preprint server for health sciences Elser, H. n., Kiang, M. V., John, E. M., Simard, J. F., Bondy, M. n., Nelson, L. M., Chen, W. T., Linos, E. n. 2020


    The U.S. has experienced an unprecedented number of shelter-in-place orders throughout the COVID-19 pandemic. There is limited empirical research that examines the impact of these orders. We aimed to rapidly ascertain whether social distancing; difficulty with daily activities (obtaining food, essential medications and childcare); and levels of concern regarding COVID-19 changed after the March 16, 2020 announcement of shelter-in-place orders for seven counties in the San Francisco Bay Area.We conducted an online, cross-sectional social media survey from March 14 - April 1, 2020. We measured changes in social distancing behavior; experienced difficulties with daily activities (i.e., access to healthcare, childcare, obtaining essential food and medications); and level of concern regarding COVID-19 after the March 16 shelter-in-place announcement in the San Francisco Bay Area and elsewhere in the U.S.The percentage of respondents social distancing all of the time increased following the shelter-in-place announcement in the Bay Area (9.2%, 95% CI: 6.6, 11.9) and elsewhere in the U.S. (3.4%, 95% CI: 2.0, 5.0). Respondents also reported increased difficulty with obtaining food, hand sanitizer, and medications, particularly with obtaining food for both respondents from the Bay Area (13.3%, 95% CI: 10.4, 16.3) and elsewhere (8.2%, 95% CI: 6.6, 9.7). We found limited evidence that level of concern regarding the COVID-19 crisis changed following the shelter-in-place announcement.These results capture early changes in attitudes, behaviors, and difficulties. Further research that specifically examines social, economic, and health impacts of COVID-19, especially among vulnerable populations, is urgently needed. =.

    View details for DOI 10.1101/2020.06.29.20143156

    View details for PubMedID 32637974

    View details for PubMedCentralID PMC7340200

  • Still- and Live Births in the Periviable Period. Annals of epidemiology Elser, H. n., Gemmill, A. n., Casey, J. A., Karasek, D. n., Bruckner, T. n., Mayo, J. A., Lee, H. C., Stevenson, D. K., Shaw, G. M., Catalano, R. n. 2020


    We use data from California, where 13% of US births occur, to address two questions arising from efforts in the first decade of this century to avoid stillbirth before 25 6/7 weeks of gestation (i.e., in the periviable period). First, did stillbirths decline in the first decade of this century? Second, if stillbirths did decline, did periviable live births increase simultaneously? Answering these questions would seem important given that periviable infants represent <1% of live births but account for roughly 40% of infant mortality and 20% of hospital-based obstetric costs in the US.We constructed 240 monthly conception cohorts, starting with that conceived in January 1991, from 9,880,536 singleton pregnancies that reached the 20 0/7 week of gestation. We used time-series design and Box-Jenkins methods that address confounding by autocorrelation, including secular trends and seasonality to answer our questions.We detected a downward shift in stillbirths in April 2007 that coincided with an upward shift in periviable live births.Our findings imply that, since 2007, fewer Californians than expected from history and from the size of conception cohorts reaching 20 0/7 weeks of gestation, have had to contend with the sequelae of stillbirth, but more than expected likely have had to contend with those of periviable birth.

    View details for DOI 10.1016/j.annepidem.2020.07.002

    View details for PubMedID 32648545

  • Alternative flavored and unflavored tobacco product use and cigarette quit attempts among current smokers experiencing homelessness. Addictive behaviors reports Alizaga, N. M., Hartman-Filson, M. n., Elser, H. n., Halpern-Felsher, B. n., Vijayaraghavan, M. n. 2020; 12: 100280


    Alternative tobacco product (ATP) use is common in the general population; however, few studies have explored ATP among individuals experiencing homelessness. We recruited individuals experiencing homelessness who were current cigarette smokers to explore flavored and unflavored ATP use and its association with past-year cigarette quit attempts.Using time-location sampling, we recruited participants from eight service sites in San Francisco, CA between December 2017 and July 2018. We explored type of ATP use and perceptions of product addiction, harm and risk between cigarette-only smokers and those who used cigarettes and ATPs ('ATP users'). We used logistic regression to examine the association between ATP and past-year quit attempts, adjusting for demographics, substance use disorders, depressive symptoms, and cigarette use characteristics.Among the 470 participants, 34.5% were cigarette-only users and 65.5% were ATP users. Among ATP users, 74.0% used cigars and 29.8% used e-cigarettes in the past month, with fruit-flavored products being the most common. ATP users were more likely to perceive cigars, blunts, and smokeless tobacco to be quite to extremely harmful or addictive compared to cigarette-only users. ATP use was not associated with past-year quit attempts, whereas hazardous alcohol use (OR = 2.07; CI 1.07-4.02) was associated with higher odds and and amphetamine use (OR = 0.50; CI 0.26-0.98) was associated with lower odds of past-year attempts.High rates of ATP use highlight a need for studies that explore motivations for use, beyond use as a smoking cessation aid, among people experiencing homelessness.

    View details for DOI 10.1016/j.abrep.2020.100280

    View details for PubMedID 32637560

    View details for PubMedCentralID PMC7330871

  • Language-Related Disparities in Pain Management in the Post-Anesthesia Care Unit for Children Undergoing Laparoscopic Appendectomy. Children (Basel, Switzerland) Dixit, A. A., Elser, H. n., Chen, C. L., Ferschl, M. n., Manuel, S. P. 2020; 7 (10)


    Race and ethnicity are associated with disparities in pain management in children. While low English language proficiency is correlated with minority race/ethnicity in the United States, it is less frequently explored in the study of health disparities. We therefore investigated whether English language proficiency influenced pain management in the post-anesthesia care unit (PACU) in a cohort of children who underwent laparoscopic appendectomy at our pediatric hospital in San Francisco. Our primary exposure was English language proficiency, and our primary outcome was administration of any opioid medication in the PACU. Secondary outcomes included the amount of opioid administered in the PACU and whether any pain score was recorded during the patient's recovery period. Statistical analysis included adjusting for demographic covariates including race in estimating the effect of language proficiency on these outcomes. In our cohort of 257 pediatric patients, 57 (22.2%) had low English proficiency (LEP). While LEP and English proficient (EP) patients received the same amount of opioid medication intraoperatively, in multivariable analysis, LEP patients had more than double the odds of receiving any opioid in the PACU (OR 2.45, 95% CI 1.22-4.92). LEP patients received more oral morphine equivalents (OME) than EP patients (1.64 OME/kg, CI 0.67-3.84), and they also had almost double the odds of having no pain score recorded during their PACU recovery period (OR 1.93, CI 0.79-4.73), although the precision of these estimates was limited by small sample size. Subgroup analysis showed that children over the age of 5 years, who were presumably more verbal and would therefore undergo verbal pain assessments, had over triple the odds of having no recorded pain score (OR 3.23, CI 1.48-7.06). In summary, English language proficiency may affect the management of children's pain in the perioperative setting. The etiology of this language-related disparity is likely multifactorial and should be investigated further.

    View details for DOI 10.3390/children7100163

    View details for PubMedID 33020409

  • Chronic obstructive pulmonary disease mortality: The Diesel Exhaust in Miners Study (DEMS). Environmental research Ferguson, J. M., Costello, S., Elser, H., Neophytou, A. M., Picciotto, S., Silverman, D. T., Eisen, E. A. 2019: 108876


    BACKGROUND: Miners are highly exposed to diesel exhaust emissions from powered equipment. Although biologically plausible, there is little evidence based on quantitative exposure assessment, that long-term diesel exposure increases risk of chronic obstructive pulmonary disease (COPD). To fill this gap, we examined COPD mortality and diesel exhaust exposure in the Diesel Exhaust in Miners Study (DEMS).METHODS: We fit Cox models to estimate hazard ratios (HRs) for COPD mortality and cumulative exposure (mug/m3-years) to respirable elemental carbon (REC), a key metric for diesel exhaust exposure. Separate models were fit for ever-underground and surface-only miners to allow for effect modification. Exposure was lagged by 0, 10 and 15 years. In a secondary analysis, we addressed the healthy worker survivor effect by applying the parametric g-formula to handle time-varying confounding affected by prior exposure among ever-underground workers.RESULTS: Based on 140 cases, the HRs for COPD mortality increased as categories of lagged REC exposure increased for all workers. Among surface-only workers, those in the middle exposure category (0 lag) had a significantly elevated hazard ratio of 2.34 (95% CI: 1.11-4.61) relative to those in the lowest category. Among the ever-underground, that ratio was 1.35, with wide confidence intervals. Using the g-formula, we estimated that the lifetime cumulative risk of COPD mortality would have been reduced from the observed 5.0%-3.1% under a hypothetical intervention where all ever-underground workers were always unexposed.CONCLUSIONS: Our results suggest long term exposure to diesel exhaust may increase risk of COPD in miners, though power was limited.

    View details for DOI 10.1016/j.envres.2019.108876

    View details for PubMedID 31711661

  • Layoffs and the mental health and safety of remaining workers: a difference-in-differences analysis of the US aluminium industry. Journal of epidemiology and community health Elser, H., Ben-Michael, E., Rehkopf, D., Modrek, S., Eisen, E. A., Cullen, M. R. 2019


    BACKGROUND: Relatively few studies have examined the effects of layoffs on remaining workers, although the effects of layoffs and downsizing events may extend beyond those employees who lose their jobs.METHODS: We examined the effects of layoffs on mental healthcare utilisation and injury risk among workers at 30 US plants between 2003 and 2013. We defined layoffs as reductions in the hourly workforce of 20% or more at each plant. Using a difference-in-differences approach, we compared the change in outcomes during layoffs versus the same 3-month period 1year previously, accounting for secular trends with control plants.RESULTS: Our study population included 15502 workers and 7 layoff events between 2003 and 2013. Layoffs were associated with only minor decreases in injuries (-0.006, 95%CI -0.013 to 0.001). The probability of outpatient visits related to mental health increased by 1% during layoffs (0.010, 95%CI 0.003 to 0.017), and the probability of mental health-related prescriptions increased by 1.4% (0.014, 95%CI -0.0006 to 0.027). Among women, the increase in outpatient visits was more pronounced (0.017, 95%CI 0.003 to 0.031). Increased prescription utilisation appeared attributable primarily to opioid use (0.016, 95%CI 0.005 to 0.027).CONCLUSION: Our results indicate an association between layoffs and remaining workers' mental health and safety, although changes mental healthcare utilisation may reflect both changes in underlying mental health and changes in care-seeking. Future research on concordance of service utilisation and underlying health may yield valuable insight into the experiences employed workers in the wake of layoffs.

    View details for DOI 10.1136/jech-2018-211774

    View details for PubMedID 31533963

  • Association of Preterm Births Among US Latina Women With the 2016 Presidential Election JAMA NETWORK OPEN Gemmill, A., Catalano, R., Casey, J. A., Karasek, D., Alcala, H. E., Elser, H., Torres, J. M. 2019; 2 (7): e197084


    The circumstances surrounding the 2016 US presidential election have been proposed as a significant stressor in the lives of the US Latino population. Few studies to date, however, have evaluated the population health implications of the election for Latina mothers and their children.To determine whether preterm births (gestational age, <37 weeks) among US Latina women increased above expected levels after the 2016 US presidential election.In this national population-based study, an interrupted time series design, used to evaluate whether policies or other population-level changes interrupt a trend in an outcome, compared monthly counts of preterm births to Latina women after the 2016 presidential election with the number expected had the election not taken place. Women residing in the United States who had singleton births during the study period were included. Counts of singleton term and preterm births by month and race/ethnicity from January 1, 2009, through July 30, 2017 (32 860 727 live births), were obtained from the Centers for Disease Control and Prevention Wonder online database. These methods were applied separately to male and female births. Data were analyzed from November 8, 2018, through May 7, 2019.Pregnancy in the 2016 US presidential election.The number of male and female preterm births based on the last menstrual period.Among the 32 860 727 live births recorded during the study period, 11.0% of male and 9.6% of female births to Latina women were preterm compared with 10.2% and 9.3%, respectively, to other women. In the 9-month period beginning with November 2016, an additional 1342 male (95% CI, 795-1889) and 995 female (95% CI, 554-1436) preterm births to Latina women were found above the expected number of preterm births had the election not occurred.The 2016 US presidential election appears to have been associated with an increase in preterm births among US Latina women. Anti-immigration policies have been proposed and enforced in the aftermath of the 2016 presidential election; future research should evaluate the association of these actions with population health.

    View details for DOI 10.1001/jamanetworkopen.2019.7084

    View details for Web of Science ID 000477895900038

    View details for PubMedID 31322687

    View details for PubMedCentralID PMC6647358

  • Sun Smoke in Sweden: Perinatal Implications of the Laki Volcanic Eruptions, 1783-1784. Epidemiology (Cambridge, Mass.) Casey, J. A., Gemmill, A., Elser, H., Karasek, D., Catalano, R. 2019; 30 (3): 330-333


    The Icelandic volcano Laki erupted from June 1783 through January 1784. It produced 122 megatons of sulfur dioxide, particulate matter, and acid rain and contributed to one of the coldest winters on record in Western Europe. Although uncontrollable volcanic eruptions continue, few studies have investigated their perinatal health implications.Using the Human Mortality Database, we assessed the association between the Laki event and the secondary sex ratio, infant mortality rates, and the number of births from 1751 to 1800 with time-series models that controlled for temporal trends.The secondary sex ratio decreased 3% below expected levels in 1784 (95% CI = -4%, -1%). Both female and male infant mortality rates exceeded expectation in 1785, by 54% (95% CI = 25%, 83%) and 37% (-1%, 74%), respectively. We observed little change in female live births but a reduction in male live births in 1784.Our findings are consistent with the hypothesis that the large-scale Laki volcanic eruptions of 1783-1784 resulted in adverse perinatal health outcomes in Sweden.

    View details for DOI 10.1097/EDE.0000000000000977

    View details for PubMedID 30789427

    View details for PubMedCentralID PMC6456407

  • Developing Tobacco Control Interventions in Permanent Supportive Housing for Formerly Homeless Adults. Health promotion practice Alizaga, N. M., Nguyen, T., Petersen, A. B., Elser, H., Vijayaraghavan, M. 2019: 1524839919839358


    Smoke-free policies are effective population-based strategies to reduce tobacco use yet are uncommon in permanent supportive housing (PSH) for formerly homeless individuals who have high rates of smoking. In this study, we partnered with six supportive housing agencies in the San Francisco Bay Area to examine the implementation of smoke-free policies and cessation services. We administered a questionnaire and conducted in-depth, semistructured interviews with agency directors (n = 6), property management staff (n = 23), and services staff (n = 24) from 23 PSH sites on the barriers to implementing tobacco control interventions. All properties restricted smoking in indoor shared areas, but only two had policies restricting smoking in living areas. While there was staff consensus that smoke-free policies were important to reduce tobacco-related harm, participants disagreed on whether smoke-free policies were aligned with PSH's harm reduction framework. Residents' comorbid mental illness and substance use and the lack of appropriate enforcement tools were barriers to implementation. Using these formative findings, we present a framework for a toolkit of strategies to increase implementation of smoke-free policies and cessation interventions in PSH. Successful implementation of indoor smoke-free policies in PSH will require concurrent cessation services to support smoking cessation efforts and address the mental health and substance use needs of residents.

    View details for PubMedID 30971139

  • Increased motor vehicle crashes following induced earthquakes in Oklahoma, USA SCIENCE OF THE TOTAL ENVIRONMENT Casey, J. A., Elser, H., Goldman-Mellor, S., Catalano, R. 2019; 650: 2974–79


    Anxiety-inducing life events increase the risk of motor vehicle crashes. We test the hypothesis that earthquakes, known to increase anxiety in the population, also increase the incidence of motor vehicle crashes. Our study took place in Oklahoma, USA where wastewater injection resulted in increased induced seismicity between 2010 and 2016. We identified dates of earthquakes ≥ magnitude 4 (a level felt by most people) with data from the U.S. Geologic Survey. The Oklahoma Highway Safety Office provided county-level monthly vehicle crash counts. We defined high, medium, and low earthquake exposure counties based on the location of earthquake epicenters. Using time-series analyses, we evaluated the association between monthly counts of ≥magnitude 4 earthquakes and motor vehicle crashes by exposure group. Earthquakes ≥ magnitude 4 took place in 38 of 84 study months, and a monthly average of 5813 (SD = 384) crashes occurred between 2010 and 2016. In high-exposure counties, we observed an additional 39.2 motor vehicle crashes per each additional ≥ magnitude 4 earthquake in the prior month (SE = 11.5). We found no association between the timing of ≥magnitude 4 earthquakes and motor vehicle crashes in the medium or low exposure counties. With a binary earthquake exposure variable, we found a 4.6% (SE = 1.4%) increase in motor vehicle crashes in the high exposure counties in the month following 1 or more ≥magnitude 4 earthquakes. Consistent with our hypothesis, there was no association between earthquakes of magnitude ≤ 2.5 and motor vehicle crashes in the high-exposure counties. This novel evidence of an association between induced earthquakes in Oklahoma and motor vehicle crashes warrants future research given the high economic and social costs of such vehicle crashes.

    View details for DOI 10.1016/j.scitotenv.2018.10.043

    View details for Web of Science ID 000447871400124

    View details for PubMedID 30373073

    View details for PubMedCentralID PMC6214370

  • Blue-collar work and women's health: A systematic review of the evidence from 1990 to 2015 SSM-POPULATION HEALTH Elser, H., Falconi, A. M., Bass, M., Cullen, M. R. 2018; 6: 195–244
  • How and why studies disagree about the effects of education on health: A systematic review and meta-analysis of studies of compulsory schooling laws SOCIAL SCIENCE & MEDICINE Hamad, R., Elser, H., Tran, D. C., Rehkopf, D. H., Goodman, S. N. 2018; 212: 168–78


    Rich literatures across multiple disciplines document the association between increased educational attainment and improved health. While quasi-experimental studies have exploited variation in educational policies to more rigorously estimate the health effects of education, there remains disagreement about whether education and health are causally linked. The aim of this study was to conduct a systematic review and meta-analysis to characterize this literature, with a focus on quasi-experimental studies of compulsory schooling laws (CSLs). Articles from 1990 to 2015 were obtained through electronic searches and manual searches of reference lists. We searched for English-language studies and included manuscripts if: (1) they involved original data analysis; (2) outcomes were health-related; and (3) the primary predictor utilized variation in CSLs. We identified 89 articles in 25 countries examining over 25 health outcomes, with over 600 individual point estimates. We systematically characterized heterogeneity on key study design features and conducted a meta-analysis of studies with comparable health outcome and exposure variables. Within countries, studies differed in terms of birth cohorts included, the measurement of health outcomes within a given category, and the type of CSL variation examined. Over 90% of manuscripts included multiple analytic techniques, such as econometric and standard regression methods, with as many as 31 "primary" models in a single study. A qualitative synthesis of study findings indicated that educational attainment has an effect on the majority of health outcomes-most beneficial, some negative-while the meta-analysis demonstrated small beneficial effects for mortality, smoking, and obesity. Future work could focus on inconsistent findings identified by this study, or review the health effects of other types of educational policies.

    View details for PubMedID 30036767

  • Smoking Policy Change Within Permanent Supportive Housing JOURNAL OF COMMUNITY HEALTH Petersen, A., Stewart, H. C., Walters, J., Vijayaraghavan, M. 2018; 43 (2): 312–20


    Smoke-free policies effectively reduce secondhand smoke (SHS) exposure among non-smokers, and reduce consumption, encourage quit attempts, and minimize relapse to smoking among smokers. Such policies are uncommon in permanent supportive housing (PSH) for formerly homeless individuals. In this study, we collaborated with a PSH provider in San Diego, California to assess a smoke-free policy that restricted indoor smoking. Between August and November 2015, residents completed a pre-policy questionnaire on attitudes toward smoke-free policies and exposure to secondhand smoke, and then 7-9 months after policy implementation residents were re-surveyed. At follow-up, there was a 59.7% reduction in indoor smoking. The proportion of residents who identified as current smokers reduced by 13% (95% CI: -38, 10.2). The proportion of residents who reported never smelling SHS indoors (apartment 24.2%, 95% CI: 4.2, 44.1; shared areas 17.2%, 95% CI: 1.7, 32.7); in outdoor areas next to the living unit (porches or patio 56.7%, 95% CI: 40.7, 72.8); and in other outdoor areas (parking lot 28.6%, 95% CI: 8.3, 48.9) was lower post-policy compared with pre-policy. Overall, resident support increased by 18.7%; however, the greatest increase in support occurred among current smokers (from 14.8 to 37.5%). Fewer current smokers reported that the policy would enable cessation at post-policy compared to pre-policy. Our findings demonstrate the feasibility of implementing smoke-free policies in PSH for formerly homeless adults. However, policy alone appears insufficient to trigger change in smoking behavior, highlighting the need for additional cessation resources to facilitate quitting.

    View details for DOI 10.1007/s10900-017-0423-7

    View details for Web of Science ID 000426397200015

    View details for PubMedID 28884243

    View details for PubMedCentralID PMC5832576

  • Separating the Bruce and Trivers-Willard effects in theory and in human data AMERICAN JOURNAL OF HUMAN BIOLOGY Catalano, R., Gemmill, A., Casey, J., Karasek, D., Stewart, H., Saxton, K. 2018; 30 (2)


    Theories of reproductive suppression predict that natural selection would conserve mechanisms that abort the gestation of offspring otherwise unlikely to thrive in prevailing environments. Research reports evidence among humans of at least two such mechanisms-the Trivers-Willard and Bruce Effects. No literature, however, compares the mechanisms nor estimates their relative contribution to observed characteristics of human birth cohorts. We describe similarities and differences between the Trivers-Willard and Bruce Effects and explore high quality historical data from Sweden to determine which mechanism better describes temporal variation in the ratio of males to females in birth cohorts.We measure Trivers-Willard exposures with the death rate among women of reproductive age. We measure Bruce exposures with the death rate among children. We use time-series regression methods to estimate the relative contribution of the Trivers-Willard and Bruce Effects to temporal variation in historical Swedish secondary sex ratio data.We find that the Bruce Effect appears to be a better predictor of the secondary sex ratio than does the Trivers-Willard Effect.Attempts to identify mechanisms by which reproductive suppression affects fetal loss and characteristics of human birth cohorts should consider the Bruce Effect as an alternative to the Trivers-Willard Effect.

    View details for DOI 10.1002/ajhb.23074

    View details for Web of Science ID 000427233300002

    View details for PubMedID 29083077

  • Understanding periviable birth: A microeconomic alternative to the dysregulation narrative. Social science & medicine (1982) Catalano, R., Bruckner, T., Avalos, L. A., Stewart, H., Karasek, D., Kariv, S., Gemmill, A., Saxton, K., Casey, J. 2017


    Periviable infants (i.e., those born in the 20th through 26th weeks of gestation) suffer much morbidity and approximately half die in the first year of life. Attempts to explain and predict these births disproportionately invoke a "dysregulation" narrative. Research inspired by this narrative has not led to efficacious interventions. The clinical community has, therefore, urged novel approaches to the problem. We aim to provoke debate by offering the theory, inferred from microeconomics, that risk tolerant women carry, without cognitive involvement, high risk fetuses farther into pregnancy than do other women. These extended high-risk pregnancies historically ended in stillbirth but modern obstetric practices now convert a fraction to periviable births. We argue that this theory deserves testing because it suggests inexpensive and noninvasive screening for pregnancies that might benefit from the costly and invasive interventions clinical research will likely devise.

    View details for DOI 10.1016/j.socscimed.2017.12.014

    View details for PubMedID 29274689

  • Attitudes Toward Smoking Cessation Among Sheltered Homeless Parents Journal of community health Stewart, H. C., Stevenson, T. N., Bruce, J. S., Greenberg, B., Chamberlain, L. J. 2015: 1-9