MORTALITY IN THE MEDICARE POPULATION AND CHRONIC EXPOSURE TO FINE PARTICULATE AIR POLLUTION

Prospective cohort studies have provided evidence on longer-term mortality risks of fine particulate matter (PM2.5), but due to their complexity and costs, only a few have been conducted. By linking monitoring data to the U.S. Medicare system by county of residence, we developed a retrospective cohort study, the Medicare Air Pollution Cohort Study (MCAPS), comprising over 20 million enrollees in the 250 largest counties during 2000-2002. We estimated log-linear regression models having as outcome the age-specific mortality rate for each county and as the main predictor, the average level for the study period 2000. Area-level covariates were used to adjust for socio-economic status and smoking. We reported results under several degrees of adjustment for spatial confounding and with stratification into by eastern, central and western counties. We estimated that a 10 µg/m3 increase in PM25 is associated with a 7.6% increase in mortality (95% CI: 4.4 to 10.8%). We found a stronger association in the eastern counties than nationally, with no evidence of an association in western counties. When adjusted for spatial confounding, the estimated log-relative risks drop by 50%. We demonstrated the feasibility of using Medicare data to establish cohorts for follow-up for effects of air pollution. Particulate matter (PM) air pollution is a global public health problem (1). In developing countries, levels of airborne particles still reach concentrations at which serious health consequences are well-documented; in developed countries, recent epidemiologic evidence shows continued adverse effects, even though particle levels have declined in the last two decades (2-6). Increased mortality associated with higher levels of PM air pollution has been of particular concern, giving an imperative for stronger protective regulations (7). Evidence on PM and health comes from studies of acute and chronic adverse effects (6). The London Fog of 1952 provides dramatic evidence of the unacceptable short-term risk of extremely high levels of PM air pollution (8-10); multi-site time-series studies of daily mortality show that far lower levels of particles are still associated with short-term risk (5)(11-13). Cohort studies provide complementary evidence on the longer-term risks of PM air pollution, indicating the extent to which exposure reduces life expectancy. The design of these studies involves follow-up of cohorts for mortality over periods of years to decades and an assessment of mortality risk in association with estimated long-term exposure to air pollution (2-4;14-17). Because of the complexity and costs of such studies, only a small number have been conducted. The most rigorously executed, including the Harvard Six Cities Study and the American Cancer Society’s (ACS) Cancer Prevention Study II, have provided generally consistent evidence for an association of long- term exposure to particulate matter air pollution with increased all-cause and cardio-respiratory mortality (2,4,14,15). Results from these studies have been used in risk assessments conducted for setting the U.S. National Ambient Air Quality Standard (NAAQS) for PM and for estimating the global burden of disease attributable to air pollution (18,19). Additional prospective cohort studies are necessary, however, to confirm associations between long-term exposure to PM and mortality, to broaden the populations studied, and to refine estimates by regions across which particle composition varies. Toward this end, we have used data from the U.S. Medicare system, which covers nearly all persons 65 years of age and older in the United States. We linked Medicare mortality data to (particulate matter less than 2.5 µm in aerodynamic diameter) air pollution monitoring data to create a new retrospective cohort study, the Medicare Air Pollution Cohort Study (MCAPS), consisting of 20 million persons from 250 counties and representing about 50% of the US population of elderly living in urban settings. In this paper, we report on the relationship between longer-term exposure to PM2.5 and mortality risk over the period 2000 to 2002 in the MCAPS.

Observation errors in early historical upper-air observations

Upper-air observations are a fundamental data source for global atmospheric data products, but uncertainties, particularly in the early years, are not well known. Most of the early observations, which have now been digitized, are prone to a large variety of undocumented uncertainties (errors) that need to be quantified, e.g., for their assimilation in reanalysis projects. We apply a novel approach to estimate errors in upper-air temperature, geopotential height, and wind observations from the Comprehensive Historical Upper-Air Network for the time period from 1923 to 1966. We distinguish between random errors, biases, and a term that quantifies the representativity of the observations. The method is based on a comparison of neighboring observations and is hence independent of metadata, making it applicable to a wide scope of observational data sets. The estimated mean random errors for all observations within the study period are 1.5 K for air temperature, 1.3 hPa for pressure, 3.0 ms−1for wind speed, and 21.4° for wind direction. The estimates are compared to results of previous studies and analyzed with respect to their spatial and temporal variability.

A prospective cohort study evaluating the state of medical readiness in the United States Air Force and risk factors to improve the medical readiness posture

A cohort of 418 United States Air Force (USAF) personnel from over 15 different bases deployed to Morocco in 1994. This was the first study of its kind and was designed with two primary goals: to determine if the USAF was medically prepared to deploy with its changing mission in the new world order, and to evaluate factors that might improve or degrade USAF medical readiness. The mean length of deployment was 21 days. The cohort was 95% male, 86% enlisted, 65% married, and 78% white.^ This study shows major deficiencies indicating the USAF medical readiness posture has not fully responded to meet its new mission requirements. Lack of required logistical items (e.g., mosquito nets, rainboots, DEET insecticide cream, etc.) revealed a low state of preparedness. The most notable deficiency was that 82.5% (95% CI = 78.4, 85.9) did not have permethrin pretreated mosquito nets and 81.0% (95% CI = 76.8, 84.6) lacked mosquito net poles. Additionally, 18% were deficient on vaccinations and 36% had not received a tuberculin skin test. Excluding injections, the overall compliance for preventive medicine requirements had a mean frequency of only 50.6% (95% CI = 45.36, 55.90).^ Several factors had a positive impact on compliance with logistical requirements. The most prominent was "receiving a medical intelligence briefing" from the USAF Public Health. After adjustment for mobility and age, individuals who underwent a briefing were 17.2 (95% CI = 4.37, 67.99) times more likely to have received an immunoglobulin shot and 4.2 (95% CI = 1.84, 9.45) times more likely to start their antimalarial prophylaxsis at the proper time. "Personnel on mobility" had the second strongest positive effect on medical readiness. When mobility and briefing were included in models, "personnel on mobility" were 2.6 (95% CI = 1.19, 5.53) times as likely to have DEET insecticide and 2.2 (95% CI = 1.16, 4.16) times as likely to have had a TB skin test.^ Five recommendations to improve the medical readiness of the USAF were outlined: upgrade base level logistical support, improve medical intelligence messages, include medical requirements on travel orders, place more personnel on mobility or only deploy personnel on mobility, and conduct research dedicated to capitalize on the powerful effect from predeployment briefings.^ Since this is the first study of its kind, more studies should be performed in different geographic theaters to assess medical readiness and establish acceptable compliance levels for the USAF. ^

Blind intubation of anaesthetised children with supraglottic airway devices AmbuAura-i and Air-Q cannot be recommended: A randomised controlled trial.

BACKGROUND Paediatric supraglottic airway devices AmbuAura-i and Air-Q were designed as conduits for tracheal intubation. Although fibreoptic-guided intubation has proved successful, blind intubation as a rescue technique has never been evaluated. OBJECTIVE Evaluation of blind intubation through AmbuAura-i and Air-Q. On the basis of fibreoptic view data, we hypothesised that the success rate with the AmbuAura-i would be higher than with the Air-Q. DESIGN A prospective, randomised controlled trial with institutional review board (IRB) approval and written informed consent. SETTING University Childrens' Hospital; September 2012 to July 2014. PATIENTS Eighty children, American Society of Anesthesiologists (ASA) class I to III, weight 5 to 50 kg. INTERVENTIONS Tracheal intubation was performed through the randomised device with the tip of a fibrescope placed inside and proximal to the tip of the tracheal tube. This permitted sight of tube advancement, but without fibreoptic guidance (visualised blind intubation). MAIN OUTCOME MEASURES Primary outcome was successfully visualised blind intubation; secondary outcomes included supraglottic airway device success, insertion times, airway leak pressure, fibreoptic view and adverse events. RESULTS Personal data did not differ between groups. In contrast to our hypothesis, blind intubation was possible in 15% with the Air-Q and in 3% with the AmbuAura-i [95% confidence interval (95% CI) 6 to 31 vs. 0 to 13%; P = 0.057]. First attempt supraglottic airway device insertion success rates were 95% (Air-Q) and 100% (AmbuAura-i; 95% CI 83 to 99 vs. 91 to 100; P = 0.49). Median leak pressures were 18 cmH2O (Air-Q) and 17 cmH2O [AmbuAura-i; interquartile range (IQR) 14 to 18 vs. 14 to 19 cmH2O; P = 0.66]. Air-Q insertion was slower (27 vs. 19 s, P < 0.001). There was no difference in fibreoptic view, or adverse events (P > 0.05). In one child (Air-Q size 1.5, tube size 3.5), the tube dislocated during device removal. CONCLUSION Ventilation with both devices is reliable, but success of blind intubation is unacceptably low and cannot be recommended for elective or rescue purposes. If intubation through a paediatric supraglottic airway device is desired, we suggest that fibreoptic guidance is used. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT01692522.

A feasibility study for assessing building occupants' indoor air quality expectations compared to nationally recognized standards

Indoor Air Quality (IAQ) can have significant implications for health, productivity, job performance, and operating cost. Professional experience in the field of indoor air quality suggests that high expectations (better than nationally established standards) (American Society of Heating, Refrigerating, and Air-conditioning Engineers (ASHRAE)) of workplace indoor air quality lead to increase air quality complaints. To determine whether there is a positive association between expectations and indoor air quality complaints, a one-time descriptive and analytical cross-sectional pilot study was conducted. Area Safety Liaisons (n = 330) at University of Texas Health Science Center – Houston were asked to answer a questionnaire regarding their expectations of four workplace indoor air quality indicators i.e., (temperature, relative humidity, carbon dioxide, and carbon monoxide) and if they experienced and reported indoor air quality problems. A chi-square test for independence was used to evaluate associations among the variables of interest. The response rate was 54% (n = 177). Results did not show significant associations between expectation and indoor air quality. However, a greater proportion of Area Safety Liaisons who expected indoor air quality indicators to be better than the established standard experienced greater indoor air quality problems. Similarly, a slightly higher proportion of Area Liaisons who expected indoor air quality indicators to be better than the standard reported greater indoor air quality complaints. ^ The findings indicated that a greater proportion of Area Safety Liaisons with high expectations (conditions that are beyond what is considered normal and acceptable by ASHRAE) experienced greater indoor air quality discomfort. This result suggests a positive association between high expectations and experienced and reported indoor air quality complaints. Future studies may be able to address whether the frequency of complaints and resulting investigations can be reduced through information and education about what are acceptable conditions.^

Impact of traffic pollution on telomere length and chronic diseases: Results from the multi-ethnic study of atherosclerosis and the Mexican-American cohort study

Exposure to air pollutants in urban locales has been associated with increased risk for chronic diseases including cardiovascular disease (CVD) and pulmonary diseases in epidemiological studies. The exact mechanism explaining how air pollution affects chronic disease is still unknown. However, oxidative stress and inflammatory pathways have been posited as likely mechanisms. ^ Data from the Multi-Ethnic Study of Atherosclerosis (MESA) and the Mexican-American Cohort Study (2003-2009) were used to examine the following aims, respectively: 1) to evaluate the association between long-term exposure to ambient particulate matter (PM) (PM10 and PM2.5) and nitrogen oxides (NO x) and telomere length (TL) among approximately 1,000 participants within MESA; and 2) to evaluate the association between traffic-related air pollution with self-reported asthma, diabetes, and hypertension among Mexican-Americans in Houston, Texas. ^ Our results from MESA were inconsistent regarding associations between long-term exposure to air pollution and shorter telomere length based on whether the participants came from New York (NY) or Los Angeles (LA). Although not statistically significant, we observed a negative association between long-term air pollution exposure and mean telomere length for NY participants, which was consistent with our hypothesis. Positive (statistically insignificant) associations were observed for LA participants. It is possible that our findings were more influenced by both outcome and exposure misclassification than by the absence of a relationship between pollution and TL. Future studies are needed that include longitudinal measures of telomere length as well as focus on effects of specific constituents of PM and other pollutant exposures on changes in telomere length over time. ^ This research provides support that Mexican-American adults who live near a major roadway or in close proximity to a dense street network have a higher prevalence of asthma. There was a non-significant trend towards an increased prevalence of adult asthma with increasing residential traffic exposure especially for residents who lived three or more years at their baseline address. Even though the prevalence of asthma is low in the Mexican-origin population, it is the fastest growing minority group in the U.S. and we would expect a growing number of Mexican-Americans who suffer from asthma in the future. Future studies are needed to better characterize risks for asthma associated with air pollution in this population.^

(Table 1) Climate characteristics of the four North American Tundra Experiment (ITEX) sites

Climate warming is expected to differentially affect CO2 exchange of the diverse ecosystems in the Arctic. Quantifying responses of CO2 exchange to warming in these ecosystems will require coordinated experimentation using standard temperature manipulations and measurements. Here, we used the International Tundra Experiment (ITEX) standard warming treatment to determine CO2 flux responses to growing-season warming for ecosystems spanning natural temperature and moisture ranges across the Arctic biome. We used the four North American Arctic ITEX sites (Toolik Lake, Atqasuk, and Barrow [USA] and Alexandra Fiord [Canada]) that span 10° of latitude. At each site, we investigated the CO2 responses to warming in both dry and wet or moist ecosystems. Net ecosystem CO2 exchange (NEE), ecosystem respiration (ER), and gross ecosystem photosynthesis (GEP) were assessed using chamber techniques conducted over 24-h periods sampled regularly throughout the summers of two years at all sites. At Toolik Lake, warming increased net CO2 losses in both moist and dry ecosystems. In contrast, at Atqasuk and Barrow, warming increased net CO2 uptake in wet ecosystems but increased losses from dry ecosystems. At Alexandra Fiord, warming improved net carbon uptake in the moist ecosystem in both years, but in the wet and dry ecosystems uptake increased in one year and decreased the other. Warming generally increased ER, with the largest increases in dry ecosystems. In wet ecosystems, high soil moisture limited increases in respiration relative to increases in photosynthesis. Warming generally increased GEP, with the notable exception of the Toolik Lake moist ecosystem, where warming unexpectedly decreased GEP >25%. Overall, the respiration response determined the effect of warming on ecosystem CO2 balance. Our results provide the first multiple-site comparison of arctic tundra CO2 flux responses to standard warming treatments across a large climate gradient. These results indicate that (1) dry tundra may be initially the most responsive ecosystems to climate warming by virtue of strong increases in ER, (2) moist and wet tundra responses are dampened by higher water tables and soil water contents, and (3) both GEP and ER are responsive to climate warming, but the magnitudes and directions are ecosystem-dependent.

Influence of air drag on the optimal hand launching of a small, round projectile

Conditions leading to a maximum range for a small, round projectile, fired by hand, are discussed taking into account air drag and the dependence of the initial speed on the mass launched. Both the optimal angle of release for given projectile and initial speed, and the optimal radius for given density (i.e., among a bed of pebbles) are determined; an increase on the height of release is found to always decrease the angle and increase the radius. The influence of the projectile mass on the optimal manner of launching is considered. The validity of the approximations used in the analysis is discussed. Results from very simple measurements show good agreement with theory.

Air quality modeling and mortality impact of fine particles reduction policies in Spain

Background: In recent years, Spain has implemented a number of air quality control measures that are expected to lead to a future reduction in fine particle concentrations and an ensuing positive impact on public health. Objectives: We aimed to assess the impact on mortality attributable to a reduction in fine particle levels in Spain in 2014 in relation to the estimated level for 2007. Methods: To estimate exposure, we constructed fine particle distribution models for Spain for 2007 (reference scenario) and 2014 (projected scenario) with a spatial resolution of 16x16 km2. In a second step, we used the concentration-response functions proposed by cohort studies carried out in Europe (European Study of Cohorts for Air Pollution Effects and Rome longitudinal cohort) and North America (American Cancer Society cohort, Harvard Six Cities study and Canadian national cohort) to calculate the number of attributable annual deaths corresponding to all causes, all non-accidental causes, ischemic heart disease and lung cancer among persons aged over 25 years (2005-2007 mortality rate data). We examined the effect of the Spanish demographic shift in our analysis using 2007 and 2012 population figures. Results: Our model suggested that there would be a mean overall reduction in fine particle levels of 1mg/m3 by 2014. Taking into account 2007 population data, between 8 and 15 all-cause deaths per 100,000 population could be postponed annually by the expected reduction in fine particle levels. For specific subgroups, estimates varied from 10 to 30 deaths for all non-accidental causes, from 1 to 5 for lung cancer, and from 2 to 6 for ischemic heart disease. The expected burden of preventable mortality would be even higher in the future due to the Spanish population growth. Taking into account the population older than 30 years in 2012, the absolute mortality impact estimate would increase approximately by 18%. Conclusions: Effective implementation of air quality measures in Spain, in a scenario with a short-term projection, would amount to an appreciable decline infine particle concentrations, and this, in turn, would lead to notable health-related benefits. Recent European cohort studies strengthen the evidence of an association between long-term exposure to fine particles and health effects, and could enhance the health impact quantification in Europe. Air quality models can contribute to improved assessment of air pollution health impact estimates, particularly in study areas without air pollution monitoring data.

Bases y procesos de certificación de sistemas aéreos no tripulados

El objetivo de la tesis es el de crear unas bases de certificación para sistemas aéreos remotamente pilotados teniendo en consideración los siguientes requisitos: 1) La base ha de tener una estructura similar a la existente para los aviones tripulados. De esta manera se favorecerá una futura convergencia entre las bases de certificación según las misiones realizadas y las tecnologías empleadas por aviones tripulados y pilotados a distancia vayan convergiendo. La CS 23 y FAR 23 van a ser modificadas en profundidad en un futuro inmediato. Se ha considerado la redacción de la nueva normativa propuesta. 2) Los requisitos han de considerar los cambios definidos por las autoridades que gestionan el espacio aéreo. En Europa es SESAR JU quien gestiona el proceso. 3) Los organismos reguladores de la aviación están emitiendo consejos y recomendaciones para permitir la operación de los RPAS en el espacio aéreo no segregado. Asimismo han establecido unos principios fundamentales en los que han de basarse las bases de certificación. Se analizarán los documentos publicados al respecto por OACI, FAA y EASA que han aumentado significativamente en 2015. 4) Los altos niveles de seguridad alcanzados por la aviación han sido principalmente conseguidos gracias a la existencia de unas bases de certificación que se han actualizado frecuentemente considerando la experiencia en el diseño y la operación. Esta experiencia en los RPAS es reducida pero puede aportar importante información de seguridad. ABSTRACT The Goal of the Thesis is to create a certification specification for remotely piloted systems (RPAS). The methodology used for the development of the standard considers the following constrains: 1. The Base shall be defined in a similar way as the standards used for manned aircraft of the same category. This procedure will make possible a future merging of the standards for manned and unmanned system. It is foreseen that the missions performed and the technology used will be similar in a near future. CS23 and FAR 23 are going to be completely modified in a near future. The changed proposed will also be considered. 2. The standards developed must consider all the changes that are being defined by the air traffic management authorities around the globe. In Europe the program is being managed by SESAR Joint Undertaking. 3. The regulatory organizations are providing technical advice and recommendations in order to permit the operation of the RPAS in non-segregated airspace. There has been a big amount of documentation issued in the last year by ICAO, EASA and FAA. The standards developed should consider and implement these requirements. 4. The high safety record obtained by the manned aviation has been mainly due to the continuous update of the certifications standards based on the experience. The experience in the design and operation of RPAS is reduced but can already provide important safety information.

Acclimation of Photosynthesis to Elevated CO2 under Low-Nitrogen Nutrition Is Affected by the Capacity for Assimilate Utilization. Perennial Ryegrass under Free-Air CO2 Enrichment1

Acclimation of photosynthesis to elevated CO2 has previously been shown to be more pronounced when N supply is poor. Is this a direct effect of N or an indirect effect of N by limiting the development of sinks for photoassimilate? This question was tested by growing a perennial ryegrass (Lolium perenne) in the field under elevated (60 Pa) and current (36 Pa) partial pressures of CO2 (pCO2) at low and high levels of N fertilization. Cutting of this herbage crop at 4- to 8-week intervals removed about 80% of the canopy, therefore decreasing the ratio of photosynthetic area to sinks for photoassimilate. Leaf photosynthesis, in vivo carboxylation capacity, carbohydrate, N, ribulose-1,5-bisphosphate carboxylase/oxygenase, sedoheptulose-1,7-bisphosphatase, and chloroplastic fructose-1,6-bisphosphatase levels were determined for mature lamina during two consecutive summers. Just before the cut, when the canopy was relatively large, growth at elevated pCO2 and low N resulted in significant decreases in carboxylation capacity and the amount of ribulose-1,5-bisphosphate carboxylase/oxygenase protein. In high N there were no significant decreases in carboxylation capacity or proteins, but chloroplastic fructose-1,6-bisphosphatase protein levels increased significantly. Elevated pCO2 resulted in a marked and significant increase in leaf carbohydrate content at low N, but had no effect at high N. This acclimation at low N was absent after the harvest, when the canopy size was small. These results suggest that acclimation under low N is caused by limitation of sink development rather than being a direct effect of N supply on photosynthesis.

Does Leaf Position within a Canopy Affect Acclimation of Photosynthesis to Elevated CO2?1 : Analysis of a Wheat Crop under Free-Air CO2 Enrichment

Previous studies of photosynthetic acclimation to elevated CO2 have focused on the most recently expanded, sunlit leaves in the canopy. We examined acclimation in a vertical profile of leaves through a canopy of wheat (Triticum aestivum L.). The crop was grown at an elevated CO2 partial pressure of 55 Pa within a replicated field experiment using free-air CO2 enrichment. Gas exchange was used to estimate in vivo carboxylation capacity and the maximum rate of ribulose-1,5-bisphosphate-limited photosynthesis. Net photosynthetic CO2 uptake was measured for leaves in situ within the canopy. Leaf contents of ribulose-1,5-bisphosphate carboxylase/oxygenase (Rubisco), light-harvesting-complex (LHC) proteins, and total N were determined. Elevated CO2 did not affect carboxylation capacity in the most recently expanded leaves but led to a decrease in lower, shaded leaves during grain development. Despite this acclimation, in situ photosynthetic CO2 uptake remained higher under elevated CO2. Acclimation at elevated CO2 was accompanied by decreases in both Rubisco and total leaf N contents and an increase in LHC content. Elevated CO2 led to a larger increase in LHC/Rubisco in lower canopy leaves than in the uppermost leaf. Acclimation of leaf photosynthesis to elevated CO2 therefore depended on both vertical position within the canopy and the developmental stage.