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This study was designed to estimate the economic burden of poststroke aphasia in the United States. The economic burden of aphasia was calculated based on three cost factors: medical and healthcare...

Introduction: Health services research has demonstrated the association between patient satisfaction and treatment outcomes illustrating the importance of satisfaction in determining favorable treatment outcomes. Despite abundant evidence in the acute care setting, few researchers have explored these associations among patients receiving speech rehabilitation or therapeutic treatment particularly those receiving treatment through nontraditional delivery methods. Objective: To examine the satisfaction with a community-based telepractice approach for treating aphasia among stroke survivors who reside in rural areas and assess potential correlations between satisfaction and patient outcomes. Methods: In total, 22 adults with poststroke aphasia who resided in rural areas received comprehensive language-oriented treatment (LOT) for aphasia through community-based telepractice. Post-treatment satisfaction with the telepractice approach was assessed using the Client Satisfaction Questionnaire-8 (CSQ-8). Results: After 12 sessions of LOT, Western Aphasia Battery-revised (WAB-R) aphasia quotients (AQs) improved on average 4.64 U. Mean scores on the CSQ-8 averaged 31.0/32.0, indicating a high level of satisfaction with the telepractice approach. In addition, each 1 U of improvement in patient satisfaction was associated with a 1.75 U increase in the WAB-R AQ. Conclusions: Examination of post-treatment satisfaction indicated that satisfaction was highly predictive of effectiveness—a one-point increase in satisfaction was associated with a nearly two-point increase in WAB-R AQ. Results echo findings from acute care studies underscoring the importance of the patient experience in treatment efficacy.

Health disparities have once again moved to the forefront of America's consciousness with the recent significant observation of dramatically higher death rates among African Americans with COVID-19 when compared to White Americans. Health disparities have a long history in the United States, yet little consideration has been given to their impact on the clinical outcomes in the rehabilitative health professions such as speech-language pathology/audiology (SLP/A). Consequently, it is unclear how the absence of a careful examination of health disparities in fields like SLP/A impacts the clinical outcomes desired or achieved. The purpose of this tutorial is to examine the issue of health disparities in relationship to SLP/A. This tutorial includes operational definitions related to health disparities and a review of the social determinants of health that are the underlying cause of such disparities. The tutorial concludes with a discussion of potential directions for the study of health disparities in SLP/A to identify strategies to close the disparity gap in health-related outcomes that currently exists.

The 2010 report of the President's Cancer Panel concluded that the burden of cancer from chemical exposures is substantial, while the programs for testing and regulation of carcinogens remain inadequate. New research on the role of early life exposures and the ability of chemicals to act via multiple biological pathways, including immunosuppression, inflammation, and endocrine disruption as well as mutagenesis, further supports the potential for chemicals and chemical mixtures to influence disease. Epidemiologic observations, such as higher leukemia incidence in children living near roadways and industrial sources of air pollution, and new in vitro technologies that decode carcinogenesis at the molecular level, illustrate the diverse evidence that primary prevention of some cancers may be achieved by reducing harmful chemical exposures. The path forward requires cross-disciplinary approaches, increased environmental research investment, system-wide collaboration to develop safer economic alternatives, and community engagement to support evidence-informed action. Engagement by cancer researchers to integrate environmental risk factors into prevention initiatives holds tremendous promise for reducing the rates of disease. See all articles in this CEBP Focus section, “Environmental Carcinogenesis: Pathways to Prevention.”

Background Clinical provision of intensive behavioral therapy for obesity (IBTO) has been a reimbursable treatment for obesity since 2012. However, gaps remain in the literature regarding its impact on patient outcomes. Objectives The primary objective of this study was to examine the integration of registered dietitian nutritionist provided IBTO into a primary care setting and evaluate clinic outcomes for Medicare Part B beneficiaries. A secondary objective was to examine intensity of IBTO (quantity of IBTO visits) versus clinical outcomes and influence of socioeconomic factors. Methods A case–control retrospective chart review was conducted at a rural, Academic Family Medicine Clinic in Eastern North Carolina for patients seen between 1 January 2016 and 1 January 2019. In order to be included in the treatment group, patients had to be female, white or black race, have Medicare insurance and a body mass index ≥ 30 kg/m2. Results Mixed model analysis showed statistically significant improvements in clinical outcomes from IBTO treatment. Weight decreased by nearly 3 pounds, while body mass index was half a point lower. A1C was 0.1 units lower for IBTO patients, and they took prescription medication and average of 6 days less than the control group. Minorities and older respondents experienced smaller, all else constant, and annual fixed effects suggest that differentials widen over time. Conclusions Registered dietitian nutritionist (RDN) provision of IBTO has demonstrated benefit in improving clinical outcomes including weight, A1C, and reduced medication duration (use) as demonstrated by the IBTO treatment group versus control. IBTO intensity was not predictive of success, and its impact was reduced with older and African American patients. IBTO is beneficial and can be delivered within the primary care setting by a RDN.

Background Debates over the importance of “lifestyle” versus “environment” contributions to cancer have been going on for over 40 years. While it is clear that cigarette smoking is the most significant cancer risk factor, the contributions of occupational and environmental carcinogens in air, water and food remain controversial. In practice, most cancer prevention messaging focuses on reducing cigarette smoking and changing other personal behaviors with little mention of environmental chemicals, despite widespread exposure to many known carcinogens. To inform decision-making on cancer prevention priorities, we evaluated the potential impact of smoking cessation on cancer rates. Methods Using cancer incidence data from 612 counties in the SEER database, and county-level smoking prevalences, we investigated the impact of smoking cessation on incidence for 12 smoking-related cancer types, 2006—2016. A multilevel mixed-effects regression model quantified the association between county-level smoking prevalence and cancer incidence, adjusting for age, gender and variability over time and among counties. We simulated complete smoking cessation and estimated the effects on county-level cancer rates. Results Regression models showed the expected strong association between smoking prevalence and cancer incidence. Simulating complete smoking cessation, the incidence of the 12 smoking-related cancer types fell by 39.8% (54.9% for airways cancers; 28.9% for non-airways cancers). And, while the actual rates of smoking-related cancers from 2006 to 2016 declined (annual percent change (APC) = − 0.8, 95% CI = − 1.0 to − 0.5%), under the scenario of smoking elimination, the trend in cancer incidence at these sites was not declining (APC = − 0.1, 95% CI = − 0.4 to + 0.1%). Not all counties were predicted to benefit equally from smoking elimination, and cancer rates would fall less than 10% in some counties. Conclusions Smoking prevention has produced dramatic reductions in cancer in the US for 12 major types. However, we estimate that eliminating smoking completely would not affect about 60% of cancer cases of the 12 smoking-related types, leaving no improvement in the incidence trend from 2006 to 2016. We conclude that cancer prevention strategies should focus not only on lifestyle changes but also the likely contributions of the full range of risk factors, including environmental/occupational carcinogens.

A stroke is a life-altering event that occurs without warning. Strokes differ in severity with some being mild and others leaving survivors with permanent disabilities. While the physical and mental consequences of stroke can require extensive treatment and rehabilitation, the emotional ramifications are often ignored. In addition to outlining the prevalence and severity of depression among stroke survivors, this study examines the likelihood of mental health service utilization and barriers to care. Using data from the 2018 National Health Interview Survey, regression analysis evaluated the association between depression, depression frequency, and race/ethnicity controlling for income, insurance, and demographic characteristics among adult stroke survivors. Analyses also tested the likelihood of mental health services utilization and potential barriers to care among survivors who reported depression. Results indicated that Blacks and Hispanics stroke survivors were more likely to experience depression and experience depression more frequently than Whites. Minority groups were also less likely to utilize mental health services but did not cite lack of insurance or affordability as the reason for low utilization. This study found a higher prevalence and frequency of depression among Blacks and Hispanics and lower likelihood of receiving mental health services. Findings suggest lower mental health service utilization among depressed minority stroke survivors may be related to unobservable factors such as social stigma, lack of available care, inability to clearly identify depressive symptoms, and potentially greater resilience to overcome the negative impact of the condition. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

This study investigated the relationship between redeeming a voucher at hospital-based Medical Food Pantry (MFP) and hospital readmissions in Greenville, NC. Admitted patients at Vidant Medical Center identified as food insecure were given a voucher to the MFP. A retrospective chart review identified demographic information, type of insurance, voucher provision, and redemption dates, food bag type and number of subsequent hospital readmissions for all patients issued a voucher (n = 542) between June 21, 2018 and July 1, 2019. Negative binomial regression analysis assessed the relationship between readmissions and voucher redemption. Sixty percent of patients receiving a voucher were minority (African American) with an average age of 55. Nearly half (48 percent) had Medicare. Thirty-eight percent of those vouchers that were issued were redeemed, usually within five days. Regression results indicate that the number of readmissions was higher among women and non-whites in the sample relative to men and whites. Those patients who redeemed a food voucher had a seven percent lower likelihood of being readmitted (CI, 0.05–0.27). Food insecure patients who redeemed MFP vouchers had a comparatively lower likelihood of subsequent readmissions. These findings suggest that programs targeting modifiable social determinants of health like food insecurity could improve health outcomes and reduce utilization of the healthcare system.

Purpose The purpose of this article is to explore how racism, privilege, power, and positionality negatively impact clinical research conducted in the discipline of communication sciences and disorders. Conclusions Evidence suggests solutions will not emerge from a minor revision or adjustment of current research approaches. Instead, to make deep and necessary changes, a complete restructuring of the research process is needed. This restructuring calls for a reconceptualization of how research questions and hypotheses are formed, how methods are selected, how data are analyzed and interpreted, and who is at the table throughout this process of knowledge generation. Such an overhaul of current research approaches will offer the field a solution-oriented roadmap for scientific investigation that facilitates greater equity in the research enterprise that translates into improved clinical outcomes for all clients served.

Background Although age specific stroke rates are higher in men, women have a higher lifetime risk and are more likely to die from a stroke. Despite this increased severity, most studies focus on male/female differences in stroke onset, patterns of care and stroke-related outcomes. Given that stroke presents differently in men and women, mixed sex studies fail to fully capture heterogeneity among women with stroke and the subsequent impact on their outcomes. This study examined the sociodemographic characteristics, factors related to stroke incidence and post-stroke functional status between young ( Methods Using 5 years of data from the National Health Interview Survey (NHIS), a nationally representative sample of US adults, cohorts of young and old women with stroke were identified. A set of demographic/lifestyle, health services utilization and health status characteristics were used evaluate within gender heterogeneity in three ways. First, disparities in population characteristics were assessed using Chi-Square and t tests. Second, young and old women with stroke were matched with women without stroke in their respective cohorts to determine differences in factors related to stroke incidence. Finally, the determinants of post-stroke functional limitation for the two cohorts were determined. Results Young women with stroke were more likely to be Black, smoke regularly and frequently consume alcohol than older women. Young women were also less likely to engage with their health provider regularly or receive preventative health screenings. Diabetes, high blood pressure, high cholesterol and high BMI were correlated with an increased relative likelihood of stroke among older women. In contrast, family size, smoking frequency, alcohol consumption and sleep were correlated with an increased prevalence of stroke among young women. Although factors correlated with stroke varied between young and old women, health status and receipt of healthcare were the most significant determinants of post-stroke functional status for both cohorts. Conclusions Health related characteristics were the primary correlates of stroke in older women, whereas post-stroke lifestyle and behaviors are the most significant correlates for younger stroke survivors. These findings suggest that while receipt of health services is essential for preventing stroke in both young and old women, providers should stress the importance of post-stoke lifestyle and behaviors to younger women at risk of stroke using approaches that may be different from older stroke women.

Background In addition to the threat of serious illness, COVID-19 brought abrupt changes in lifestyle resulting in widespread fear among many Americans. This study examines the evolution of anxiety over the first months of the COVID-19 pandemic, testing for differential experiences among vulnerable populations. Methods Phase 1 of the Census Bureau's Household Pulse Survey details the frequency of anxiety among a nationally representative sample of adults from April 23, 2020 through July 21, 2020. Negative binomial regression assessed differences in the frequency of anxiety among demographic, income, health and employment status cohorts. Propensity score matching to the 2019 National Health Interview Survey allowed previous anxiety and health status to be included in the model. Results Anxiety frequency for 944,719 individuals was observed over three months. Whites, blacks and Hispanics showed increasing frequency of anxiety over the time period, particularly blacks. Prior to COVID-19, 13% of respondents reported regular or semiregular anxiety, compared to 25–35% during the pandemic. Regression analysis suggests that frequent anxiety was highly and positively correlated with COVID-19 case fatality rate and higher levels of frequency were observed among those with poor health, incomes below $25,000, and without paid employment. Limitations Causal inference was not able to be investigated due to the cross-sectional study design. Conclusions While blacks showed lower levels of anxiety initially, the proportion of the population experiencing regular anxiety increased nearly 20% over the first months of the COVID-19 pandemic. This rapid increase in anxiety could be due to inequity in health and economic outcomes among blacks.

Measures of satisfaction following treatment for aphasia have been limited. The challenge associated with reduced verbal output among many persons with aphasia (PWA) has reportedly been a key reason measures of treatment satisfaction have been limited. A novel approach to measure treatment satisfaction is the use of content analysis (CA), which uses the presence of certain words, themes, or concepts to explore outcomes such as treatment satisfaction particularly among individuals who generate limited output. CA utilizes responses and response patterns to assign meaning to client responses. The aim of this study was to use CA to measure posttreatment satisfaction with a telepractice approach for aphasia treatment. Seventeen PWA received 12 treatment sessions over a 6-week period. At the conclusion of the treatment, CA was utilized to explore patient satisfaction with this treatment approach. The participants reported an overall positive sentiment for the telepractice approach. Two primary topics emerged which were healthcare provider and healthcare delivery, where text analysis revealed discussion of these topics to be centered around being “helpful” and “being effective.” This study demonstrated that CA can be an effective approach for determining satisfaction with aphasia treatment particularly among PWA with limited verbal abilities.

Purpose The purpose of this study was to investigate the relationship between depressive symptoms and suicidal ideation and living with stuttering while accounting for time, sex, and health-related confounders. Method The data for this study come from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative survey study that has followed 13,564 respondents over the course of 14 years. Responses to the question “Do you have a problem with stuttering or stammering?” at two time points were used to establish stuttering and non-stuttering groups. Regression analysis, propensity score matching, and structural equation modeling were used. Results Compared to their fluent counterparts, males and females reported significantly elevated symptoms of depression. Although symptoms of depression among males who stutter were stable over time, depressive symptoms among females who stutter increased with age. Compared to males who do not stutter, males who stutter were significantly more likely to report feelings of suicidal ideation. There were no differences in suicidal ideation between females who do and do not stutter. Conclusions Speech-language pathologists should be aware of the associations between stuttering and depressive symptoms, as well as the increased risk for suicidal ideation among males who stutter. Clinicians should be knowledgeable about symptoms of depression and suicidal ideation and be familiar with processes to refer as needed.

Background Debates over the importance of “lifestyle” versus “environment” contributions to cancer have been going on for over 40 years. While it is clear that cigarette smoking is the most significant cancer risk factor, the contributions of occupational and environmental carcinogens in air, water and food remain controversial. In practice, most cancer prevention messaging focuses on reducing cigarette smoking and changing other personal behaviors with little mention of environmental chemicals, despite widespread exposure to many known carcinogens. To inform decision-making on cancer prevention priorities, we evaluated the potential impact of smoking cessation on cancer rates. Methods Using cancer incidence data from 612 counties in the SEER database, and county-level smoking prevalences, we investigated the impact of smoking cessation on incidence for 12 smoking-related cancer types, 2006—2016. A multilevel mixed-effects regression model quantified the association between county-level smoking prevalence and cancer incidence, adjusting for age, gender and variability over time and among counties. We simulated complete smoking cessation and estimated the effects on county-level cancer rates. Results Regression models showed the expected strong association between smoking prevalence and cancer incidence. Simulating complete smoking cessation, the incidence of the 12 smoking-related cancer types fell by 39.8% (54.9% for airways cancers; 28.9% for non-airways cancers). And, while the actual rates of smoking-related cancers from 2006 to 2016 declined (annual percent change (APC) = − 0.8, 95% CI = − 1.0 to − 0.5%), under the scenario of smoking elimination, the trend in cancer incidence at these sites was not declining (APC = − 0.1, 95% CI = − 0.4 to + 0.1%). Not all counties were predicted to benefit equally from smoking elimination, and cancer rates would fall less than 10% in some counties. Conclusions Smoking prevention has produced dramatic reductions in cancer in the US for 12 major types. However, we estimate that eliminating smoking completely would not affect about 60% of cancer cases of the 12 smoking-related types, leaving no improvement in the incidence trend from 2006 to 2016. We conclude that cancer prevention strategies should focus not only on lifestyle changes but also the likely contributions of the full range of risk factors, including environmental/occupational carcinogens.

Context Aphasia is a post-stroke condition that can dramatically impact a person with aphasia’s (PWA) communication abilities. To date, few if any studies have considered the cost and cost-effectiveness of functional change in aphasia nor considered measures of patient’s value for aphasia treatment. Objective To assess the cost, cost-effectiveness, and perceived value associated with improved functional communication in individuals receiving telerehabilitation treatment for aphasia. Design Twenty PWA completed between 5 and 12 telehealth rehabilitation sessions of 45–60 minutes within a 6-week time frame using a Language-Oriented Treatment (LOT) designed to address a range of language issues among individuals with aphasia. National Outcomes Measures (NOMS) comprehension and verbal expression and the ASHA Quality of Communication Life (QCL) were completed prior to and at the completion of rehabilitation to obtain baseline and treatment measures. Results Age, education, and race are significantly correlated with improvement in the NOMS verbal expression. African Americans (OR = 2.0917) are twice as likely as Whites to experience improvement after treatment. The likelihood of improvement also increases with each additional year of education (OR = 1.002) but decrease with age (OR = 0.9463). A total of 15 PWA showed improvement in NOMS comprehension and nine patients showed improvement in NOMS verbal expression. Improving patients attended between five and 12 treatment sessions. The average cost of improvement in NOMS comprehension was $1,152 per patient and NOMS verbal expression was $1,128 per patient with individual treatment costs varying between $540 and $1,296. However, on average, the monetary equivalent in patient’s improved QCL was between $1,790.39 to $3,912,54—far exceeding the financial cost of treatment. Conclusions When measuring the functional improvement of patients with aphasia, patient’s quality of communication life received from treatment exceeded financial cost of services provided.

Background Studies relating cigarette smoking and body weight yield conflicting results. Weight-lowering effects in women and men have been associated with smoking, however, no effects on weight have been proven. This study examined the association between cigarette smoking and relative weight in adolescent males and females as they age into young adults. Methods Data from the National Longitudinal Survey of Youth—a nationally representative survey conducted annually—was used for this analysis. The sample consists of 4225 males and females observed annually from 1997 at age 12 to 17 through 2011 at age 27 to 31. Hierarchical generalized models (HGM) assess the impact of smoking on the likelihood of having higher BMI controlling for demographic, household and environmental impacts. The second estimation considers the possibility that smoking is endogenous and utilizes a multinomial instrument (IV) for smoking level. Results HGM models reveal a negative association between cigarette smoking and BMI for both males and females. Individuals who smoke more have lower BMI compared to infrequent or non-smokers. General health rating, region of residence and income were used instrument for smoking in a linear two-stage IV specification. The instrument is highly correlated with BMI and results mirror the HGM. Finally, models run on early, middle and advanced adolescents show that the relationship diminishes over time. The relationship between BMI and smoking decreases as females age but increases for males. Conclusions Empirical models confirm an association cigarette consumption and BMI in both males and females. This negative relationship varies with age. It is important to identify health risks—obesity—and modifiable risk factors—smoking—that contribute to health disparities among adolescents. However, the increase in one risky behavior leading to the decrease in the prevalence of the other, complicates the issue. The higher prevalence of frequent cigarette uses among both adolescents and young adults of lower BMI suggest that smoking could be used curb or suppress appetite., Highlights • The weight impact of tobacco use by adolescents, unlike adults, has not been conclusively determined. • This study examines the relationship between cigarette use and the body weight (BMI) of high school aged youth. • Since smoking can be considered endogeneous in weight studies, smoking is instrumented in a two-stage process. • Cigarette use is associated with higher BMI, but magnitudes vary by age. • Models run on early, middle and older adolescents show that the relationship diminishes over time. • The relationship between BMI and smoking decreases as females age but increases for males. • Overweight and obese adolescents were more frequent tobacco users. • Results suggest that electronic and conventional tobacco has similar BMI associations when used independently.

Purpose Social connections are essential for health and well-being at all ages and may be especially important for promoting health in later life. Maintaining social connections, however, became increasingly difficult during the COVID-19 pandemic when stay-at-home orders were enacted, and social distancing became necessary. This study examines the social connectivity among Medicare beneficiaries during the COVID-19 pandemic highlighting the importance technological availability, income, and race. Methods Data from the 2020 Medicare Beneficiaries Survey COVID supplement was used to evaluate social connectedness during the spring and fall of 2020. Binomial logistic regression evaluated the relationship between feelings of social connectedness and race/ethnicity, urban status of residence, income, availability of household technologies, internet access, and chronic conditions. Results Lower social connectivity is significantly correlated with race and income. Blacks had a nearly 30% higher likelihood of feeling socially disconnected than other racial groups. Individuals with chronic conditions, particularly cancer, were significantly more likely to feel socially disconnected. Internet access and the availability of technological devices decreased the odds of feeling socially disconnected by 20% and 15% respectively. Conclusion The COVID-19 pandemic decreased the social connectedness of many vulnerable groups specifically Blacks, those living with chronic conditions, and individuals with limited access to technology. While it is outside the scope of the current study, additional research is needed to determine how to address the social and psychological impacts of the COVID-19 pandemic among elderly Americans.

This article summarizes the evidence for environmental toxic exposures contributing to cancers in early life, focusing on the most common cancer sites in this age group. It provides examples of widespread avoidable exposures to human carcinogens through air, water, and food and then describes recent examples of successful initiatives to reduce exposure to chemicals linked to these cancer sites, through government policy, industry initiatives, and consumer activism. State government initiatives to reduce toxic chemical exposures have made important gains; the Toxics Use Reduction Act of Massachusetts is now 25 years old and has been a major success story. There are a growing number of corporate initiatives to eliminate toxics, especially carcinogens, from the products they manufacture and sell. Another important opportunity for cancer prevention is provided by online databases that list chemicals, their toxicity, and lower-toxicity alternatives; these can be used by businesses, health care institutions, consumers, and workers to reduce exposures to chemicals of concern. The article concludes by inviting pediatricians and public health professionals to include elimination of carcinogen exposures in their work to promote primary prevention of cancer in early life.

The use of alternatives assessment to substitute hazardous chemicals with inherently safer options is gaining momentum worldwide as a legislative and corporate strategy to minimize consumer, occupational, and environmental risks. Engineered nanomaterials represent an interesting case for alternatives assessment approaches, because they can be considered both emerging "chemicals" of concern, as well as potentially safer alternatives to hazardous chemicals. However, comparing the hazards of nanomaterials to traditional chemicals or to other nanomaterials is challenging, and critical elements in chemical hazard and exposure assessment may have to be fundamentally altered to sufficiently address nanomaterials. The aim of this paper is to assess the overall applicability of alternatives assessment methods for nanomaterials and to outline recommendations to enhance their use in this context. The present paper focuses on the adaptability of existing hazard and exposure assessment approaches to engineered nanomaterials as well as strategies to design inherently safer nanomaterials. We argue that alternatives assessment for nanomaterials is complicated by the sheer number of nanomaterials possible. As a result, the inclusion of new data tools that can efficiently and effectively evaluate nanomaterials as substitutes is needed to strengthen the alternatives assessment process. However, we conclude that with additional tools to enhance traditional hazard and exposure assessment modules of alternatives assessment, such as the use of mechanistic toxicity screens and control banding tools, alternatives assessment can be adapted to evaluate engineered nanomaterials as potential substitutes for chemicals of concern and to ensure safer nanomaterials are incorporated in the design of new products. Integr Environ Assess Manag 2017;13:177-187. © 2016 SETAC.

Cancer prevention research and practice largely focus on three overlapping areas: precision prevention (e.g., genetic, social, and other factors specific to an individual patient), genetics, and health behaviors. All three of these envision the individual patient and her provider as the agents of change. A fourth realm of research and practice with potential to contribute to the primary prevention of cancers targets environmental and social factors over which the individual has little control, but governments, businesses, and communities do. These include environmental carcinogens in consumer products, workplaces, and air and water pollution. For example, flame retardants, dry cleaning solvents, formaldehyde, and diesel exhaust are widespread and often pose disproportionately high risks for people in low-income communities. Historically, laws and regulations have been the primary tools for controlling environmental and workplace contaminants, but despite important successes, significant cancer risks from pollution still occur. This presentation explores two questions based on our recent policy and program research: 1) What does systems analysis tell us about actions that impede and hold promise for reducing exposure to environmental carcinogens at the scale needed? 2) How might a systems approach inform the integration of environmental carcinogen reduction into cancer prevention research and practice? Particularly in the current political climate, system-level interventions that shift dominant narratives about cancer, prioritize interdisciplinary research, and harness market forces deserve prioritization. Citation Format: Polly J. Hoppin, David Kriebel, Molly Jacobs. A systems approach to cancer prevention [abstract]. In: Proceedings of the AACR Special Conference on Environmental Carcinogenesis: Potential Pathway to Cancer Prevention; 2019 Jun 22-24; Charlotte, NC. Philadelphia (PA): AACR; Can Prev Res 2020;13(7 Suppl): Abstract nr IA21.

Background: There has been rapid growth in ever and current electronic cigarette (e-cigarettes) use over the past 4 years. Use is highest among adolescents and current cigarette smokers. This trend follows a rise in the number of overweight and obese adolescents and teens. This study examined the relationship between BMI and the use of both electronic and conventional cigarette in high school aged youth. Methods: Data from the Youth Risk Behavior Surveillance System (YRBSS)-a nationally representative survey of 9th through 12th grade students conducted every two years-was used for analysis. Two different statistical models-a multinomial logit (mlogit) and quantile regression (QR) of BMI levels-tested the relationship between BMI and electronic/conventional cigarette use among adolescents. Results: BMI was positively related to age, race, and ethnicity. Those who use either conventional or electronic cigarettes had higher BMI than those using neither product. Magnitude vary by demographic groups, particularly among women. While solitary product use was associated with elevated weight, simultaneous use of both products was associated with lower BMI values. Overweight and obese adolescents were more frequent tobacco users than other weight classes. Associations were impervious to model specification. Conclusion: Findings showed that use of either conventional and electronic cigarettes was associated with higher BMI. However, these findings suggest the need for additional research into the health impacts of substance use by adolescents. Research into the physical, emotional and psychological health impacts of electronic tobacco needs to be fully explored as it continues to grow in popularity among adolescents.

Suboptimal healing of the tendon-bone interface remains an unsolved problem. The authors hypothesized that (1) platelet-rich plasma and prolonged in vitro incubation will produce interface scaffolds with greater reseeding of viable adipose-derived stem cells; and (2) when implanted with extracellular matrix hydrogel, constructs will display superior in vivo strength repair and biocompatibility.Achilles-calcaneal composite tendon-bone interface scaffold grafts were harvested from 30 Wistar rats. After physicochemical decellularization and lyophilization, scaffolds were revitalized in rat plasma or 100% activated rat platelet-rich plasma and reseeded with viable adipose-derived stem cells. For part 2 of the study, 90 Sprague-Dawley rats underwent reconstruction with one of five decellularized, lyophilized scaffold revitalization/reseeding conditions: (1) phosphate-buffered saline; (2) lyophilized, 100% activated platelet-rich plasma; (3) platelet-rich plasma and extracellular matrix hydrogel; (4) platelet-rich plasma and 14-day reseeding with ASC-luc2-eGFP cells; and (5) plasma, reseeding, and hydrogel.In part 1, platelet-rich plasma-revitalized grafts demonstrated greater live viable adipose-derived stem cell loads at 3, 7, and 14 days and total adipose-derived stem cell loads at 7 and 14 days with visibly greater live surface cellularity, layering, migration, and penetration. In part 2, bioluminescence imaging confirmed cell viability to day 22 after implantation. Biomechanical strength testing demonstrated a significant increase in ultimate failure load for reseeded groups compared with all other groups at week 2, whereas only reseeded grafts with hydrogel remained significantly stronger at weeks 4 and 8. Histologic examination demonstrated most increased tendinous cellular invasion and fibrocartilage repopulation at 8 weeks in the reseeded group with hydrogel. Masson trichrome staining demonstrated persistence of the scaffold structure at week 8 and blinded ImageJ analysis demonstrated significantly more type III collagen in the reseeded/hydrogel group at 2, 4, and 8 weeks.Decellularized lyophilized allogeneic tendon-bone interface scaffolds can be optimized by revitalization in platelet-rich plasma, reseeding with viable adipose-derived stem cells, and supplemented by an extracellular matrix tendon hydrogel at the time of implantation. When this is done, they display greater repair strength and biocompatibility.

Scientific, policy and consumer concerns regarding the health and environmental impacts of toxic substances have resulted in increased pressures to restrict potentially hazardous chemicals in processes and products.1 However, selecting chemical alternatives without regard to their hazard profiles can have regrettable consequences when substitutes are as toxic or are even more toxic than the chemicals they replace. Examples of regrettable substitutions include flame retardants (eg, substituting tris(1,3-dichloro-2-propyl) phosphate for polybrominated diphenyl ether), solvents (eg, substituting n-propyl bromide for methylene chloride and trichloroethylene (TCE)) and replacements for endocrine disrupting plastics components (eg, substituting bisphenol-S for bisphenol-A).2 These mistakes occur, in part, because performance and cost are elevated over health and safety in chemical selection decisions. They also occur because the environmental health community has been slow to provide strategies and guidelines for identifying, evaluating and adopting alternatives that include a thoughtful examination of environmental health and safety alongside cost and performance considerations. When public health scientists identify problematic chemicals, scientific justification for substituting that chemical based on identifying a safer alternative is rarely pursued. In a previous JECH commentary, we noted the challenges related to an over-reliance on studying environmental problems versus solutions in environmental health science, using the example of bisphenol-A.3 We argued that the ‘problem-centred’ approach to chemicals management is often reactive, extremely resource intensive, fosters extended debates over regulatory benchmarks, and inaction that benefits neither health nor innovation. This reactive approach is fortified by a number of factors including policies that require significant evidence of risk before action can be taken, which then focuses research and agency resources on risk assessment, risk management and enforcement; the lack of interdisciplinary collaboration between those designing molecules, materials, and products and those evaluating their risks; and the fact that many chemicals of concern have important functionality and cost …

What do we currently know about the occupational and environmental causes of cancer? As of 2007, the International Agency for Research on Cancer (IARC) identified 415 known or suspected carcinogens. Cancer arises through an extremely complicated web of multiple causes, and we will likely never know the full range of agents or combinations of agents. We do know that preventing exposure to individual carcinogens prevents the disease. Declines in cancer rates-such as the drop in male lung cancer cases from the reduction in tobacco smoking or the drop in bladder cancer among cohorts of dye workers from the elimination of exposure to specific aromatic amines-provides evidence that preventing cancer is possible when we act on what we know. Although the overall age-adjusted cancer incidence rates in the United States among both men and women have declined in the last decade, the rates of several types of cancers are on the rise; some of which are linked to environmental and occupational exposures. This report chronicles the most recent epidemiologic evidence linking occupational and environmental exposures with cancer. Peer-reviewed scientific studies published from January 2005 to June 2007 were reviewed, supplementing our state-of-the-evidence report published in September 2005. Despite weaknesses in certain individual studies, we consider the evidence linking the increased risk of several types of cancer with specific exposures somewhat strengthened by recent publications, among them brain cancer from exposure to non-ionizing radiation, particularly radiofrequency fields emitted by mobile telephones; breast cancer from exposure to the pesticide dichlorodiphenyltrichloroethane (DDT) before puberty; leukemia from exposure to 1,3-butadiene; lung cancer from exposure to air pollution; non-Hodgkin's lymphoma (NHL) from exposure to pesticides and solvents; and prostate cancer from exposure to pesticides, polyaromatic hydrocarbons (PAHs), and metal working fluids or mineral oils. In addition to NHL and prostate cancer, early findings from the National Institutes of Health Agricultural Health Study suggest that several additional cancers may be linked to a variety of pesticides. Our report also briefly describes the toxicological evidence related to the carcinogenic effect of specific chemicals and mechanisms that are difficult to study in humans, namely exposures to bis-phenol A and epigenetic, trans-generational effects. To underscore the multi-factorial, multi-stage nature of cancer, we also present a technical description of cancer causation summarizing current knowledge in molecular biology. We argue for a new cancer prevention paradigm, one based on an understanding that cancer is ultimately caused by multiple interacting factors rather than a paradigm based on dubious attributable fractions. This new cancer prevention paradigm demands that we limit exposure to avoidable environmental and occupational carcinogens, in combination with additional important risk factors like diet and lifestyle. The research literature related to environmental and occupational causes of cancer is constantly growing, and future updates will be carried out in light of new biological understanding of the mechanisms and new methods for studying exposures in human populations. The current state of knowledge is sufficient to compel us to act on what we know. We repeat the call of ecologist Sandra Steingraber: "From the right to know and the duty to inquire flows the obligation to act."

This chapter provides an overview of what is known and not known about emissions from wood combustion, with a particular focus on the nonresidential scale. In addition, it reviews the state of the evidence on health effects associated with of exposure to emissions from wood combustion, information that is relevant to decisions about wood biomass applications at any scale. Finally, the chapter describes policy approaches available for protecting public health from pollution and concludes with solutions: recommendations for changes in technologies, policy and programs to better protect public health. While the discussion focuses on the Northeast region of the USA, it has broader implications, providing a framework for incorporating health in renewable energy decision-making across the country.

The discussion of the scientific evidence linking cancer to environmental and occupational exposures has been an area of contention for atleast the past three decades, since the assertion in 1977 by Higginson and Muir that 80% of all cancers were due to environmental exposures. Over the past three decades, there have been additional efforts to estimate the proportion of cancer due to these involuntary exposures, including the 1981 monograph by Doll and Peto and the more recent reports by the Harvard Center for Cancer Prevention. In this paper, we review the evidence that Doll and Peto and other authors have summarized, provide an alternative interpretation of the evidence, and caution against the very idea of attributing specific fractions or proportions of cancer to particular factors. We also review the scientific evidence, particularly epidemiologic evidence, regarding the contribution of environmental and occupational exposures to the overall cancer burden in the US. We conclude with a call for action to prevent exposures to environmental and occupational carcinogens.

We recently completed a review of scientific evidence, particularly epidemiologic evidence, regarding the contribution of environmental and occupational exposures to the overall cancer burden in the US. We evaluated the efforts to estimate the proportion of cancer due to these involuntary exposures, including the ambitious effort by Doll and Peto and an update by a group of authors at the Harvard Center for Cancer Prevention. In this paper, we critique these efforts, and their resulting estimates of the proportion of cancer due to various factors. We also provide an alternative interpretation of the evidence and a caution against the very idea of attributing specific fractions or proportions of cancer to particular factors. We conclude by recommending that environmental and occupational links to cancer be given serious consideration by individuals and institutions concerned with cancer prevention, particularly those involved in research and public education. We support the new initiative in the European Union to evaluate chemicals more fully before they reach the market.