Dayna T. Neo

Background: Complementary and Alternative Medicine (CAM) therapies, such as massage, meditation, and yoga, are widely used to promote wellness, including sleep improvement. Although some CAM therapies may improve sleep through stress reduction, relaxation, and relief of physical discomfort, little is known about associations between individual CAM modalities and sleep health at the population level. Therefore, we investigated the associations between CAM therapies and short sleep duration as well as insomnia symptoms. Methods: Participants from the nationally-representative 2012 National Health Interview Survey (NHIS) self-reported the use of CAM therapies and short sleep duration (<7 hours vs. 7-9 hours) as well as insomnia symptoms (yes vs. no). Poisson regression with robust variance was used to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for cross-sectional associations between CAM therapy use and sleep outcomes. Results: Among 30,405 participants, the average age was 46.1 +/- 0.2 years and 51% were women. Adults reporting any vs. no CAM therapy use had a higher prevalence of short sleep duration (aPR: 1.11; 95% CI: 1.05-1.16) and insomnia symptoms (aPR: 1.56; 95% CI: 1.47-1.65) after adjustment for sociodemographic and clinical characteristics. Herbal supplements (aPR: 1.13; 95% CI: 1.07-1.19) and massage (aPR: 1.14; 95% CI: 1.05-1.23) were associated with higher prevalence of short sleep duration. Most CAM therapies were associated with higher prevalence of insomnia symptoms, with the strongest associations observed for meditation/guided imagery/progressive relaxation (aPR: 1.84; 95% CI: 1.68-2.02). Conclusion: The higher prevalence of short sleep duration and insomnia symptoms among CAM users may reflect reverse causation, as adults with more severe or persistent sleep disturbances may be more likely to seek CAM therapies. Longitudinal studies are needed to clarify directionality.

Importance Sleep-disordered breathing (SDB) is preventable but underdiagnosed, with disparities among sociodemographic groups with limited material and social resources, partly driven by community-level environmental and social conditions along with healthcare-related factors. Objectives We sought to investigate associations between multifactorial community-level environmental, social, and health burdens and SDB prevalence. We also determined effect modification by age, sex, race, and ethnicity. Design, Setting, and Participants Cross-sectional analysis of electronic health records (EHR) data collected in 2022 from 1,957,775 adult patients in the OCHIN network (>2,000 community health centers across 40 U.S. states). Exposures Patients’ 2022 residential addresses were linked to a census tract-level environmental, social, and health burden (ESHB) index created by the Centers for Disease Control and Prevention and the Agency for Toxic Substances Disease Registry. The ESHB comprises 36 indicators that capture and rank community-level social (e.g., socioeconomic status), environmental (e.g., air pollution), and health (e.g., hypertension) vulnerability. Higher percentile ranks of ESHB (range: 0-1) indicated higher vulnerability. Main Outcomes and Measures SDB was identified via diagnostic and procedural codes, and subtypes were categorized as obstructive (OSA), central (CSA), other/unspecified (OUSA), multiple apneas, and procedure-based cases. Log-binomial regression estimated prevalence ratios (PRs) and 95% confidence intervals (CIs), adjusting for age, sex, race, and ethnicity. We assessed effect modification by testing cross-product terms. Results Among 1,957,775 patients (median age was 43.0 years [IQR: 30.0–58.0]; 40.6% men), SDB prevalence was 5.5%, with CSA at 0.03%, OSA at 3.8%, OUSA at 1.4%, multiple sleep apneas at 0.03%, and procedure-based cases at 0.21%. Each 0.1-unit increase in ESHB percentile rank was associated with higher prevalence of SDB (PR=1.01 [1.01–1.01]), OUSA (PR=1.01 [1.01–1.02]), and procedure-based cases (PR=1.05 [1.03–1.06]). The ESHB-SDB association was elevated among adults aged 18-49 years, women, American Indian/Alaska Native and White, and non-Hispanic. ESHB was not associated with CSA. Conclusions and Relevance Higher community-level environmental, social, and health vulnerabilities were associated with higher SDB prevalence (although future prospective studies are warranted). Our findings underscore the need to address community-level factors with potential tailoring of interventions across sociodemographic groups. Question Are community-level environmental, social, and health burdens associated with the prevalence of sleep-disordered breathing (SDB) among medically underserved patients in United States (U.S.) community health centers? If so, to what extent? Findings This cross-sectional study included electronic health records data from 1,957,775 patients of 2,000 community-based health centers in 40 states linked to the 2022 census tract-level environmental, social, and health burden (ESHB) index. Higher ESHB was associated with a higher prevalence of SDB and its subtypes (e.g., obstructive sleep apnea [OSA] and central sleep apnea [CSA]). Elevated associations were observed among adults aged 18-49 years, women, American Indian/Alaska Native and White, and non-Hispanic. Meaning Multifactorial community adversity was associated with SDB prevalence. Our findings underscore the need for future intervention studies to address environmental, social, and health burdens at the community level to reduce SDB prevalence in medically underserved populations. Prospective studies are needed.

Introduction: Indoor temperature extremes contribute to thermal discomfort and can threaten sleep health. Few studies have investigated indoor temperature-sleep associations, especially across differentially-exposed sociodemographic groups. Methods: Using cross-sectional Sister Study data (2017-2019), we estimated associations between perceived sleep-disrupting indoor temperature extremes (SDITE) and sleep dimensions. Eligible women reported frequent vs. infrequent SDITE considered ‘too hot’ or ‘too cold’ and sleep dimensions (sleep duration; Pittsburgh Sleep Quality Index-derived sleep disturbances; healthcare professional-diagnosed sleep apnea). Adjusting for trouble sleeping for reasons other than temperature, sociodemographic characteristics, and clinical characteristics, we used Poisson regression with robust variance to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs). Results: Among 33,545 women (mean±SD age = 67±8.5 years), 90% self-identified as non- Hispanic White, 6.6% as non-Hispanic Black, and 3.7% as Latina, and 27% reported an annual household income (AHI) ≤$49,999 while 37% reported an AHI $50,000-$99,999 and 37% reported an AHI ≥$100,000. Prevalence of ‘too hot’ SDITE was highest among non-Hispanic Black women (15% vs. 9.0% overall) and women with an AHI ≥$100,000 (11%); ‘too cold’ SDITE prevalence was highest among Latina women (3.8% vs. 1.4% overall) and women with an AHI ≤$49,999 (2.2%). ‘Too hot’ and ‘too cold’ SDITE were consistently associated with long sleep onset latency (LSOL) (PR _hot =1.89 [1.75-2.04] and PR _cold =1.99 [1.70-2.33]) and daytime dysfunction (PR _hot =1.76 [1.23-2.51] and PR _cold =4.69 [2.83-7.76]). Conclusions: Perceived SDITE were associated with insomnia symptoms and may contribute to sleep disparities given the higher burdens often observed among Black women, Latina women, and women with lower annual household incomes.

Background: Two strong risk factors for gastroschisis are young maternal age (<20 years) and low/normal pre‐pregnancy body mass index (BMI), yet the reasons remain unknown. We explored whether neighborhood‐level socioeconomic position (nSEP) during pregnancy modified these associations.Methods: We analyzed data from 1269 gastroschisis cases and 10,217 controls in the National Birth Defects Prevention Study (1997–2011). To characterize nSEP, we applied the neighborhood deprivation index and used generalized estimating equations to calculate odds ratios and relative excess risk due to interaction.Results: Elevated odds of gastroschisis were consistently associated with young maternal age and low/normal BMI, regardless of nSEP. High‐deprivation neighborhoods modified the association with young maternal age. Infants of young mothers in high‐deprivation areas had lower odds of gastroschisis (adjusted odds ratio [aOR]: 3.1, 95% confidence interval [CI]: 2.6, 3.8) than young mothers in low‐deprivation areas (aOR: 6.6; 95% CI: 4.6, 9.4). Mothers of low/normal BMI had approximately twice the odds of having an infant with gastroschisis compared to mothers with overweight/obese BMI, regardless of nSEP (aOR range: 1.5–2.3).Conclusion: Our findings suggest nSEP modified the association between gastroschisis and maternal age, but not BMI. Further research could clarify whether the modification is due to unidentified biologic and/or non‐biologic factors.

Background: Neighborhood-level socioeconomic position has been shown to influence birth outcomes, including selected birth defects. This study examines the un derstudied association between neighborhood-level socioeconomic position during early pregnancy and the risk of gastroschisis, an abdominal birth defect of increasing prevalence. Methods: We conducted a case–control study of 1,269 gastroschisis cases and 10,217 controls using data from the National Birth Defects Prevention Study (1997–2011). To characterize neighborhood-level socioeconomic position, we conducted a principal component analysis to construct two indices—Neighborhood Deprivation Index (NDI) and Neighborhood Socioeconomic Position Index (nSEPI). We created neighborhood-level indices using census socioeconomic indicators corresponding to census tracts associated with addresses where mothers lived the longest during the periconceptional period. We used generalized estimating equations to estimate odds ratios (ORs) and 95% confidence intervals (CIs), with multiple imputations for missing data and adjustment for maternal race–ethnicity, household income, education, birth year, and duration of residence. Results: Mothers residing in moderate (NDI Tertile 2 aOR = 1.23; 95% CI = 1.03, 1.48 and nSEPI Tertile 2 aOR = 1.24; 95% CI = 1.04, 1.49) or low socioeconomic neighborhoods (NDI Tertile 3 aOR = 1.28; 95% CI = 1.05, 1.55 and nSEPI Tertile 3 aOR = 1.32, 95% CI = 1.09, 1.61) were more likely to deliver an infant with gastroschisis compared with mothers residing in high socioeconomic neighborhoods. Conclusions: Our findings suggest that lower neighborhood-level socioeconomic position during early pregnancy is associated with elevated odds of gastroschisis. Additional epidemiologic studies may aid in confirming this finding and evaluating potential mechanisms linking neighborhood-level socioeconomic factors and gastroschisis.

Background: Pelvic inflammatory disease (PID) is an infection of the upper female reproductive organs that can lead to infertility and ectopic pregnancies. It is a reportable condition in North Carolina (NC) but is likely underreported. We aimed to quantify PID diagnoses in NC emergency department (ED) visits. Methods: The NC Disease Event Tracking and Epidemiology Collection Tool tracks all ED visits in NC. We identified PID diagnoses among women of reproductive age (15–44 years) between 2008 and 2017 using International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification codes, and calculated the yearly proportion with PID diagnoses. We assessed the number of PID visits per patient each year, and the proportion of ED visits with a PID diagnosis by age, proportion of the patient's ZIP code living below the poverty line, insurance coverage, and NC provider region. Results: The percent of women with PID decreased from 6189 (1.0%) in 2008 to 4337 (0.58%) in 2016 before increasing slightly to 4371 (0.61%) in 2017. We identified 54,502 (0.45%) ED visits among 51,847 (0.76%) women with ≥1 PID diagnosis code. Most (95.5%) women with PID had one ED visit during the calendar year. Each year, the proportion with PID was highest among women aged 20 to 24 years, covered under public insurance, from the most impoverished areas, and whose provider was in the Coastal region of NC. Conclusions: The percent with PID among women visiting EDs decreased between 2008 and 2017 in NC. Although this decline was observed across all demographics, disparities associated with PID continued to persist over time.