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Dunn MR, Metwally EM, Vohra S, Hyslop T, Henderson LM, Reeder-Hayes K, Thompson CA, Lafata JE, Troester MA, Butler EN. Understanding mechanisms of racial disparities in breast cancer: an assessment of screening and regular care in the Carolina Breast Cancer Study. Cancer Causes Control 2024; 35:825-837. [PMID: 38217760 PMCID: PMC11045315 DOI: 10.1007/s10552-023-01833-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/16/2023] [Indexed: 01/15/2024]
Abstract
PURPOSE Screening history influences stage at detection, but regular preventive care may also influence breast tumor diagnostic characteristics. Few studies have evaluated healthcare utilization (both screening and primary care) in racially diverse screening-eligible populations. METHODS This analysis included 2,058 women age 45-74 (49% Black) from the Carolina Breast Cancer Study, a population-based cohort of women diagnosed with invasive breast cancer between 2008 and 2013. Screening history (threshold 0.5 mammograms per year) and pre-diagnostic healthcare utilization (i.e. regular care, based on responses to "During the past ten years, who did you usually see when you were sick or needed advice about your health?") were assessed as binary exposures. The relationship between healthcare utilization and tumor characteristics were evaluated overall and race-stratified. RESULTS Among those lacking screening, Black participants had larger tumors (5 + cm) (frequency 19.6% vs 11.5%, relative frequency difference (RFD) = 8.1%, 95% CI 2.8-13.5), but race differences were attenuated among screening-adherent participants (10.2% vs 7.0%, RFD = 3.2%, 0.2-6.2). Similar trends were observed for tumor stage and mode of detection (mammogram vs lump). Among all participants, those lacking both screening and regular care had larger tumors (21% vs 8%, RR = 2.51, 1.76-3.56) and advanced (3B +) stage (19% vs 6%, RR = 3.15, 2.15-4.63) compared to the referent category (screening-adherent and regular care). Under-use of regular care and screening was more prevalent in socioeconomically disadvantaged areas of North Carolina. CONCLUSIONS Access to regular care is an important safeguard for earlier detection. Our data suggest that health equity interventions should prioritize both primary care and screening.
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Affiliation(s)
- Matthew R Dunn
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
| | - Eman M Metwally
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Sanah Vohra
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Terry Hyslop
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Louise M Henderson
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Division of Pulmonary Disease and Critical Care Medicine, Department of Radiology, University of North Carolina, Chapel Hill, NC, USA
| | - Katherine Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Division of Oncology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Caroline A Thompson
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jennifer Elston Lafata
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Melissa A Troester
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | - Eboneé N Butler
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
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Crego N, Douglas C, Bonnabeau E, Eason K, Earls M, Tanabe P, Shah N. Opioid Use Among Children and Adults With Sickle Cell Disease in North Carolina Medicaid Enrollees in the Era of Opioid Harm Reduction. J Pediatr Hematol Oncol 2024; 46:181-187. [PMID: 38551912 DOI: 10.1097/mph.0000000000002852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 02/12/2024] [Indexed: 04/24/2024]
Abstract
Adults and children with sickle cell disease (SCD) are predominantly African American, with pain-related health disparities. We examined opioid prescription fill patterns in adults and children with SCD and compared factors associated with fills in North Carolina Medicaid enrollees. Our retrospective cohort study included 955 enrollees diagnosed with SCD having at least one opioid fill. Associations were measured between two cohorts (12 and 24 mo of continuous enrollment) for the following characteristics: sex, age, enrollee residence, hydroxyurea adherence, comanagement, enrollment in Community Care North Carolina, prescription for short versus short and long-acting opioids, and emergency department reliance. The majority of individuals did not have an opioid claim over a 12 or 24-month period. Claims increased at ages 10 to 17, peaking at ages 18 to 30. The increased number of claims was associated with the following factors: increasing age, male, short versus long-acting opioids, and Medicaid enrollment for 24 versus 12 months. Community Care North Carolina enrollees in the 12-month cohort had higher opioid days of supply per month; the inverse was true of the 24-month cohort.
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Affiliation(s)
| | | | | | - Kern Eason
- School of Medicine, Duke University, Durham
| | | | - Paula Tanabe
- School of Nursing
- School of Medicine, Duke University, Durham
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Dillon D, Ward-Caviness C, Kshirsagar AV, Moyer J, Schwartz J, Di Q, Weaver A. Associations between long-term exposure to air pollution and kidney function utilizing electronic healthcare records: a cross-sectional study. Environ Health 2024; 23:43. [PMID: 38654228 PMCID: PMC11036746 DOI: 10.1186/s12940-024-01080-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 04/05/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Chronic kidney disease (CKD) affects more than 38 million people in the United States, predominantly those over 65 years of age. While CKD etiology is complex, recent research suggests associations with environmental exposures. METHODS Our primary objective is to examine creatinine-based estimated glomerular filtration rate (eGFRcr) and diagnosis of CKD and potential associations with fine particulate matter (PM2.5), ozone (O3), and nitrogen dioxide (NO2) using a random sample of North Carolina electronic healthcare records (EHRs) from 2004 to 2016. We estimated eGFRcr using the serum creatinine-based 2021 CKD-EPI equation. PM2.5 and NO2 data come from a hybrid model using 1 km2 grids and O3 data from 12 km2 CMAQ grids. Exposure concentrations were 1-year averages. We used linear mixed models to estimate eGFRcr per IQR increase of pollutants. We used multiple logistic regression to estimate associations between pollutants and first appearance of CKD. We adjusted for patient sex, race, age, comorbidities, temporality, and 2010 census block group variables. RESULTS We found 44,872 serum creatinine measurements among 7,722 patients. An IQR increase in PM2.5 was associated with a 1.63 mL/min/1.73m2 (95% CI: -1.96, -1.31) reduction in eGFRcr, with O3 and NO2 showing positive associations. There were 1,015 patients identified with CKD through e-phenotyping and ICD codes. None of the environmental exposures were positively associated with a first-time measure of eGFRcr < 60 mL/min/1.73m2. NO2 was inversely associated with a first-time diagnosis of CKD with aOR of 0.77 (95% CI: 0.66, 0.90). CONCLUSIONS One-year average PM2.5 was associated with reduced eGFRcr, while O3 and NO2 were inversely associated. Neither PM2.5 or O3 were associated with a first-time identification of CKD, NO2 was inversely associated. We recommend future research examining the relationship between air pollution and impaired renal function.
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Affiliation(s)
- David Dillon
- Center for Public Health and Environmental Assessment, United States Environmental Protection Agency, Research Triangle Park, NC, USA
| | - Cavin Ward-Caviness
- Center for Public Health and Environmental Assessment, United States Environmental Protection Agency, Research Triangle Park, NC, USA
| | - Abhijit V Kshirsagar
- Division of Nephrology and Hypertension, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Joshua Moyer
- Center for Public Health and Environmental Assessment, United States Environmental Protection Agency, Research Triangle Park, NC, USA
| | - Joel Schwartz
- T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Qian Di
- Research Center for Public Health, School of Medicine, Tsinghua University, Beijing, China
| | - Anne Weaver
- Center for Public Health and Environmental Assessment, United States Environmental Protection Agency, Research Triangle Park, NC, USA.
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Mokashi NV, Brown Marusiak A, Giandomenico D, Cleinmark M, Schmitz JL, Boyce RM. Does Paging Clinicians about Tick-Borne Disease Serological Results Impact Clinical Care? A Retrospective Analysis of 70 Cases in North Carolina. Am J Trop Med Hyg 2024; 110:815-818. [PMID: 38412547 PMCID: PMC10993845 DOI: 10.4269/ajtmh.23-0251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 11/27/2023] [Indexed: 02/29/2024] Open
Abstract
Delayed treatment of Rocky Mountain spotted fever is associated with increased morbidity and mortality. Because the diagnosis cannot be established from a single serological test, guidelines recommend empirical antibiotic initiation in suspect patients. We evaluated a policy used by UNC Health of paging clinicians when acute testing for Rickettsia returned with a titer ≥1:256. Our objective was to assess the potential effect of paging on routine treatment practices. Notably, we found that a high proportion of cases (N = 28, 40%) were not prescribed antibiotics until the results were available. The vast majority of these cases did not have evidence of compatible symptoms or disease progression. These findings suggest that paging may have prompted unnecessary treatment. Overall, the policy, which has now been discontinued, appears to have had limited benefit. Efforts are urgently needed to improve adherence to testing and treatment guidelines.
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Affiliation(s)
- Neha V. Mokashi
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Amanda Brown Marusiak
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Dana Giandomenico
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina
| | - Meghan Cleinmark
- McLendon Clinical Laboratories, University of North Carolina, Chapel Hill, North Carolina
| | - John L. Schmitz
- McLendon Clinical Laboratories, University of North Carolina, Chapel Hill, North Carolina
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Ross M. Boyce
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina
- Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina
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Soltany KA, Segovia Molina R, Pappo C, Thomson S, Pring K, Cox S, Merrill R, Fishman E, Ambrosini A, Bognet G, Dodenhoff K, Munger Clary H, Strauss L, Graham R, Guzik AK, Strowd RE. Interest and Satisfaction of Telemedicine Use Among Ambulatory Neurology Patients in Western North Carolina During the COVID-19 Pandemic. Telemed J E Health 2024; 30:e1071-e1080. [PMID: 37883644 DOI: 10.1089/tmj.2023.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Introduction: During the COVID-19 pandemic, care shifted from exclusively telemedicine to hybrid models with in-person, video, and telephone visits. We explored how patient satisfaction and visit preferences have changed by comparing in-person versus virtual visits (telephone and video) in an ambulatory neurology practice across three time points. Methods: Patients who completed a virtual visit in March 2020 (early-pandemic), May 2020 (mid-pandemic), and March 2021 (later-pandemic) were contacted. Patients were assessed for visit satisfaction and desire for future telemedicine. Univariate and multivariable logistic regression analysis was conducted to determine factors independently associated with video visit completion. Results: Four thousand seven hundred seventy-eight the number of ambulatory visits (n = 4,778) were performed (1,004 early; 1,265 mid; and 2,509 later); 1,724 patients (36%) assented to postvisit feedback; mean age 45.8 ± 24.4 years, 58% female, 79% white, and 56% with Medicare/Medicaid insurance. Patient satisfaction significantly increased (73% early, 79% mid, 81% later-pandemic, p = 0.008). Interest in telemedicine also increased for patients completing telephone visits (40% early, 50% mid, 59% later, p = 0.027) and video visits (52% early, 59% mid, 62% later, p = 0.035). Patients satisfied with telemedicine visits were younger (p < 0.001). White patients were more interested in future telemedicine (p = 0.037). Multivariable analysis showed that older patients (for each 1 year older), Black patients, and patients with Medicare/Medicaid were 2%, 45%, and 54% less likely to complete a video visit than telephone, respectively. Discussion: Patients, especially younger ones, have become more satisfied and more interested in hybrid care models during the COVID-19 pandemic. Barriers to conducting video visits persist for older, Black patients with Medicare or Medicaid insurance.
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Affiliation(s)
- K Alexander Soltany
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Reyna Segovia Molina
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Carly Pappo
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sharon Thomson
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Kelly Pring
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Siobhan Cox
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Rebecca Merrill
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Emily Fishman
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Alexander Ambrosini
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Gabby Bognet
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Kristen Dodenhoff
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Heidi Munger Clary
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Lauren Strauss
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Rachel Graham
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Amy K Guzik
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Roy E Strowd
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Nyante SJ, Deal AM, Heiling HM, Kim KS, Kuzmiak CM, Calhoun BC, Ray EM. Trends in breast, colon, pancreatic, and uterine cancers in women during the COVID-19 pandemic in North Carolina. Cancer Med 2024; 13:e7156. [PMID: 38572934 PMCID: PMC10993709 DOI: 10.1002/cam4.7156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 03/03/2024] [Accepted: 03/22/2024] [Indexed: 04/05/2024] Open
Abstract
IMPORTANCE The COVID-19 pandemic led to reductions in primary care and cancer screening visits, which may delay detection of some cancers. The impact on incidence has not been fully quantified. We examined change in cancer incidence to determine how the COVID-19 pandemic may have altered the characteristics of cancers diagnosed among women. METHODS This study included female patients aged ≥18 years and diagnosed with breast (n = 9489), colon (n = 958), pancreatic (n = 669), or uterine (n = 1991) cancer at three hospitals in North Carolina. Using interrupted time series, we compared incidence of cancers diagnosed between March 2020 and November 2020 (during pandemic) with cancers diagnosed between January 2016 and February 2020 (pre-pandemic). RESULTS During the pandemic, incidence of breast and uterine cancers was significantly lower than expected compared to pre-pandemic (breast-18%, p = 0.03; uterine -20%, p = 0.05). Proportions of advanced pathologic stage and hormone receptor-negative breast cancers, and advanced clinical stage and large size uterine cancers were more prevalent during the pandemic. No significant changes in incidence were detected for pancreatic (-20%, p = 0.08) or colon (+14%, p = 0.30) cancers. CONCLUSION AND RELEVANCE In women, the COVID-19 pandemic resulted in a significant reduction in the incidence of breast and uterine cancers, but not colon or pancreatic cancers. A change in the proportion of poor prognosis breast and uterine cancers suggests that some cancers that otherwise would have been diagnosed at an earlier stage will be detected in later years. Continued analysis of long-term trends is needed to understand the full impact of the pandemic on cancer incidence and outcomes.
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Affiliation(s)
- Sarah J. Nyante
- Department of RadiologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Allison M. Deal
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Hillary M. Heiling
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Kyung Su Kim
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Cherie M. Kuzmiak
- Department of RadiologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Benjamin C. Calhoun
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Emily M. Ray
- Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Division of Oncology, Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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LePrevost CE, Cofie LE, Nieuwsma J, Harwell EL, Rivera ND, Acevedo PA, Lee JGL. Community health worker outreach to farmworkers in rural North Carolina: Learning from adaptations to the SARS-CoV-2 pandemic. Health Expect 2024; 27:e14047. [PMID: 38613767 PMCID: PMC11015864 DOI: 10.1111/hex.14047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/18/2024] [Accepted: 04/03/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Community health workers represent a critical part of the health outreach and services for migrant and seasonal farmworkers ('farmworkers') in rural areas of the United States. PURPOSE We sought to identify adaptations to farmworker patient engagement and health outreach made by community health workers during the first 18 months of the COVID-19 pandemic. METHODS In this qualitative study, we used semi-structured interviews with community health workers from August 2020 to February 2022 (n = 21). Two coders used thematic analysis to identify three themes related to the experiences of community health workers in conducting health education and outreach to farmworkers prior to and following the onset of the pandemic. FINDINGS We found themes related to pre-pandemic outreach efforts to provide health education resource sharing with farmworkers and pandemic-related outreach efforts that included adoption of porch drops and distanced delivery of health education, adaptation of modes of health education and communication through technology and the internet, and taking on new roles related to COVID-19. Finally, we identified changes that reverted after the pandemic or will continue as adaptations. CONCLUSIONS Community health workers created practice-based innovations in outreach in response to the COVID-19 pandemic. These innovations included new COVID-19 related roles and new modes of health education and outreach, including the use of digital resources. The changes developed for emergency use in COVID-19, particularly related to internet and technology, have likely altered how community health workers conduct outreach in North Carolina going forward. Funders, community health worker training programs, and researchers should take note of these innovations. PATIENT OR PUBLIC CONTRIBUTION Community health workers who typically come from patient populations and provide critical navigation and connection with the health care system advised on the design and creation of this research project, including serving on an advisory board. Two authors have experience working as community health workers.
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Affiliation(s)
- Catherine E. LePrevost
- Department of Applied Ecology, College of Agriculture and Life SciencesNC State UniversityRaleighNorth CarolinaUSA
| | - Leslie E. Cofie
- Department of Health Education and Promotion, College of Health and Human PerformanceEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Julianna Nieuwsma
- Department of Applied Ecology, College of Agriculture and Life SciencesNC State UniversityRaleighNorth CarolinaUSA
| | - Emery L. Harwell
- Department of Applied Ecology, College of Agriculture and Life SciencesNC State UniversityRaleighNorth CarolinaUSA
| | - Natalie D. Rivera
- NC Farmworker Health Program, Office of Rural HealthNC Department of Health and Human ServicesRaleighNorth CarolinaUSA
| | - Paula A. Acevedo
- Department of Health Education and Promotion, College of Health and Human PerformanceEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Joseph G. L. Lee
- Department of Health Education and Promotion, College of Health and Human PerformanceEast Carolina UniversityGreenvilleNorth CarolinaUSA
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Burch AE, Lee E, Bolin LP, Shackelford P, Bolin P. Health Screening Among a Rural, Hourly Workforce: North Carolina SERVIRE Project. Am J Prev Med 2024; 66:730-734. [PMID: 37972798 DOI: 10.1016/j.amepre.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION This study demonstrates the feasibility of a novel, business-partnered, and worksite-based approach to healthcare access to facilitate chronic disease screening and diagnosis among rural hourly workers. The prevalence of undiagnosed and untreated diabetes and hypertension among screening participants was determined. METHODS From February 2021 to June 2023, investigators partnered with 29 businesses to screen 1,114 workers. Health screenings included a demographic questionnaire, A1c testing for prediabetes (A1c of 5.7-6.4) and diabetes (A1c≥6.5), hypertension (Stage 1: systolic blood pressure of 130-139 mmHg; Stage 2: systolic blood pressure ≥140 mmHg), kidney disease (estimated glomerular filtration rate <60; urine protein ≥1+), and questionnaire assessment of stroke (CHA2DS2-VASc) and sleep apnea (STOP-bang) risk. RESULTS Of the 1,114 individuals screened (n=632, 56.7% male; n=497, 44.6% Black)), 388 (36%) screened positive for prediabetes or diabetes. Diabetes was previously undiagnosed in 273 (70.4%) of these participants. More than half of the participants (n=680, 62.4%) had an elevated blood pressure reading during the screening, and the majority of these participants (n=445, 65.4%) had not been previously diagnosed with hypertension. In addition, 241 (21.6%) participants were at an increased risk of stroke (CHA2DS2-VASc≥2), and 182 (23.7%) had a STOP-Bang score ≥4, indicating an increased risk of obstructive sleep apnea. CONCLUSIONS By partnering with local businesses to deliver worksite-based health screenings, high rates of undiagnosed and uncontrolled diabetes and hypertension were identified among the rural, hourly workforce. This worksite-based approach to healthcare access could facilitate early detection of chronic disease, improve patient engagement in the healthcare system, and ultimately yield better long-term public health outcomes.
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Affiliation(s)
- Ashley E Burch
- Department of Health Services & Information Management, East Carolina University, Greenville, North Carolina; Department of Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina.
| | - Elisabeth Lee
- Department of Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Linda P Bolin
- Department of Nursing Science, College of Nursing, East Carolina University, Greenville, North Carolina
| | - Paul Shackelford
- Department of Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Paul Bolin
- Department of Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
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Boyce RM, Pretsch P, Tyrlik K, Schulz A, Giandomenico DA, Barbarin AM, Williams C. Delayed Diagnosis of Locally Acquired Lyme Disease, Central North Carolina, USA. Emerg Infect Dis 2024; 30:564-567. [PMID: 38407256 PMCID: PMC10902532 DOI: 10.3201/eid3003.231302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
Healthcare providers in North Carolina, USA, have limited experience diagnosing and managing Lyme disease because few cases occur annually statewide. We outline the prolonged diagnostic course for a patient with locally acquired Lyme disease in North Carolina. This case highlights the need for greater awareness and professional education.
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Singichetti B, Golightly YM, Wang YC, Marshall SW, Naumann RB. Impact of alcohol driving-while-impaired license suspension duration on future alcohol-related license events and motor vehicle crash involvement in North Carolina, 2007 to 2016. Accid Anal Prev 2024; 197:107449. [PMID: 38211544 DOI: 10.1016/j.aap.2023.107449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 12/05/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND/PURPOSE License suspensions are a strategy to address alcohol-impaired driving behavior and recidivism following an alcohol driving while impaired (alcohol-DWI) conviction. Little is known about the specific impacts of conviction-related suspensions on safety outcomes and given recent fluctuations in alcohol-impaired driving behavior, crashes, and suspension trends, updated and focused assessments of this intervention are necessary. This study aimed to 1) examine the association between type of recent alcohol-DWI suspension and having a secondary alcohol-related license outcome and/or future crash event in North Carolina (NC) between 2007 and 2016; and 2) assess potential modification of these associations by race/ethnicity. METHODS We used linked NC licensing data, NC crash data, and county-level contextual data from a variety of data sources. We compared individuals ages 21 to 64 who sustained initial (1-year) versus repeat (4-year) suspensions for alcohol-related license and crash involvement outcomes. We estimated unadjusted and adjusted hazard ratios (aHRs) using Cox proportional hazards models and produced Kaplan-Meier (KM) survival curves using a three-year follow-up period. After observing statistically significant modification by race/ethnicity, we calculated stratified aHRs for each outcome (Black and White subgroups only, as other subgroups had low numbers of outcomes). RESULTS 122,002 individuals sustained at least one alcohol-DWI conviction suspension (117,244 initial, 4,758 repeat). Adjusted KM survival curves indicated that within three years of the index suspension, the predicted risks of having a license outcome and crash outcome were about 8 % and 15 %, respectively, among individuals with an initial suspension and 5 % and 10 %, respectively, among individuals with a repeat suspension. After adjusting for potential confounding, we found that compared to those with an initial suspension, those with repeat suspensions had a lower incidence of future license (aHR: 0.49; 95 % CI: 0.42, 0.57) and crash outcomes (aHR: 0.67; 95 % CI: 0.60, 0.75). Among Black individuals, license outcome incidence was 162 % lower among repeat versus initial index suspension groups (aHR: 0.38; 95 % CI: 0.26, 0.55), while for White individuals, the incidence was 87 % lower (aHR: 0.54; 95 % CI: 0.45, 0.64). Similarly, crash incidence for repeat versus initial suspensions among Black individuals was 56 % lower (aHR: 0.64; 95 % CI: 0.50, 0.83), while only 39 % lower among White individuals (aHR: 0.72; 95 % CI: 0.63, 0.81). CONCLUSIONS Decreased incidence of both license and crash outcomes were observed among repeat versus initial index suspensions. The magnitude of these differences varied by race/ethnicity, with larger decreases in incidence among Black compared to White individuals. Future research should examine the underlying mechanisms leading to alcohol-impaired driving behavior, convictions, recidivism, and crashes from a holistic social-ecological perspective so that interventions are designed to both improve road safety and maximize other critical public health outcomes, such as access to essential needs and services (e.g., healthcare and employment).
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Affiliation(s)
- Bhavna Singichetti
- Injury Prevention Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Yvonne M Golightly
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Yudan Chen Wang
- Department of Counseling, North Carolina A&T State University, Greensboro, NC 27514, USA; Department of Maternal and Child Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Stephen W Marshall
- Injury Prevention Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Rebecca B Naumann
- Injury Prevention Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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11
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Martin CL, Richey M, Richardson DB, Nocera M, Cantrell J, McClure ES, Martin AT, Marshall SW, Ranapurwala SI. 25-Year fatal workplace suicide trends in North Carolina: 1992-2017. Am J Ind Med 2024; 67:214-223. [PMID: 38197263 DOI: 10.1002/ajim.23563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/06/2023] [Accepted: 12/21/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Suicide is a serious public health problem in the United States, but limited evidence is available investigating fatal suicides at work. There is a substantial need to characterize workplace suicides to inform suicide prevention interventions and target high-risk settings. This study aims to examine workplace suicide rates in North Carolina (NC) by worker characteristics, means of suicide used, and industry between 1992 and 2017. METHODS Fatal workplace suicides were identified from records of the NC Office of the Chief Medical Examiner system and the NC death certificate. Sex, age, race, ethnicity, class of worker, manner of death, and industry were abstracted. Crude and age-standardized homicide rates were calculated as the number of suicides that occurred at work divided by an estimate of worker-years (w-y). Rate ratios and 95% confidence intervals (CIs) were calculated, and trends over calendar time for fatal workplace suicides were examined overall and by industry. RESULTS 81 suicides over 109,464,430 w-y were observed. Increased rates were observed in workers who were male, self-employed, and 65+ years old. Firearms were the most common means of death (63%) followed by hanging (16%). Gas service station workers experienced the highest fatal occupational suicide rate, 11.5 times (95% CI: 3.62-36.33) the overall fatal workplace suicide rate, followed by Justice, Public Order, and Safety workers at 3.23 times the overall rate (95% CI: 1.31-7.97). CONCLUSION Our findings identify industries and worker demographics that were vulnerable to workplace suicides. Targeted and tailored mitigation strategies for vulnerable industries and workers are recommended.
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Affiliation(s)
- Chelsea L Martin
- Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, Chapel Hill, North Carolina, USA
| | - Morgan Richey
- Department of Population Sciences, Duke University, Durham, North Carolina, USA
| | - David B Richardson
- Susan and Henry Samueli College of Health Sciences, Irvine, California, USA
| | - Maryalice Nocera
- Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - John Cantrell
- Injury Prevention Research Center, Chapel Hill, North Carolina, USA
| | - Elizabeth S McClure
- Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, Chapel Hill, North Carolina, USA
| | - Amelia T Martin
- Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, Chapel Hill, North Carolina, USA
| | - Stephen W Marshall
- Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, Chapel Hill, North Carolina, USA
| | - Shabbar I Ranapurwala
- Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, Chapel Hill, North Carolina, USA
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12
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Nelson AE. Multiple joint osteoarthritis (MJOA): What's in a name? Osteoarthritis Cartilage 2024; 32:234-240. [PMID: 37984559 PMCID: PMC10922529 DOI: 10.1016/j.joca.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/13/2023] [Accepted: 10/26/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To summarize the current state of the literature regarding multi-joint osteoarthritis (MJOA) and discuss important future directions. DESIGN A narrative review of the author's work and other key references on this topic with a focus on the Johnston County studies, definitions of MJOA and their impact, multi-site pain in osteoarthritis (OA), genetics and biomarkers in MJOA, and perspectives on future work. RESULTS MJOA is variably defined and lacks a clear consensus definition, making comprehensive study challenging. Involvement of both symptoms and structural changes of OA in multiple joints in an individual is common, but patterns vary by sex, race/ethnicity, and other factors. Outcomes (e.g., general health, function, falls, mortality) are negatively impacted by a greater whole-body OA burden. Recent genetic and biomarker studies including whole-body OA assessments have begun to shed some light on potentially unique factors in the MJOA population. CONCLUSIONS Consideration of MJOA is essential for ongoing study of OA phenotypes, epidemiology, risk factors, genetics, biomarkers, and outcomes, to fully understand and eventually limit the negative impact of OA burden on health.
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Affiliation(s)
- Amanda E Nelson
- Department of Medicine, Division of Rheumatology, Allergy, and Immunology, Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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13
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Rosenstrom ET, Ivy JS, Mayorga ME, Swann JL. COVSIM: A stochastic agent-based COVID-19 SIMulation model for North Carolina. Epidemics 2024; 46:100752. [PMID: 38422675 DOI: 10.1016/j.epidem.2024.100752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 09/30/2023] [Accepted: 02/20/2024] [Indexed: 03/02/2024] Open
Abstract
We document the evolution and use of the stochastic agent-based COVID-19 simulation model (COVSIM) to study the impact of population behaviors and public health policy on disease spread within age, race/ethnicity, and urbanicity subpopulations in North Carolina. We detail the methodologies used to model the complexities of COVID-19, including multiple agent attributes (i.e., age, race/ethnicity, high-risk medical status), census tract-level interaction network, disease state network, agent behavior (i.e., masking, pharmaceutical intervention (PI) uptake, quarantine, mobility), and variants. We describe its uses outside of the COVID-19 Scenario Modeling Hub (CSMH), which has focused on the interplay of nonpharmaceutical and pharmaceutical interventions, equitability of vaccine distribution, and supporting local county decision-makers in North Carolina. This work has led to multiple publications and meetings with a variety of local stakeholders. When COVSIM joined the CSMH in January 2022, we found it was a sustainable way to support new COVID-19 challenges and allowed the group to focus on broader scientific questions. The CSMH has informed adaptions to our modeling approach, including redesigning our high-performance computing implementation.
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Affiliation(s)
| | - Julie S Ivy
- Industrial and Systems Engineering, North Carolina State University, Raleigh, USA; Industrial and Operations Engineering, University of Michigan, Ann Arbor, USA
| | - Maria E Mayorga
- Industrial and Systems Engineering, North Carolina State University, Raleigh, USA
| | - Julie L Swann
- Industrial and Systems Engineering, North Carolina State University, Raleigh, USA
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14
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Bass R, Flinchum G, Ramage M, Galvin SL, Cabello-De la Garza A, Caron O, Marietta A. Accessing perinatal substance use disorder care in your local community: A case study of an innovative hub and spoke network in western North Carolina. J Subst Use Addict Treat 2024; 158:209268. [PMID: 38097044 DOI: 10.1016/j.josat.2023.209268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 01/08/2024]
Abstract
INTRODUCTION The incidence of substance use disorders (SUD) in the general population and in the pregnant person population has risen over the last 20 years. Concurrently, both perinatal and SUD care in rural areas is laden with access barriers including but not limited to geographical distance from potential treatment and stigma. An integrated outpatient perinatal substance use disorder (PSUD) clinic in an urban area in western North Carolina (WNC) found that patients who traveled further for prenatal care were less likely to continue seeking care in the postpartum period. Acknowledging that the risk of overdose increases in the postpartum period, the PSUD clinic utilized a hub and spoke model to promote healthcare accessibility. METHODS The clinic adapted the Vermont hub and spoke model and the CHARM (Children and Recovering Mothers) collaborative. The urban hub in WNC has now developed eight spokes in rural communities. The hub provides education and technical assistance to the rural spokes, and the two engage in bidirectional referral pathways. This manuscript details the model and analyzes the existing strengths and barriers at two spokes, a family medicine Federally Qualified Health Center and a hospital affiliated obstetrics and gynecology practice and analyzes their process of implementation of integrated outpatient perinatal substance use care. RESULTS Both spokes found coaching relationships and the sharing of resources such as clinical guidelines useful to begin prescribing buprenorphine for PSUD. Their context led one spoke to begin prescribing within one year while the other took two years. CONCLUSION Comparing and contrasting these spokes serves to demonstrate that across many contexts, a hub and spoke model is a replicable intervention for rural perinatal substance use access to care barriers. Comparing the two spokes emphasizes the need for adaptation as well as standardization of the model to improve evidence-based PSUD care most effectively.
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Affiliation(s)
- Rebekah Bass
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA.
| | - Grace Flinchum
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA
| | - Melinda Ramage
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA
| | - Shelley L Galvin
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA
| | - Ana Cabello-De la Garza
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA
| | - Olivia Caron
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA; Department of Pharmacotherapy at Mountain Area Health Education Center (MAHEC), 125 Hendersonville Road, Asheville, NC 28803, USA; UNC-Chapel Hill Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC 27599, USA
| | - Amy Marietta
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA
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15
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Fitch KV, Pence BW, Rosen DL, Miller VE, Gaynes BN, Swilley-Martinez ME, Kavee AL, Carey TS, Proescholdbell SK, Ranapurwala SI. Suicide Mortality Among Formerly Incarcerated People Compared With the General Population in North Carolina, 2000-2020. Am J Epidemiol 2024; 193:489-499. [PMID: 37939151 DOI: 10.1093/aje/kwad214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 10/11/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023] Open
Abstract
We aimed to compare rates and characteristics of suicide mortality in formerly incarcerated people with those of the general population in North Carolina. We conducted a retrospective cohort study of 266,400 people released from North Carolina state prisons between January 1, 2000, and March 1, 2020. Using direct and indirect standardization by age, sex, and calendar year, we calculated standardized suicide mortality rates and standardized mortality ratios comparing formerly incarcerated people with the North Carolina general population. We evaluated effect modification by race/ethnicity, sex, age, and firearm involvement. Formerly incarcerated people had approximately twice the overall suicide mortality of the general population for 3 years after release, with the highest rate of suicide mortality being observed in the 2-week period after release. In contrast to patterns in the general population, formerly incarcerated people had higher rates of non-firearm-involved suicide mortality than firearm-involved suicide mortality. Formerly incarcerated female, White and Hispanic/Latino, and emerging adult people had a greater elevation of suicide mortality than their general-population peers compared with other groups. These findings suggest a need for long-term support for formerly incarcerated people as they return to community living and a need to identify opportunities for interventions that reduce the harms of incarceration for especially vulnerable groups. This article is part of a Special Collection on Mental Health.
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16
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Gigot C, Lowman A, Ceryes CA, Hall DJ, Heaney CD. Industrial Hog Operation Workers' Perspectives on Occupational Exposure to Zoonotic Pathogens: A Qualitative Pilot Study in North Carolina, USA. New Solut 2024; 33:209-219. [PMID: 38062664 DOI: 10.1177/10482911231217055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Industrial hog operation (IHO) workers face a range of occupational hazards, including exposure to zoonotic pathogens such as livestock-associated antimicrobial-resistant Staphylococcus aureus and swine-origin influenza viruses with epidemic or pandemic potential. To better understand this population's occupational exposure to zoonotic pathogens, we conducted a community-driven qualitative research study in eastern North Carolina. We completed in-depth interviews with ten IHO workers and used thematic analysis to identify and analyze patterns of responses. Workers described direct and indirect occupational contact with hogs, with accompanying potential for dermal, ingestion, and inhalation exposures to zoonotic pathogens. Workers also described potential take-home pathways, wherein they could transfer livestock-associated pathogens and other contaminants from IHOs to their families and communities. Findings warrant future research, and suggest that more restrictive policies on antimicrobials, stronger health and safety regulations, and better policies and practices across all IHOs could afford greater protection against worker and take-home zoonotic pathogen exposures.
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Affiliation(s)
- Carolyn Gigot
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amy Lowman
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Caitlin A Ceryes
- Department of Health Sciences, Towson University, Towson, MD, USA
| | - Devon J Hall
- Rural Empowerment Association for Community Help, Warsaw, NC, USA
| | - Christopher D Heaney
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Environmental Health and Engineering, Community Science and Innovation for Environmental Justice Initiative, Center for a Livable Future, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
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17
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Luo H, Moss ME, Webb MD, Winterbauer NL, Tucker-McLaughlin M, Yockey RA, Smith AW, Wright WG. The most common types of nontraumatic dental conditions among emergency department visits in North Carolina before and during the COVID-19 pandemic. J Am Dent Assoc 2024; 155:149-157. [PMID: 38069961 PMCID: PMC11044986 DOI: 10.1016/j.adaj.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/09/2023] [Accepted: 10/14/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND This study aimed to identify the most common types of nontraumatic dental conditions (NTDCs) before and during the COVID-19 pandemic and assess the variations in the most common NTDCs by patient age groups and rural or urban locations and the impact of COVID-19 on emergency department (ED) visits for NTDCs in North Carolina. METHODS The authors conducted a retrospective data analysis of ED data from the North Carolina Disease Event Tracking and Epidemiology Collection Tool. The authors estimated the proportions of NTDCs of all ED visits in 2019 and 2021 and ranked the proportions of the major categories of NTDCs by age groups and rural or urban locations. They used a multiple logistic regression model to assess the impact of COVID-19 on NTDCs. RESULTS By the first diagnosis, the proportion of NTDCs dropped from 1.1% in 2019 to 0.99% in 2021 (P < .001). Caries was specified as the third most common NTDC. Oral infection was the top NTDC among young (≤ 17 years) and older patients (≥ 65 years). No significant differences were found in NTDCs between rural and urban areas (P = .68). Children younger than 2 years (adjusted odds ratio, 4.36) and adults aged 18 through 44 years (adjusted odds ratio, 4.54) were more likely to visit the ED for NTDCs than those 75 years and older. CONCLUSIONS The proportion of NTDCs seen at the ED was lower during the COVID-19 pandemic in 2021 than in 2019. The common NTDCs varied by age group but were similar in rural and urban areas. The most common NTDCs were related to toothache, oral infection, and caries. PRACTICAL IMPLICATIONS More efforts are needed to reduce ED visits for NTDCs.
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18
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Richardson DB, Martin AT, McClure ES, Nocera M, Cantrell J, Ranapurwala SI, Marshall S. Forty-year trends in fatal occupational injuries in North Carolina. Am J Ind Med 2024; 67:87-98. [PMID: 37970734 DOI: 10.1002/ajim.23549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/25/2023] [Accepted: 11/01/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND We describe progress in the control of deaths on-the-job due to fatal occupational injury in North Carolina over the period 1978-2017. METHODS Forty years of information on fatal occupational injuries in North Carolina has been assembled from medical examiners' reports and death certificates, supplemented by newspaper and police reports. Cases were defined as unintentional fatal occupational injuries among adults. Annual estimates of the population at risk were derived from US Census data, and rates were quantified using Poisson regression methods. RESULTS There were 4434 eligible deaths. The unintentional fatal occupational injury rate at the beginning of the study period was more than threefold the rate at the end of the study. The fatal occupational injury rate among men declined from 9.6 per 100,000 worker-years in the period 1978-1982 to 3.1 per 100,000 worker-years in the period 2013-2017. The fatal occupational injury rate among women declined from 0.3 per 100,000 worker-years in the period 1978-1981 to 0.1 per 100,000 worker-years in the period 2013-2017. Declines in rates were observed for young adults as well as older workers and were observed across all major industry categories. Average annual declines in rates were greatest in those industries and occupations that had the highest fatal injury rates at the start of the study period. CONCLUSIONS The substantial decline in fatal injury rates underscores the importance of injury prevention and demonstrates the ability to make meaningful reductions in unintentional fatal injury.
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Affiliation(s)
- David B Richardson
- Department of Environmental and Occupational Health, Program in Public Health, University of California, Irvine, California, USA
| | - Amelia T Martin
- Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elizabeth S McClure
- Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Maryalice Nocera
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - John Cantrell
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shabbar I Ranapurwala
- Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephen Marshall
- Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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19
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Neuroth LM, Singichetti B, Harmon KJ, Waller AE, Naumann RB. Racial and ethnic disparities in motor vehicle crash-related outcomes in North Carolina surrounding the COVID-19 pandemic. Inj Prev 2024; 30:84-88. [PMID: 37857475 DOI: 10.1136/ip-2023-045005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Long-term impacts of the COVID-19 pandemic on racial and ethnic disparities in motor vehicle crash (MVC) injuries and death are poorly understood. This study aimed to characterize trends and investigate the heterogeneity of MVC-related disparities in North Carolina across several data sources. Crash reports, emergency department visit records, and death certificates from 2018 to 2021 were used to calculate monthly population-rates of MVC-related public health outcomes. We estimated trendlines using joinpoint regression and compared outcomes across racial and ethnic classifications. MVC and MVC-related injury rates declined in conjunction with NC's stay-at-home order, while rates of severe outcomes remained unimpacted. By December 2021 rates of MVC-related outcomes met or exceeded pre-pandemic levels, with the highest rates observed among non-Hispanic Black individuals. Racial and ethnic disparities in MVC-related outcomes remained prevalent throughout the COVID-19 pandemic. These results highlight the importance of a holistic approach to traffic injury surveillance when assessing the impact of MVCs.
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Affiliation(s)
- Lucas M Neuroth
- Department of Epidemiology, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
- The University of North Carolina at Chapel Hill Injury Prevention Research Center, Chapel Hill, North Carolina, USA
| | - Bhavna Singichetti
- Department of Epidemiology, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
- The University of North Carolina at Chapel Hill Injury Prevention Research Center, Chapel Hill, North Carolina, USA
| | - Katherine J Harmon
- The University of North Carolina at Chapel Hill Injury Prevention Research Center, Chapel Hill, North Carolina, USA
- The University of North Carolina at Chapel Hill Highway Safety Research Center, Chapel Hill, North Carolina, USA
| | - Anna E Waller
- The University of North Carolina at Chapel Hill Injury Prevention Research Center, Chapel Hill, North Carolina, USA
- The University of North Carolina at Chapel Hill Carolina Center for Health Informatics, Chapel Hill, North Carolina, USA
| | - Rebecca B Naumann
- Department of Epidemiology, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
- The University of North Carolina at Chapel Hill Injury Prevention Research Center, Chapel Hill, North Carolina, USA
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Choi HM, Heo S, Bell ML. The effect modification of greenspace and impervious surface on the heat-mortality association: Differences by the dissimilarity index. Sci Total Environ 2024; 908:168074. [PMID: 37898198 PMCID: PMC10841598 DOI: 10.1016/j.scitotenv.2023.168074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/26/2023] [Accepted: 10/21/2023] [Indexed: 10/30/2023]
Abstract
Recent studies have shown that heat-mortality risk differs by level of greenspace and impervious surface. However, these studies do not consider both green spaces and impervious surfaces simultaneously, and further did not fully consider community- and individual-level characteristics. In this study we explored the effect modification of greenspace and impervious surface on the association between heat and mortality and how it differs by race/ethnicity dissimilarity index levels in North Carolina, USA. We aggregated datasets for greenspace, impervious surface estimates, temperature, and mortality for 1275 census tracts for North Carolina, USA, for 2000 to 2016 for 5 warm months (May to September). We used distributed lag non-linear models to estimate the heat-mortality relationship in each census tract. Heat-mortality relative risk (RR) was higher for census tracts with low greenspace than high greenspace (RR comparing risk at 99th temperature and minimum mortality temperature: 1.08 (1.02, 1.15) for low greenspace and 0.97 (0.87, 1.08) for high greenspace). Heat-mortality RR was higher for tracts with high impervious surface than low impervious surface (1.04 (1.00, 1.09) for high impervious surface and 0.94 (0.84, 1.05) for low impervious surface). Census tracts with high dissimilarity value and low greenspace had the highest heat-mortality risk compared to the tracts with high dissimilarity value with and high greenspace (1.13 (1.02, 1.24) for high dissimilarity index and 0.97 (0.86, 1.09) for low dissimilarity index). Communities with low greenspace or high impervious surfaces had higher heat-mortality associations, and this effect modification was higher for high race/ethnicity dissimilarity regions.
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Affiliation(s)
| | - Seulkee Heo
- School of the Environment, Yale University, New Haven, CT, USA
| | - Michelle L Bell
- School of the Environment, Yale University, New Haven, CT, USA
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Kucera KS, Boyea BL, Migliore B, Potter SN, Robles VR, Kutsa O, Cope H, Okoniewski KC, Wheeler A, Rehder CW, Smith EC, Peay HL. Two years of newborn screening for Duchenne muscular dystrophy as a part of the statewide Early Check research program in North Carolina. Genet Med 2024; 26:101009. [PMID: 37864479 DOI: 10.1016/j.gim.2023.101009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023] Open
Abstract
PURPOSE Current and emerging treatments for Duchenne muscular dystrophy (DMD) position DMD as a candidate condition for newborn screening (NBS). In anticipation of the nomination of DMD for universal NBS, we conducted a prospective study under the Early Check voluntary NBS research program in North Carolina, United States. METHODS We performed screening for creatine kinase-MM (CK-MM), a biomarker of muscle damage, on residual routine newborn dried blood spots (DBS) from participating newborns. Total creatine kinase testing and next generation sequencing of an 86-neuromuscular gene panel that included DMD were offered to parents of newborns who screened positive. Bivariate and multivariable analyses were performed to assess effects of biological and demographic predictors on CK-MM levels in DBS. RESULTS We screened 13,354 newborns and identified 2 males with DMD. The provisional 1626 ng/mL cutoff was raised to 2032 ng/mL to improve specificity, and additional cutoffs (900 and 360 ng/mL) were implemented to improve sensitivity for older and low-birthweight newborns. CONCLUSION Population-scale screening for elevated CK-MM in DBS is a feasible approach to identify newborns with DMD. Inclusion of birthweight- and age-specific cutoffs, repeat creatine kinase testing after 72 hours of age, and DMD sequencing improve sensitivity and specificity of screening.
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Affiliation(s)
| | | | | | | | | | - Oksana Kutsa
- RTI International, Research Triangle Park, Durham, NC
| | - Heidi Cope
- RTI International, Research Triangle Park, Durham, NC
| | | | - Anne Wheeler
- RTI International, Research Triangle Park, Durham, NC
| | | | | | - Holly L Peay
- RTI International, Research Triangle Park, Durham, NC
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22
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Donovan CV, MacFarquhar JK, Wilson E, Sredl M, Tanz LJ, Mullendore J, Fleischauer A, Smith JC, Lucas C, Kunz J, Moore Z. Legionnaires' Disease Outbreak Associated With a Hot Tub Display at the North Carolina Mountain State Fair, September 2019. Public Health Rep 2024; 139:79-87. [PMID: 36971250 PMCID: PMC10905752 DOI: 10.1177/00333549231159159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
OBJECTIVES On September 23, 2019, the North Carolina Division of Public Health identified a legionellosis increase in western North Carolina; most patients had recently attended the North Carolina Mountain State Fair. We conducted a source investigation. METHODS Cases were fair attendees with laboratory-confirmed legionellosis and symptom onset within 2 to 14 days (Legionnaires' disease) or ≤3 days (Pontiac fever). We conducted a case-control study matching cases to non-ill fair attendees as control participants and an environmental investigation, and we performed laboratory testing (Legionella bacteria culture and polymerase chain reaction) of 27 environmental samples from fairgrounds and hot tubs and 14 specimens from case patients. We used multivariable unconditional logistic regression models to calculate adjusted odds ratios for potential Legionella exposure sources and risk factors. RESULTS Of 136 people identified with fair-associated legionellosis, 98 (72%) were hospitalized and 4 (3%) died. Case patients were more likely than control participants to report walking by hot tub displays (adjusted odds ratio = 10.0; 95% CI, 4.2-24.1). Complete hot tub water treatment records were not kept, precluding evaluation of water maintenance conducted on display hot tubs. Legionella pneumophila sequence types (STs) were consistent among 10 typed clinical specimens (ST224) but distinct from the only positive environmental sample from the fair (ST7 and ST8). CONCLUSIONS Hot tub displays were identified as the most likely outbreak source, making this the largest hot tub-associated Legionnaires' disease outbreak worldwide. Following the investigation, the North Carolina Division of Public Health and the Centers for Disease Control and Prevention released guidance on mitigating risk of Legionella exposure from hot tub displays. Results highlight the importance of properly maintaining equipment that aerosolizes water, including hot tubs intended for display purposes only.
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Affiliation(s)
- Catherine V. Donovan
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Now with the Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jennifer K. MacFarquhar
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
- Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Erica Wilson
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | - Megan Sredl
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | - Lauren J. Tanz
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Aaron Fleischauer
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
- Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jessica C. Smith
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Claressa Lucas
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jasen Kunz
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Zack Moore
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
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23
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Thakkar PV, Scott Z, Hoffman M, Delarosa J, Hickerson J, Boutzoukas AE, Benjamin DK, Brookhart MA, Zimmerman KO, Moorthy GS. Impact of the COVID-19 Pandemic on Pediatric Preventive Health Care Among North Carolina Children Enrolled in Medicaid. J Pediatric Infect Dis Soc 2023; 12:S14-S19. [PMID: 38146859 PMCID: PMC10750309 DOI: 10.1093/jpids/piad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/21/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Children enrolled in private insurance had reduced preventive health care during the coronavirus disease 2019 (COVID-19) pandemic. However, the impact of the pandemic on children enrolled in Medicaid has been minimally described. METHODS We used an administrative claims database from North Carolina Medicaid to evaluate the rates of well-child visits and immunization administration for children ≤14 months of age, and used a quasi-Poisson regression model to estimate the rate ratio (RR) of each outcome during the pandemic period (3/15/2020 through 3/15/2021) compared with the pre-pandemic period (3/15/2019 through 3/14/2020). RESULTS We included 83 442 children during the pre-pandemic period and 96 634 children during the pandemic period. During the pre-pandemic period, 405 295 well-child visits and 715 100 immunization administrations were billed; during the pandemic period, 287 285 well-child visits and 457 144 immunization administrations were billed. The rates of well-child visits (RR 0.64; 95% CI, 0.64-0.64) and vaccine administration (RR 0.55; 95% CI, 0.55-0.55) were lower during the pandemic compared with the pre-pandemic period. CONCLUSIONS The rates of well-child visits and immunization administrations among North Carolina children enrolled in public insurance substantially decreased during the first year of the COVID-19 pandemic.
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Affiliation(s)
- Pavan V Thakkar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zeni Scott
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Molly Hoffman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jesse Delarosa
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jesse Hickerson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Angelique E Boutzoukas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - M Alan Brookhart
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kanecia O Zimmerman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ganga S Moorthy
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
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24
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Der T, Helmke N, Stout JE, Turner NA. Impact of the COVID-19 pandemic on adult mental health-related admissions at a large university health system in North Carolina - one year into the pandemic. PLoS One 2023; 18:e0293831. [PMID: 38127858 PMCID: PMC10734981 DOI: 10.1371/journal.pone.0293831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/19/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE Pandemic-associated stress may have exacerbated preexisting mental health and substance use disorders (MH/SUD) and caused new MH/SUD diagnoses which would be expected to lead to an increase in visits to emergency departments and hospital admissions for these conditions. This study assessed whether the proportion of hospital and emergency department encounters for MH/SUD diagnoses increased during the first year of the COVID-19 pandemic in the United States. METHODS We conducted a longitudinal (interrupted time series) analysis of 994,724 eligible encounters identified by electronic query between January 1, 2016 and March 31, 2021. Of these, 55,574 encounters involved MH/SUD diagnosis. The pre-pandemic period was defined as January 1, 2016 to March 31, 2020, and the pandemic period was defined as April 1, 2020 to March 31, 2021. All statistical analyses were performed with R. RESULTS No significant trend in MH/SUD encounters at baseline (rate ratio 1.00, 95% CI 0.99-1.01, p = 0.75) was observed. However, the onset of the pandemic was temporally associated with a significant level increase in the proportion of MH/SUD encounters relative to overall encounters (rate ratio 1.14, 95% CI 1.06-1.21, p<0.001) with no change in the overall trend (rate ratio 0.99, 95% CI 0.90-1.10, p = 0.89). CONCLUSIONS The significant pandemic-associated increase in the proportion of MH/SUD encounters relative to overall encounters was driven largely by sustained numbers of MH/ SUD encounters despite a decrease in total encounters. Increased support for mental health care is needed for these vulnerable patients during pandemics.
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Affiliation(s)
- Tatyana Der
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Nicole Helmke
- Department of Psychiatry and Behavioral Sciences and Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Jason E. Stout
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Nicholas A. Turner
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
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25
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Fellner A, White S, Rockwell E, Giandomenico D, Diaz MM, Weber DJ, Miller MB, Boyce RM. The clinical epidemiology, management, and outcomes of patients diagnosed with encephalitis in North Carolina, 2015-2020. J Clin Microbiol 2023; 61:e0073123. [PMID: 38014985 PMCID: PMC10729753 DOI: 10.1128/jcm.00731-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/12/2023] [Indexed: 11/29/2023] Open
Abstract
IMPORTANCE Despite the relatively high mortality and the difficulty in diagnosis, nearly one-third of patients hospitalized with a documented diagnosis of encephalitis did not undergo a lumbar puncture (LP). When an LP was performed, pathogen-specific testing was greatly underutilized. Infectious etiologies were most common, but over 40% of cases were idiopathic at discharge. These findings suggest that there is a substantial opportunity to improve the quality of care through more accurate and timely diagnosis.
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Affiliation(s)
- Anuva Fellner
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Samuel White
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Emmanuel Rockwell
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dana Giandomenico
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Monica M. Diaz
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - David J. Weber
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Melissa B. Miller
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ross M. Boyce
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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26
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Hughes PM, Ostrach B, Tak CR. Examining differences in opioid deaths by race in North Carolina following the STOP Act, 2010-2019. J Subst Use Addict Treat 2023; 155:209171. [PMID: 37739125 DOI: 10.1016/j.josat.2023.209171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 07/11/2023] [Accepted: 09/19/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION North Carolina's 2017 STOP Act implemented several measures to address the increasing opioid overdose death rate. However, due to racial differences prescription opioid use and treatment service access, the STOP Act may exhibit differential impacts by race. This study examined the impact of the STOP Act on opioid overdose deaths by race. METHODS State-level secondary data were compiled for all 50 states. Race-stratified opioid overdose rates were obtained from the Centers for Disease Control and Prevention's WONDER database from 2010 to 2019. The study obtained state-level population characteristics from the Current Population Surveys from 2010 to 2016, the CDC's 2017 Drug Surveillance Report, the National Survey of Substance Abuse Treatment Services from 2011 to 2016, and the National Survey on Drug Use and Health from 2010 to 2016. We obtained outcomes from 2010 to 2019 and state characteristics were obtained for the pre-STOP Act period (2010-2016) as available. Using the synthetic control method, we created two synthetic North Carolinas, one Black/African American and one White, from a weighted average of other states similar to North Carolina in terms of pre-STOP Act race-stratified opioid overdose rates and population characteristics. Change was assessed as the difference in the race-stratified opioid overdose death rate for North Carolina the corresponding synthetic control. RESULTS The opioid overdose death rate among the White population decreased by 7.17 and 8.96 deaths/100 k in 2018 and 2019 following the STOP Act (overall decrease p = .0217); however, the study found no significant change in the opioid overdose death rate among the Black/African American population (overall decrease p = .1053), with decreases 1.68 and 3.2 deaths/100 k in 2018 and 2019, respectively. CONCLUSIONS Our findings suggest that the STOP Act reduced the opioid overdose death rate in North Carolina among the White, but not Black/African American, population. This heterogeneous effect has implications for health equity and can inform the development of future substance use policies.
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Affiliation(s)
- Phillip M Hughes
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, United States of America; Division of Research, UNC Health Sciences at MAHEC, Asheville, NC, United States of America.
| | - Bayla Ostrach
- Medical Anthropology & Family Medicine, Boston University School of Medicine, Boston, MA, United States of America
| | - Casey R Tak
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, United States of America
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27
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Singh P, Gemmill A, Bruckner TA. Casino-based cash transfers and fertility among the Eastern Band of Cherokee Indians in North Carolina: A time-series analysis. Econ Hum Biol 2023; 51:101315. [PMID: 37952441 PMCID: PMC10842125 DOI: 10.1016/j.ehb.2023.101315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
Fertility decline remains a key concern among high-income countries. Prior research indicates that income supplementation through unconditional cash transfers (UCT) may correspond with increased fertility. We examine whether a casino-based UCT, in the form of per capita (percap) payments to members of the Eastern Band of Cherokee Indians (EBCI) corresponds with an acute increase in fertility. We use North Carolina vital statistics datasets from 1990 to 2006 and apply time-series analysis methods to examine the relation between specific months of percap payments (exposure) and monthly number of conceptions that result in live births (outcome) among the EBCI. We control for autocorrelation and monthly counts of births (arrayed by conception cohorts) among white women (ineligible for UCT receipt) in the study region. Results indicate an increase in conceptions that result in live births at 1 and 3 months after percap receipt among EBCI women aged ≥20 years (exposure month lag 1 coefficient = 1.74, p = 0.03; exposure month lag 3 coefficient = 1.60, p = 0.04). Exploratory analyses indicate that the observed fertility increase concentrates among primiparae EBCI women. We do not find any association between percap payment timing and births to EBCI women aged <20 years.
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Affiliation(s)
- Parvati Singh
- Division of Epidemiology, College of Public Health, The Ohio State University, USA.
| | - Alison Gemmill
- Department of Population Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, USA
| | - Tim-Allen Bruckner
- Program in Public Health and Center for Population, Inequality, and Policy, University of California, Irvine, USA
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28
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Lich KH, Mills SD, Kuo TM, Baggett CD, Wheeler SB. Multi-level predictors of being up-to-date with colorectal cancer screening. Cancer Causes Control 2023; 34:187-198. [PMID: 37285065 PMCID: PMC10244851 DOI: 10.1007/s10552-023-01723-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 05/17/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE Assessing factors associated with being up-to-date with colorectal cancer (CRC) screening is important for identifying populations for which targeted interventions may be needed. METHODS This study used Medicare and private insurance claims data for residents of North Carolina to identify up-to-date status in the 10th year of continuous enrollment in the claims data and in available subsequent years. USPSTF guidelines were used to define up-to-date status for multiple recommended modalities. Area Health Resources Files provided geographic and health care service provider data at the county level. A generalized estimating equation logistic regression model was used to examine the association between individual- and county-level characteristics and being up-to-date with CRC screening. RESULTS From 2012-2016, 75% of the sample (n = 274,660) age 59-75 was up-to-date. We identified several individual- (e.g., sex, age, insurance type, recent visit with a primary care provider, distance to nearest endoscopy facility, insurance type) and county-level (e.g., percentage of residents with a high school education, without insurance, and unemployed) predictors of being up-to-date. For example, individuals had higher odds of being up-to-date if they were age 73-75 as compared to age 59 [OR: 1.12 (1.09, 1.15)], and if living in counties with more primary care physicians [OR: 1.03 (1.01, 1.06)]. CONCLUSION This study identified 12 individual- and county-level demographic characteristics related to being up-to-date with screening to inform how interventions may optimally be targeted.
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Affiliation(s)
- Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg Hall, Chapel Hill, NC, CB #7411, USA.
| | - Sarah D Mills
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tzy-Mey Kuo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chris D Baggett
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg Hall, Chapel Hill, NC, CB #7411, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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29
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Hale LM, Kapp SL, Robertson JB, Lewbart GA, Ozawa SM. The clinical features and treatment of fishhook injuries in freshwater turtles: 126 cases from 1997-2022. J Am Vet Med Assoc 2023; 261:1829-1837. [PMID: 37541676 DOI: 10.2460/javma.23.03.0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/11/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVE To describe the clinical features, treatment, and outcomes of wild freshwater turtles with fishing hook injuries. ANIMALS 126 wild turtles residing in central North Carolina that were presented to a wildlife rescue clinic. METHODS Medical records from July 1997 to July 2022 were reviewed, and data were collected and analyzed. RESULTS The most common species presenting for a fishhook injury was the yellow-bellied slider (Trachemys scripta scripta) (n = 69/126 [54.8%]; 95% CI, 45.7 to 63.6). The most common location identified was the oral cavity (n = 77/140 [55%]; 95% CI, 46.4 to 63.4) and the most common removal method was retrograde removal after cutting the barb off of the hook (76/120 [63.3%]; 95% CI, 54.1 to 71.9). Fishhooks embedded in the esophagus had a significantly higher chance of complications affecting recovery (OR estimate, 3.49; 95% CI, 1.07 to 11.38). There was no significant increase in mortality associated with the location of the injury; however, there was a significant increase in mortality in patients that experienced complications (P < 0.001). The time in care ranged from 1 to 150 days (median, 16 days). Of the turtles evaluated, 10.8% (n = 12/111; 95% CI, 5.7 to 18.1) were euthanized or died after treatment and 89.2% (99/111; 95% CI, 81.9 to 94.3) were released. CLINICAL RELEVANCE These findings describe various successful techniques to remove fishhooks from turtles. While no superior treatment was identified, considerations should be taken to provide patient comfort, decrease injury-associated complications, and shorten recovery time by using minimally invasive techniques. Overall, freshwater turtles with fishhook injuries have a high release rate even when the injuries are severe.
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Affiliation(s)
- Lily M Hale
- 1College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Sabrina L Kapp
- 1College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - James B Robertson
- 2Office of Research, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Gregory A Lewbart
- 3Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Sarah M Ozawa
- 3Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
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30
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Martin AT, McClure ES, Ranapurwala SI, Nocera M, Cantrell J, Marshall SW, Richardson DB. Fatal occupational injuries in North Carolina, 1992-2017. Occup Environ Med 2023; 80:680-686. [PMID: 37940382 DOI: 10.1136/oemed-2023-109050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/13/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES After declining for several decades, fatal occupational injury rates have stagnated in the USA since 2009. To revive advancements in workplace safety, interventions targeting at-risk worker groups must be implemented. Our study aims to identify these at-risk populations by evaluating disparities in unintentional occupational fatalities occurring in North Carolina (NC) from 1992 to 2017. METHODS Our retrospective cohort study drew on both the NC Office of the Chief Medical Examiner system and the NC death certificate data system to identify unintentional fatal occupational injuries occurring from 1992 to 2017. Unintentional fatal occupational injury rates were reported across industries, occupations and demographic groups, and rate ratios were calculated to assess disparities. RESULTS Among those aged 18 and older, 2645 unintentional fatal occupational injuries were identified. Fatal occupational injury rates declined by 0.82 injuries/100 000 person-years over this period, falling consistently from 2004 to 2009 and increasing from 2009 to 2017. Fatal injury rates were highest among Hispanic workers, who experienced 2.75 times the fatal injury rate of non-Hispanic White workers (95% CI 2.42 to 3.11) and self-employed workers, who experienced 1.44 times the fatal injury rate of private workers (95% CI 1.29 to 1.60). We also observed that fatal injury rates increased with age group and were higher among male relative to female workers even after adjustment for differential distributions across occupations. CONCLUSIONS The decline in unintentional fatal occupational injury rates over this period is encouraging, but the increase in injury rate after 2009 and the large disparities between occupations, industries and demographic groups highlight the need for additional targeted safety interventions.
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Affiliation(s)
- Amelia T Martin
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elizabeth S McClure
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shabbar I Ranapurwala
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Maryalice Nocera
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - John Cantrell
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephen W Marshall
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - David B Richardson
- Environmental and Occupational Health, University of California Irvine, Irvine, California, USA
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31
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Anderson KL, Birkenheuer A, Moore GE, Kendall A. A retrospective study of vector borne disease prevalence among anemic dogs in North Carolina. PLoS One 2023; 18:e0293901. [PMID: 37939135 PMCID: PMC10631695 DOI: 10.1371/journal.pone.0293901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/20/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Anemia is an important cause of morbidity and mortality in dogs. Further understanding of the prevalence of vector borne diseases (VBD) in anemic dogs is needed. OBJECTIVES The objective of this retrospective study was to describe the rate of exposure to or infection with VBD among anemic dogs presented to a teaching hospital in North Carolina and to further characterize the anemia in dogs with VBD exposure. ANIMALS A total of 597 anemic dogs that were concurrently tested for VBD were examined at a referral veterinary hospital between January 2012 and December 2018. METHODS Retrospective descriptive study. Demographic, clinicopathologic, and VBD testing data were obtained from medical records. RESULTS Of the 597 anemic dogs examined, 180 (30.15%; 95% CI: 26.49-34.01%) tested positive for one or more VBD. There was no difference in the severity of anemia or the proportion of dogs displaying a regenerative anemia between dogs testing positive and negative for VBD. CONCLUSIONS A large proportion of anemic dogs from this region test positive for exposure to or infection with VBD. Our study supported the use of PCR and serology run in parallel to maximize the chance of detecting exposure to or infection with VBD compared to either serology or PCR alone. At this time, it is unknown whether infection with VBD contributed to the development of anemia in these patients. However, given the prevalence of VBD exposure in anemic dogs, testing for VBD in anemic patients from this region of the United States is warranted.
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Affiliation(s)
- Katie L. Anderson
- Department of Veterinary Clinical Sciences, NC State University College of Veterinary Medicine, Raleigh, NC, United States of America
| | - Adam Birkenheuer
- Department of Veterinary Clinical Sciences, NC State University College of Veterinary Medicine, Raleigh, NC, United States of America
| | - George E. Moore
- Department of Veterinary Administration, Purdue University College of Veterinary Medicine, West Lafayette, IN, United States of America
| | - Allison Kendall
- Department of Veterinary Clinical Sciences, NC State University College of Veterinary Medicine, Raleigh, NC, United States of America
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Abstract
BACKGROUND Little is known about the role of air quality in fatal asthma exacerbations among children. METHODS We collected information about 80 deaths that occurred in North Carolina from 2001 through 2016, among children aged 5-17 years, with asthma identified as the primary cause of death. We linked information about each death with county-level estimates of particulate matter ≤2.5 µm (PM2.5) and ozone (O3). Using the linked data, we conducted a case-crossover analysis of associations between PM2.5 and O3 lagged by 3-5 days with the odds of fatal asthma exacerbations. RESULTS In the highest tertile of PM2.5 lag(3-5), the odds of a fatal exacerbation of asthma were more than twice the odds in the lowest tertile (odds ratio = 2.2; 95% confidence interval = 1.1, 4.6). CONCLUSION These findings from North Carolina provide evidence to support the hypothesis that ambient air pollution increases the risk of fatal exacerbations of asthma among children.
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Affiliation(s)
- Maria C. Mirabelli
- Asthma and Community Health Branch, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - W. Dana Flanders
- Asthma and Community Health Branch, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Ambarish Vaidyanathan
- Climate and Health Program, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Daniel P. Beavers
- Department of Statistical Sciences, Wake Forest University, Winston-Salem, NC
| | - W. Adam Gower
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Figgatt MC, Schranz AJ, Jackson BE, Dasgupta N, Hincapie-Castillo JM, Baggett C, Marshall SW, Golightly YM. Mortality associated with bacterial and fungal infections and overdose among people with drug use diagnoses. Ann Epidemiol 2023; 87:S1047-2797(23)00168-0. [PMID: 37690738 PMCID: PMC10843512 DOI: 10.1016/j.annepidem.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Hospital visits for drug use-related bacterial and fungal infections have increased alongside overdose deaths. The incidence of mortality from these infections and the comparison to overdose mortality is not established. METHODS This cohort study examined mortality outcomes among adults with drug use diagnoses who were insured by public and private plans during 2007 through 2018 in North Carolina. We examined bacterial- and fungal infection-related mortality and overdose mortality using cumulative incidence functions. RESULTS Among 131,522 people with drug use diagnoses, the median age was 45 years (interquartile range: 31-57), 58% were women and 65% had an opioid use disorder diagnosis. The 1-year incidence of bacterial and fungal infection-associated mortality was progressively higher as age increased (35-49 years: 9 per 10,000 people, 50-64 years: 23 per 10,000, 65+ years: 50 per 10,000 people). Conversely, the 1-year incidence of overdose mortality was markedly lower among older adults compared to those under the age of 65 (18-34 years: 34 deaths per 10,000 people; 35-49 years: 47 per 10,000; 50-64 years: 41 per 10,000; 65+ years: 9 per 10,000). CONCLUSIONS Bacterial and fungal infections and overdose were notable causes of death among adults with drug use diagnoses, and varied by age group.
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Affiliation(s)
- Mary C Figgatt
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill.
| | - Asher J Schranz
- Department of Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Bradford E Jackson
- Lineberger Cancer Center Cancer Information and Population Health Resource, University of North Carolina at Chapel Hill, Chapel Hill
| | - Nabarun Dasgupta
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill; Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Juan M Hincapie-Castillo
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Christopher Baggett
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Lineberger Cancer Center Cancer Information and Population Health Resource, University of North Carolina at Chapel Hill, Chapel Hill
| | - Stephen W Marshall
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill
| | - Yvonne M Golightly
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; College of Allied Health Professions, University of Nebraska Medical Center, Omaha
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Zarwell M, Witt B, Marin-Cespedes S, Gorman B, Kumtap MU, Hoff R, Rysbayeva A, Jha P, Boehm EL, Harihar S, Issel LM, Robinson P. Uptake and Discontinuation of Pre-Exposure Prophylaxis Among Uninsured Transgender and Cisgender Women: A Public-Private Partnership Model in North Carolina. AIDS Patient Care STDS 2023; 37:525-534. [PMID: 37956243 DOI: 10.1089/apc.2023.0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
HIV pre-exposure prophylaxis (PrEP) remains underutilized among cis and trans women. The PrEP Initiative Program (PIP) is a novel public-private partnership implemented at 12 local clinics in North Carolina. PIP provides HIV/sexually transmitted infection (STI) testing and clinical and laboratory monitoring for PrEP to uninsured/underinsured clients. We sought to understand service-related differences among both cis and trans women enrolled in PIP, including STIs diagnoses, clinic type, sources of referral, services needed, and reasons for PrEP discontinuation. The Kaplan-Meier curves display retention on PrEP over the duration of the program. Since 2018, 142 women (cis n = 113; trans n = 29) enrolled, and 136 started PrEP. The majority were ages 25-34 years (31.7%) or 18-24 years (29.6%), Black (57.8%) or Latinx (24.7%). Approximately 20.6% of recipients reported at least one STI while enrolled. Overall, trans women requested fewer services than cis women. After accounting for the amount of time each patient was taking PrEP, there were higher rates of trans women diagnosed with syphilis than cis women. Rates of persons with other STIs were not notably different between trans and cis women. Clinic access varied by gender: 69% of trans women were enrolled at only one site. Trans women were retained significantly longer: The Kaplan-Meier adjusted median time to discontinuation was 560 and 238 days for trans and cis women, respectively. PIP successfully reached historically marginalized and uninsured cis and trans women who may benefit from PrEP. Further investigations into factors contributing to recruitment and retention of women in HIV prevention programs are needed.
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Affiliation(s)
- Meagan Zarwell
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
- Academy for Population Health Innovation, UNC Charlotte, Charlotte, North Carolina, USA
| | - Brian Witt
- Academy for Population Health Innovation, UNC Charlotte, Charlotte, North Carolina, USA
- HIV/STI Division, Mecklenburg County Public Health Department, Charlotte, North Carolina, USA
| | - Sebastian Marin-Cespedes
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
- Academy for Population Health Innovation, UNC Charlotte, Charlotte, North Carolina, USA
| | - Brianna Gorman
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
| | - Makshwar U Kumtap
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
| | - Rhoen Hoff
- Department of Psychology, UNC Charlotte, College of Liberal Arts and Sciences, Charlotte, North Carolina, USA
| | - Ainella Rysbayeva
- Department of Biology, UNC Charlotte, College of Liberal Arts and Sciences, Charlotte, North Carolina, USA
| | - Prashant Jha
- Department of Biology, UNC Charlotte, College of Liberal Arts and Sciences, Charlotte, North Carolina, USA
| | - Elsa L Boehm
- BASIS DC High School, Washington, District of Columbia, USA
| | - Sweta Harihar
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
- Academy for Population Health Innovation, UNC Charlotte, Charlotte, North Carolina, USA
| | - L Michele Issel
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
| | - Patrick Robinson
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
- Academy for Population Health Innovation, UNC Charlotte, Charlotte, North Carolina, USA
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Fliss MD, Cox ME, Proescholdbell S, Patel A, Smith M. Tying Overdose Data to Action: North Carolina's Opioid and Substance Use Action Plan Data Dashboard. J Public Health Manag Pract 2023; 29:831-834. [PMID: 37498535 PMCID: PMC10526884 DOI: 10.1097/phh.0000000000001796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
From 2000 to 2020, more than 28 000 North Carolina (NC) residents died of drug overdose. In response, NC Department of Health and Human Services worked with community partners to develop an Opioid and Substance Use Action Plan (OSUAP), now in its third iteration. The NC OSUAP data dashboard brings together data on 15 public health indicators and 16 local actions across 8 strategies. We share innovations in design, data structures, user tasks, and visual elements over 5 years of dashboard development and maintenance, with a special focus and supplemental material covering the technical details and techniques that dashboard design and implementation teams may benefit from.
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Affiliation(s)
- Mike Dolan Fliss
- University of North Carolina Injury Prevention Research Center, Chapel Hill, North Carolina (Dr Fliss); and Injury & Violence Prevention Branch, NC Division of Public Health, Raleigh, North Carolina (Dr Fliss, Mss Cox, Patel, and Smith, and Mr Proescholdbell)
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Efird CR, Barrington C, Metzl JM, Muessig KE, Matthews DD, Lightfoot AF. "We grew up in the church": A critical discourse analysis of Black and White rural residents' perceptions of mental health. Soc Sci Med 2023; 336:116245. [PMID: 37793270 DOI: 10.1016/j.socscimed.2023.116245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 06/02/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023]
Abstract
RATIONALE Known as the "Black-White mental health paradox," Black Americans typically report better mental health than White Americans, despite chronic exposure to the psychologically harmful effects of racism and discrimination. Yet, researchers rarely examine how mental health is experienced across racial groups in economically distressed rural regions where all residents have disproportionately less access to mental healthcare resources. OBJECTIVE The purpose of this study was to explore how the racialized social system potentially contributes to the mental health beliefs and attitudes of racially majoritized and minoritized rural residents. METHODS We conducted a secondary analysis of 29 health-focused oral history interviews from Black American (n = 16) and White American (n = 13) adults in rural North Carolina. Through critical discourse analysis, we found nuanced discourses linked to three mental-health-related topics: mental illness, stressors, and coping. RESULTS White rural residents' condemning discourses illustrated how their beliefs about mental illnesses were rooted in meritocratic notions of individual choice and personal responsibility. Conversely, Black rural residents offered compassionate discourses toward those who experience mental illness, and they described how macro-level mechanisms can affect individual well-being. Stressors also differed along racial lines, such that White residents were primarily concerned about perceived social changes, and Black residents referenced experiences of interpersonal and structural racism. Related to coping, Black and White rural residents characterized the mental health benefits of social support from involvement in their respective religious organizations. Only Black residents signified that a personal relationship with a higher power was an essential positive coping mechanism. CONCLUSIONS Our findings suggest that belief (or disbelief) in meritocratic ideology and specific religious components could be important factors to probe with Black-White patterning in mental health outcomes. This research also suggests that sociocultural factors can disparately contribute to mental health beliefs and attitudes among diverse rural populations.
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Affiliation(s)
- Caroline R Efird
- Racial Justice Institute, Georgetown University, Washington, DC, USA.
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jonathan M Metzl
- Department of Medicine, Health, and Society, Vanderbilt University, Nashville, TN, USA
| | | | - Derrick D Matthews
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexandra F Lightfoot
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Gin TE, Petzold EA, Uthappa DM, Neighbors CE, Borough AR, Gin C, Lashnits E, Sempowski GD, Denny T, Bienzle D, Weese JS, Callahan BJ, Woods CW. Evaluation of SARS-CoV-2 identification methods through surveillance of companion animals in SARS-CoV-2-positive homes in North Carolina, March to December 2020. PeerJ 2023; 11:e16310. [PMID: 37901455 PMCID: PMC10607186 DOI: 10.7717/peerj.16310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
We collected oral and/or rectal swabs and serum from dogs and cats living in homes with SARS-CoV-2-PCR-positive persons for SARS-CoV-2 PCR and serology testing. Pre-COVID-19 serum samples from dogs and cats were used as negative controls, and samples were tested in duplicate at different timepoints. Raw ELISA results scrutinized relative to known negative samples suggested that cut-offs for IgG seropositivity may require adjustment relative to previously proposed values, while proposed cut-offs for IgM require more extensive validation. A small number of pet dogs (2/43, 4.7%) and one cat (1/21, 4.8%) were positive for SARS-CoV-2 RNA, and 28.6 and 37.5% of cats and dogs were positive for anti-SARS-CoV-2 IgG, respectively.
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Affiliation(s)
- Taylor E. Gin
- College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States of America
| | - Elizabeth A. Petzold
- Department of Infectious Diseases, Duke University, Durham, NC, United States of America
| | - Diya M. Uthappa
- Hubert-Yeargan Center for Global Health, Duke University, Durham, NC, United States of America
| | - Coralei E. Neighbors
- Hubert-Yeargan Center for Global Health, Duke University, Durham, NC, United States of America
| | - Anna R. Borough
- Hubert-Yeargan Center for Global Health, Duke University, Durham, NC, United States of America
| | - Craig Gin
- College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States of America
| | - Erin Lashnits
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Gregory D. Sempowski
- Duke Human Vaccine Institute, Duke University, Durham, NC, United States of America
| | - Thomas Denny
- Duke Human Vaccine Institute, Duke University, Durham, NC, United States of America
| | - Dorothee Bienzle
- Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - J. Scott Weese
- Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Benjamin J. Callahan
- College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States of America
| | - Christopher W. Woods
- Department of Infectious Diseases, Duke University, Durham, NC, United States of America
- Hubert-Yeargan Center for Global Health, Duke University, Durham, NC, United States of America
- Duke Human Vaccine Institute, Duke University, Durham, NC, United States of America
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Eaves LA, Keil AP, Jukic AM, Dhingra R, Brooks JL, Manuck TA, Rager JE, Fry RC. Toxic metal mixtures in private well water and increased risk for preterm birth in North Carolina. Environ Health 2023; 22:69. [PMID: 37845729 PMCID: PMC10577978 DOI: 10.1186/s12940-023-01021-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 09/23/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Prenatal exposure to metals in private well water may increase the risk of preterm birth (PTB) (delivery < 37 weeks' gestation). In this study, we estimated associations between arsenic, manganese, lead, cadmium, chromium, copper, and zinc concentrations in private well water and PTB incidence in North Carolina (NC). METHODS Birth certificates from 2003-2015 (n = 1,329,071) were obtained and pregnancies were assigned exposure using the mean concentration and the percentage of tests above the maximum contaminant level (MCL) for the census tract of each individuals' residence at the time of delivery using the NCWELL database (117,960 well water tests from 1998-2019). We evaluated associations between single metals and PTB using adjusted logistic regression models. Metals mixtures were assessed using quantile-based g-computation. RESULTS Compared with those in other census tracts, individuals residing in tracts where > 25% of tests exceeded the MCL for lead (aOR 1.10, 95%CI 1.02,1.18) or cadmium (aOR 1.11, 95% CI 1.00,1.23) had an increased odds of PTB. Conversely, those residing in areas with > 25% MCL for zinc (aOR 0.77 (95% CI: 0.56,1.02) and copper (aOR 0.53 (95% CI: 0.13,1.34)) had a reduced odds of PTB. A quartile increase in the concentrations of a mixture of lead, cadmium, and chromium was associated with a small increased odds for PTB (aOR 1.02, 95% CI 1.01, 1.03). This metal mixture effect was most pronounced among American Indian individuals (aOR per quartile increase in all metals: 1.19 (95% CI 1.06,1.34)). CONCLUSIONS In a large study population of over one million births, lead and cadmium were found to increase the risk of PTB individually and in a mixture, with additional mixtures-related impacts estimated from co-exposure with chromium. This study highlights critical racial and ethnic health disparities in relation to private well water thereby emphasizing the urgent need for improved private well water quality to protect vulnerable populations.
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Affiliation(s)
- Lauren A Eaves
- Department of Environmental Sciences & Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166A Rosenau Hall, CB #7431, Chapel Hill, NC, 27599, USA
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexander P Keil
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anne Marie Jukic
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, Durham, NC, USA
| | - Radhika Dhingra
- Department of Environmental Sciences & Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166A Rosenau Hall, CB #7431, Chapel Hill, NC, 27599, USA
- Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Jada L Brooks
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tracy A Manuck
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Julia E Rager
- Department of Environmental Sciences & Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166A Rosenau Hall, CB #7431, Chapel Hill, NC, 27599, USA
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Rebecca C Fry
- Department of Environmental Sciences & Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166A Rosenau Hall, CB #7431, Chapel Hill, NC, 27599, USA.
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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Lam PH, Zang E, Chen D, Liu R, Chen K. Long-Term Exposure to Fine Particulate Matter and Academic Performance Among Children in North Carolina. JAMA Netw Open 2023; 6:e2340928. [PMID: 37906198 PMCID: PMC10618843 DOI: 10.1001/jamanetworkopen.2023.40928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/20/2023] [Indexed: 11/02/2023] Open
Abstract
This cross-sectional study analyzes the association of exposure to fine particulate matter and academic performance among school age children in North Carolina.
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Affiliation(s)
- Pak Hung Lam
- The Samuel DuBois Cook Center on Social Equity, Duke University, Durham, North Carolina
| | - Emma Zang
- Department of Sociology, Yale University, New Haven, Connecticut
| | - Dieyi Chen
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Riyang Liu
- State Key Laboratory of Pollution Control and Resource Reuse, School of the Environment, Nanjing University, Nanjing, Jiangsu, China
| | - Kai Chen
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut
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Shing TL, Preisser JS, Sotres-Alvarez D, Divaris K, Beck JD. Patterns of site-level periodontal disease and within-mouth correlation among older adults in the Hispanic Community Health Study/Study of Latinos. Community Dent Oral Epidemiol 2023; 51:927-935. [PMID: 36036459 PMCID: PMC9971328 DOI: 10.1111/cdoe.12789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 08/03/2022] [Accepted: 08/15/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Clinical measures of periodontal disease such as attachment loss (CAL) and probing depth (PD) vary considerably between and within individuals with periodontitis and are known to be influenced by person-level factors (e.g. age and race/ethnicity) as well as intraoral characteristics (e.g. tooth type and location). This study sought to characterize site-level disease patterns and correlations using both person-level and intraoral factors through a model-based approach. METHODS This study used full-mouth, six sites per tooth, periodontal examination data collected from 2301 Hispanic/Latino adults aged 60-74 years in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). The presence of site-level CAL ≥3 mm and PD ≥4 mm was estimated using generalized estimating equations (GEE), explicitly modelling pairwise periodontal site correlations, while adjusting for number of teeth, sex and Hispanic/Latino background. Subsequently tooth- and tooth-site patterns of intraoral CAL ≥3 mm and PD ≥4 mm were estimated and visualized in the HCHS/SOL population. RESULTS The findings showed that posterior sites had the highest odds of CAL ≥3 mm and PD ≥4 mm. Sites located in the interproximal space had higher odds of PD ≥4 mm but lower odds of CAL ≥3 mm than non-interproximal sites. Mexicans had the lowest odds of CAL ≥3 mm among all Hispanic/Latino backgrounds. While Mexicans had lower odds of PD ≥4 mm than Central Americans and Cubans, they had higher odds than Dominicans and Puerto Ricans. Site-level proportions and pairwise correlations of PD ≥4 mm were generally smaller than those of CAL ≥3 mm. CONCLUSIONS The patterns of site-level probabilities of clinical measures of periodontal disease can be defined based on tooth, site and individual-level characteristics. Intraoral correlation patterns, while complex, are quantifiable. The risk factors for site-level CAL ≥3 mm may differ from those of PD ≥4 mm. Likewise, participant risk factors for site-level clinical measures of periodontal disease are distinct from those that affect individual-level periodontitis prevalence. Future epidemiological investigations should consider model-based approaches when examining site-level disease probabilities to identify intra-oral patterns of periodontal disease and make inferences about the larger population.
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Affiliation(s)
- Tracie L Shing
- Department of Biostatistics, Gillings School of Global Public Health University of North Carolina, Chapel Hill, North Carolina, USA
| | - John S Preisser
- Department of Biostatistics, Gillings School of Global Public Health University of North Carolina, Chapel Hill, North Carolina, USA
| | - Daniela Sotres-Alvarez
- Department of Biostatistics, Gillings School of Global Public Health University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kimon Divaris
- Division of Pediatric and Public Health, Adams School of Dentistry University of North Carolina, Chapel Hill, North Carolina, USA
| | - James D Beck
- Division of Comprehensive Oral Health/Periodontology, Adams School of Dentistry University of North Carolina, Chapel Hill, North Carolina, USA
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Patel MD, Brown AB, Kebede ES. Statewide availability of acute stroke treatment, services, and programs: A survey of North Carolina Hospitals. J Stroke Cerebrovasc Dis 2023; 32:107323. [PMID: 37633205 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023] Open
Abstract
INTRODUCTION We conducted a statewide assessment of the availability of stroke treatment, services, and programs in North Carolina (NC) hospitals. We also examined differences in stroke care capabilities between urban, suburban, and rural hospitals and trends over the past 2 decades. METHODS An electronic survey was distributed to all 111 licensed hospitals in NC. Survey questions asked about stroke center certification status (i.e., standardized levels of stroke care capabilities), diagnostic testing, acute treatments and protocols, and post-acute management. Responses were collected from October 2020-April 2021. Select characteristics were compared to those from prior NC surveys in 1998, 2003, and 2008. RESULTS All 111 hospitals responded to the survey (100% response rate). Among 108 hospitals providing acute stroke care, 12 (11%) were Comprehensive Stroke Centers or Thrombectomy-Capable Stroke Centers, which were all located in urban or suburban areas. While 38% of urban/suburban hospitals were non-certified, 48% of rural hospitals were non-certified. Non-contrast computed tomography (CT), CT angiography, and alteplase treatment were widely available (100%, 95%, and 99%, respectively). Endovascular thrombectomy was solely available in urban/suburban hospitals (29%). Of non-tertiary hospitals, 81% were using telestroke for treatment and transfer decisions. Compared to prior survey results, the availability of CT angiography (76% in 2008 to 95% in 2020-2021), alteplase treatment (69% in 2008 to 99% in 2020-2021), and acute stroke clinical pathways (47% in 2008 to 90% in 2020-2021) increased. However, having an in-house neurologist on staff dropped from approximately 55% in prior surveys to 21% in the current survey. CONCLUSIONS Rural NC hospitals were less likely to have advanced diagnostic imaging and treatment capabilities for acute stroke. Temporal trends in staffing with an in-house neurologist and use of telestroke services should be further examined.
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Affiliation(s)
- Mehul D Patel
- Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, CB# 7594, Chapel Hill, NC 27599-7594, USA.
| | - Anna Bess Brown
- Division of Public Health, North Carolina Department of Health and Human Services, NC, USA
| | - Essete S Kebede
- Division of Public Health, North Carolina Department of Health and Human Services, NC, USA
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Conley HL, Lea CS, Delgado RV, Vos P, Harris EE, Ju A, Rathbun KM. Reduced Survival Outcome After Receiving a New Cancer Diagnosis in the Emergency Department: Findings from a Hospital Network in Rural Eastern North Carolina. J Racial Ethn Health Disparities 2023; 10:2434-2443. [PMID: 36216978 DOI: 10.1007/s40615-022-01422-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/25/2022] [Accepted: 09/27/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Patients whose cancer was found during an Emergency Department (ED) visit often present at later stages when survival outcomes are worse. Limited research has characterized the survival experience of cancer patients who receive their diagnosis through the ED versus those who do not. METHODS A retrospective cohort study identified all patients presenting to the ED between 2014 and 2015 in a rural, regional hospital system with a visit or resulting admission associated with an oncologic ICD-9 code. The chart was abstracted to determine a new cancer diagnosis versus an existing case. Cox proportional hazards (HR) estimated survival time. Patient and cancer characteristics were compared between those who were newly diagnosed through the ED and patients who were not. FINDINGS Thirty-nine percent of patients in our sample received their new cancer diagnosis as a result of an ED visit. The median survival was lower in cancer cases diagnosed through the ED (13 vs. 39 months, P < .001), men (20 vs. 32 months, P < .001), and patients aged ≥ 65 (22 months vs. 32 months, P < .001). Factors associated with lower survival were having a type of cancer location other than breast (HR = 1.96; P < .001), followed by being newly diagnosed with cancer through the ED (HR = 1.71; P < .001), and stage IV at diagnosis (HR = 1.70; P < .001). CONCLUSIONS Patients who received a new cancer diagnosis through the ED and required subsequent hospitalization had shorter overall survival and presented with advanced disease. Future research should address socioeconomic factors that may influence these patterns of cancer presentation.
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Affiliation(s)
- Hannah L Conley
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
| | - C Suzanne Lea
- Department of Public Health, Brody School of Medicine, Greenville, NC, USA
| | - Raven V Delgado
- Department of Pediatrics, Baylor College of Medicine, San Antonio, TX, USA
| | - Paul Vos
- Department of Biostatistics, College of Allied Health Sciences, East Carolina University, Greenville, NC, USA
| | - Eleanor E Harris
- Department of Radiation Oncology, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Andrew Ju
- Department of Radiation Oncology, Brody School of Medicine, 600 Moye Blvd, Greenville, NC, 27834, USA.
| | - Kimberly M Rathbun
- Department of Emergency Medicine, Augusta University/University of Georgia Medical Partnership, Athens, GA, USA
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Woodul RL, Delamater PL, Woodburn M. Validating model output in the absence of ground truth data: A COVID-19 case study using the Simulator of Infectious Disease Dynamics in North Carolina (SIDD-NC) model. Health Place 2023; 83:103065. [PMID: 37352616 PMCID: PMC10267499 DOI: 10.1016/j.healthplace.2023.103065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/10/2023] [Accepted: 06/07/2023] [Indexed: 06/25/2023]
Abstract
As the COVID-19 pandemic has progressed, various models have been developed to forecast changes in the outbreak and assess intervention strategies. In this study we validate the Simulator of Infectious Disease Dynamics in North Carolina (SIDD-NC) model against an ensemble of proxy-ground truth infections datasets. We assess the performance of SIDD-NC using Spearman Rank Correlation, RMSE, and percent RMSE at a state and county level. We conduct the analysis for the period of March 2020 through November 2020 as well as in shorter time increments to assess both the recreation of the pandemic curve as well as day-to-day transmission of SARS-CoV-2 within the population. We find that SIDD-NC performs well against the datasets in the ensemble, generating an estimate of infections that is robust both spatially and temporally.
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Affiliation(s)
- Rachel L Woodul
- Department of Geography, The University of North Carolina at Chapel Hill, Carolina Hall, Campus Box 3220, Chapel Hill, NC, 27599, United States; Carolina Population Center, 123 West Franklin St, Chapel Hill, NC, 27516, United States.
| | - Paul L Delamater
- Department of Geography, The University of North Carolina at Chapel Hill, Carolina Hall, Campus Box 3220, Chapel Hill, NC, 27599, United States; Carolina Population Center, 123 West Franklin St, Chapel Hill, NC, 27516, United States.
| | - Meg Woodburn
- Department of Geography, The University of North Carolina at Chapel Hill, Carolina Hall, Campus Box 3220, Chapel Hill, NC, 27599, United States.
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Luo H, Cummings DM, Xu L, Watson A, Payton C. Diabetes Self-management Education and Support Completion Before and During the COVID-19 Pandemic: Results From Local Health Departments in North Carolina. J Public Health Manag Pract 2023; 29:686-690. [PMID: 37071075 DOI: 10.1097/phh.0000000000001749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVE To assess diabetes self-management education and support (DSMES) completion rate and explore the differences in DSMES completion by different delivery models. METHODS We conducted a retrospective analysis of 2017-2021 DSMES data at 2 local health departments (LHDs) in Eastern North Carolina. We evaluated DSMES completion by 2 delivery models. RESULTS From 2017 to 2021, the overall DSMES completion rate was 15.3%. The delivery model of two 4-hour sessions was associated with a higher completion rate than the delivery model of four 2-hour sessions ( P < .05). Patients with less than a high school education and without health insurance were less likely to have completed their DSMES training ( P < .05). CONCLUSION The DSMES completion rate at LHDs in North Carolina is very low. A delivery model consisting of 10 hours of education delivered in fewer sessions may contribute to a higher DSMES completion rate, but more research is needed. Targeted programs are needed to engage patients and improve DSMES completion.
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Affiliation(s)
- Huabin Luo
- Department of Public Health, Brody School of Medicine (Drs Luo and Cummings), and Department of Health Education & Promotion, College of Health and Human Performance (Dr Xu), East Carolina University, Greenville, North Carolina; Diabetes Program, Pitt County Health Department, Greenville, North Carolina (Ms Watson); and Community and Clinical Connections for Prevention and Health Branch, Chronic Disease and Injury Section, NC Division of Public Health, Raleigh, North Carolina (Ms Payton)
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Abstract
BACKGROUND AND OBJECTIVES Using a local measure of racial residential segregation, estimate the association between racial residential segregation and childhood blood lead levels between the early 1990s and 2015 in North Carolina. METHODS This population-based observational study uses individual-level blood lead testing records obtained from the NC Department of Health and Human Services for 320 916 children aged <7 years who were tested between 1992 and 1996 or 2013 and 2015. NC childhood blood lead levels were georeferenced to the census tract. Neighborhood racial residential segregation, assessed using a local, spatial measure of the racial isolation of non-Hispanic Blacks (RINHB), was calculated at the census tract level. RESULTS From 1990 to 2015, RINHB increased in 50% of 2195 NC census tracts, although the degree of change varied by geographic region. In 1992 to 1996 blood lead testing data, a 1-standard-deviation increase in tract-level RINHB was associated with a 2.86% (95% confidence interval: 0.96%-4.81%) and 2.44% (1.34%-3.56%) increase in BLL among non-Hispanic Black and non-Hispanic White children, respectively. In 2013 to 2015 blood lead testing data, this association was attenuated but persisted with a 1-standard-deviation increase in tract-level RINHB associated with a 1.59% (0.50%-2.70%) and 0.76% (0.08%-1.45%) increase in BLL among non-Hispanic Black and non-Hispanic White children, respectively. In the supplemental information, we show the change in racial residential segregation across the entire United States, demonstrating that RINHB increased in 69% of 72 899 US census tracts. CONCLUSIONS Racially isolated neighborhoods are associated with higher childhood lead levels, demonstrating the disproportionate environmental burdens borne by segregated communities and warranting attention to providing whole child health care.
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Affiliation(s)
- Marie Lynn Miranda
- Children’s Environmental Health Initiative
- Department of Pediatrics, University of Illinois Chicago, Chicago, Illinois
| | | | | | - Mercedes A. Bravo
- Children’s Environmental Health Initiative
- Global Health Institute, Duke University, Durham, North Carolina
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Vias NP, Cassidy CA, Edwards JK, Xiong K, Parker CB, Aiello AE, Boyce RM, Shook-Sa BE. Estimation of SARS-CoV-2 Seroprevalence in Central North Carolina: Accounting for Outcome Misclassification in Complex Sample Designs. Epidemiology 2023; 34:721-731. [PMID: 37527450 PMCID: PMC10403265 DOI: 10.1097/ede.0000000000001625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
BACKGROUND Population-based seroprevalence studies are crucial to understand community transmission of COVID-19 and guide responses to the pandemic. Seroprevalence is typically measured from diagnostic tests with imperfect sensitivity and specificity. Failing to account for measurement error can lead to biased estimates of seroprevalence. Methods to adjust seroprevalence estimates for the sensitivity and specificity of the diagnostic test have largely focused on estimation in the context of convenience sampling. Many existing methods are inappropriate when data are collected using a complex sample design. METHODS We present methods for seroprevalence point estimation and confidence interval construction that account for imperfect test performance for use with complex sample data. We apply these methods to data from the Chatham County COVID-19 Cohort (C4), a longitudinal seroprevalence study conducted in central North Carolina. Using simulations, we evaluate bias and confidence interval coverage for the proposed estimator compared with a standard estimator under a stratified, three-stage cluster sample design. RESULTS We obtained estimates of seroprevalence and corresponding confidence intervals for the C4 study. SARS-CoV-2 seroprevalence increased rapidly from 10.4% in January to 95.6% in July 2021 in Chatham County, North Carolina. In simulation, the proposed estimator demonstrates desirable confidence interval coverage and minimal bias under a wide range of scenarios. CONCLUSION We propose a straightforward method for producing valid estimates and confidence intervals when data are based on a complex sample design. The method can be applied to estimate the prevalence of other infections when estimates of test sensitivity and specificity are available.
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Affiliation(s)
- Nishma P. Vias
- Adams School of Dentistry, University of North Carolina at Chapel Hill, NC, USA
| | - Caitlin A. Cassidy
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Jessie K. Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Khou Xiong
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Cherese Beatty Parker
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Allison E. Aiello
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
- Robert N Butler Columbia Aging Center, Mailman School of Public Health, Columbia University, New York, NY
| | - Ross M. Boyce
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, NC, USA
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Bonnie E. Shook-Sa
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
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Shams RB, Chari SV, Cui ER, Fernandez AR, Brice JH, Winslow JE, Jauch EC, Patel MD. Community Socioeconomic and Urban-Rural Disparities in Prehospital Notification of Stroke by Emergency Medical Services in North Carolina. South Med J 2023; 116:765-771. [PMID: 37657786 PMCID: PMC10491424 DOI: 10.14423/smj.0000000000001601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
OBJECTIVES Notification by emergency medical services (EMS) to the destination hospital of an incoming suspected stroke patient is associated with timelier in-hospital evaluation and treatment. Current data on adherence to this evidence-based best practice are limited, however. We examined the frequency of EMS stroke prenotification in North Carolina by community socioeconomic status (SES) and rurality. METHODS Using a statewide database of EMS patient care reports, we selected 9-1-1 responses in 2019 with an EMS provider impression of stroke or documented stroke care protocol use. Eligible patients were 18 years old and older with a completed prehospital stroke screen. Incident street addresses were geocoded to North Carolina census tracts and linked to American Community Survey socioeconomic data and urban-rural commuting area codes. High, medium, and low SES tracts were defined by SES index tertiles. Tracts were classified as urban, suburban, and rural. We used multivariable logistic regression to estimate independent associations between tract-level SES and rurality with EMS prenotification, adjusting for patient age, sex, and race/ethnicity; duration of symptoms; incident day of week and time of day; 9-1-1 dispatch complaint; EMS provider primary impression; and prehospital stroke screen interpretation. RESULTS The cohort of 9527 eligible incidents was mostly at least 65 years old (65%), female (55%), and non-Hispanic White (71%). EMS prenotification occurred in 2783 (29%) patients. Prenotification in low SES tracts (27%) occurred less often than in medium (30%) and high (32%) SES tracts. Rural tracts had the lowest frequency (21%) compared with suburban (28%) and urban (31%) tracts. In adjusted analyses, EMS prenotification was less likely in low SES (vs high SES; odds ratio 0.76, 95% confidence interval 0.67-0.88) and rural (vs urban; odds ratio 0.64, 95% confidence interval 0.52-0.77) tracts. CONCLUSIONS Across a large, diverse population, EMS prenotification occurred in only one-third of suspected stroke patients. Furthermore, low SES and rural tracts were independently associated with a lower likelihood of prehospital notification. These findings suggest the need for education and quality improvement initiatives to increase EMS stroke prenotification, particularly in underserved communities.
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Affiliation(s)
- Rayad B. Shams
- School of Medicine, University of North Carolina at Chapel
Hill, Chapel Hill
| | - Srihari V. Chari
- Department of Emergency Medicine, University of North
Carolina at Chapel Hill, Chapel Hill
| | - Eric R. Cui
- School of Medicine, University of North Carolina at Chapel
Hill, Chapel Hill
| | | | - Jane H. Brice
- Department of Emergency Medicine, University of North
Carolina at Chapel Hill, Chapel Hill
| | - James E. Winslow
- Department of Emergency Medicine, Wake Forest University,
Winston Salem, North Carolina
| | - Edward C. Jauch
- Department of Research, University of North Carolina Health
Sciences at Mountain Area Health Education Center, Asheville, North Carolina
| | - Mehul D. Patel
- Department of Emergency Medicine, University of North
Carolina at Chapel Hill, Chapel Hill
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Holloway A, Williams F, Akinkuotu A, Charles A, Gallaher JR. Race, area deprivation index, and access to surgical burn care in a pediatric population in North Carolina. Burns 2023; 49:1298-1304. [PMID: 36682975 PMCID: PMC10349900 DOI: 10.1016/j.burns.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/20/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND Burns represent a leading cause of morbidity and mortality for children. This study explores the intersecting effects of social deprivation and race in pediatric burn patients. METHODS We performed a retrospective review of all pediatric patients (<18 years old) admitted to a tertiary burn center in North Carolina from 2009 to 2019. We used bivariate analysis to compare patients based on reported race, comparing African Americans (AA) to all others. Modified Poisson regression was used to model the probability of undergoing autologous skin grafting based on AA race. RESULTS Of 4227 children admitted, AA children were disproportionally represented, comprising 33.7% of patients versus a state population of 22.3%. AA patients had larger %TBSA with a median of 3% (IQR 1-6) compared to 2% (IQR 1-5, p < 0.001) and longer median length of stay at 5.8 days (SD 13.6) versus 4.9 days (SD 13.8). AA patients were more likely to have autologous skin grafting compared to other races, with an adjusted RR of 1.49 (95% CI 1.22-1.83) when controlling for Area Deprivation Index (ADI) national rank, age, %TBSA, and burn type. CONCLUSIONS AA children were disproportionately represented and had larger burns, even when controlling for ADI. They had longer hospital stays and were more likely to have autologous skin grafting, even accounting for burn size and type. The intersection between social deprivation and race creates a unique risk for AA patients. Further investigation into this phenomenon and factors underlying surgical intervention selection are indicated to inform best treatment practices and future preventative strategies.
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Affiliation(s)
- Alexa Holloway
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Felicia Williams
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Adesola Akinkuotu
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Jared R Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, United States.
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Joudrey PJ, Chen K, Oldfield BJ, Biegacki E, Fiellin DA. Drive Time to Addiction Treatment Facilities Providing Contingency Management across Rural and Urban Census Tracts in 6 US States. J Addict Med 2023; 17:615-617. [PMID: 37788621 PMCID: PMC10591456 DOI: 10.1097/adm.0000000000001170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
OBJECTIVE We examined drive times to outpatient substance use disorder treatment providers that provide contingency management (CM) and those that integrate CM with medication for opioid use disorder (MOUD) services in 6 US states. METHODS We completed cross-sectional geospatial analysis among census tracts in Delaware, Louisiana, Massachusetts, North Carolina, New York, and West Virginia. We excluded census tracts with a population of zero. Using data from the 2020 Shatterproof substance use treatment facility survey, our outcome was the minimum drive time in minutes from the census tract mean center of population to the nearest outpatient CM provider, outpatient CM provider with MOUD services, and federally qualified health centers (FQHC). We stratified census tracts by 2010 Rural-Urban Commuting Area codes and by state. RESULTS The population was greater than zero in 11,719 of 11,899 census tracts. The median drive time to the nearest CM provider was 12.2 [interquartile range (IQR), 7.0-23.5) minutes and the median drive time to the nearest CM provider increased from 9.7 (IQR, 6.0-15.0) minutes in urban census tracts to 38.8 (IQR, 25.4-53.0) minutes in rural ( H = 3683, P < 0.001). The median drive time increased to the nearest CM provider with MOUD services [14.2 (IQR, 7.9-29.5) minutes, W = 18,877, P < 0.001] and decreased to the nearest FQHC [7.9 (IQR, 4.3-13.6) minutes, W = 11,555,894, P < 0.001]. CONCLUSIONS These results suggest limited availability of CM, particularly within rural communities and for patients needing concurrent CM and MOUD treatment. Our results suggest greater adoption of CM within FQHCs could reduce urban-rural disparities in CM availability.
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Affiliation(s)
- Paul J. Joudrey
- Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Kevin Chen
- Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY
- Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York NY
| | - Benjamin J. Oldfield
- Fair Haven Community Health Care, New Haven, CT
- Yale Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Emma Biegacki
- Yale Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - David A. Fiellin
- Yale Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
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Davis SA, Carpenter DM, Loughlin CE, Garcia N, Sleath B. Impact of Hurricane Matthew on a Cohort of Adolescents With Asthma in North Carolina. Disaster Med Public Health Prep 2023; 17:e446. [PMID: 37554119 DOI: 10.1017/dmp.2023.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
OBJECTIVE The aim of this study was to look at a cohort of adolescents who were already enrolled in a randomized controlled trial to see (1) how demographics were associated with hurricane impact, and (2) how hurricane impact was associated with reported asthma quality of life. METHODS One hundred fifty-one adolescents ages 11-17 and their parents enrolled in a randomized controlled trial at 2 sites in southeastern North Carolina completed questions about asthma quality of life, demographics, and the impact of Hurricane Matthew. RESULTS The most common effects of Hurricane Matthew were that the family's home was damaged or flooded (32.5%), the school was damaged or flooded (31.8%), and the home had mold or mildew as a result of flooding or damage (25.8%). Problems with access to care were more common for families whose adolescent was non-White (P = 0.04), on Medicaid (P = 0.05), or if the family spoke Spanish at home (P < 0.001). Being affected by the hurricane was negatively associated with asthma quality of life. CONCLUSIONS Hurricane Matthew had significant impact on the health of adolescents with asthma in the affected region, especially in the most vulnerable populations. Providers should ensure that families of adolescents with asthma have a hurricane plan to mitigate impact on their children's health.
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Affiliation(s)
- Scott A Davis
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Delesha M Carpenter
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Ceila E Loughlin
- Department of Pediatric Pulmonology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Nacire Garcia
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Betsy Sleath
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Cecil G. Sheps Center for Health Services Research, Chapel Hill, North Carolina, USA
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