Culturally Competent Education and Human Papillomavirus Self-Sampling Achieves Healthy People 2030 Cervical Screening Target Among Low-Income Non-Hispanic Black and Hispanic Women.

PURPOSE: Disparities in cervical cancer screening, incidence, and mortality exist in the United States. Cervical cancer incidence and mortality rates in Texas are 20% and 32% higher, respectively, than national averages. Within Texas, these rates are significantly higher among non-Hispanic (NH) Black and Hispanic women. Cervical cancer screening uptake is lower among NH Black and Hispanic women (72.9% and 75.9%, respectively) compared with White women (85.5%) in Texas. METHODS: During March-August 2023, we conducted a pilot study that offered culturally competent education and human papillomavirus (HPV) self-sampling kits to women in two public housing projects in Houston, TX, that have predominantly NH Black or Hispanic residents. Among those eligible for cervical cancer screening, 35% (n = 24) of the NH Black and 34% (n = 16) of the Hispanic women were found to be underscreened per the US Preventive Services Task Force Guideline. We recruited 40 (24 NH Black and 16 Hispanic) eligible women for our study. The study was approved by the MD Anderson institutional review board and registered with ClinicalTrials.gov (NCT04614155-March 11, 2020). RESULTS: Seventy-five percent of the NH Black and 87% of the Hispanic participants completed the HPV self-sampling procedures per protocol. Samples of 17% NH Black and 12% Hispanic participants showed a performance error. Overall, cervical cancer screening uptake improved from 65% to 91% among NH Black and from 66% to 96% among Hispanic participants. CONCLUSION: Culturally competent education and HPV self-sampling resulted in remarkable improvement in cervical cancer screening uptake among underscreened NH Black and Hispanic women residents of Houston public housing projects. Implementing this strategy could significantly reduce cervical cancer incidence and mortality among similar populations in the United States and globally.

Baseline characteristics of SARS-CoV-2 vaccine non-responders in a large population-based sample.

INTRODUCTION: Studies indicate that individuals with chronic conditions and specific baseline characteristics may not mount a robust humoral antibody response to SARS-CoV-2 vaccines. In this paper, we used data from the Texas Coronavirus Antibody REsponse Survey (Texas CARES), a longitudinal state-wide seroprevalence program that has enrolled more than 90,000 participants, to evaluate the role of chronic diseases as the potential risk factors of non-response to SARS-CoV-2 vaccines in a large epidemiologic cohort. METHODS: A participant needed to complete an online survey and a blood draw to test for SARS-CoV-2 circulating plasma antibodies at four-time points spaced at least three months apart. Chronic disease predictors of vaccine non-response are evaluated using logistic regression with non-response as the outcome and each chronic disease + age as the predictors. RESULTS: As of April 24, 2023, 18,240 participants met the inclusion criteria; 0.58% (N = 105) of these are non-responders. Adjusting for age, our results show that participants with self-reported immunocompromised status, kidney disease, cancer, and "other" non-specified comorbidity were 15.43, 5.11, 2.59, and 3.13 times more likely to fail to mount a complete response to a vaccine, respectively. Furthermore, having two or more chronic diseases doubled the prevalence of non-response. CONCLUSION: Consistent with smaller targeted studies, a large epidemiologic cohort bears the same conclusion and demonstrates immunocompromised, cancer, kidney disease, and the number of diseases are associated with vaccine non-response. This study suggests that those individuals, with chronic diseases with the potential to affect their immune system response, may need increased doses or repeated doses of COVID-19 vaccines to develop a protective antibody level.

Apparent absence of Trypanosoma cruzi in Mexican free-tailed bats (Tadarida brasiliensis) from Texas, USA.

The Mexican free-tailed bat (Tadarida brasiliensis) is one of the most abundant mammals in North America. Mexican free-tailed bats have a wide geographic range stretching from northern South America to the western United States. Bats are theorized to be the original hosts for Trypanosoma cruzi -the causative agent of Chagas disease- and can serve as a source of infection to triatomine insect vectors that feed upon them. Chagas disease is a neglected tropical disease across the Americas where triatomines are present, including the southern United States, where Texas reports this highest number of locally-acquired human cases. To learn more about the role of bats in the ecology of Chagas disease in Texas, we surveyed a colony of Mexican free-tailed bats from Brazos County, Texas, for T. cruzi using carcasses salvaged after an extreme weather event. A total of 283 Mexican free-tailed bats collected in February 2021 were dissected and DNA from the hearts and kidneys was used for T. cruzi detection via qPCR. None of the bat hearts or kidneys tested positive for T. cruzi; this sample size affords 95% confidence that the true prevalence of T. cruzi in this population does not exceed 1%. Future sampling of multiple bat species as well as migrant and resident colonies of Mexican free-tailed bats across different times of the year over a broader geographic range would be useful in learning more about the role of bats in the ecology of Chagas disease in Texas.

Examining Health Inequities in A1C Control over Time across Individual, Geospatial, and Geopolitical Factors among Adults with Type 2 Diabetes: Analyses of a Sample from One Commercial Insurer in a Southern State.

INTRODUCTION: Type 2 diabetes impacts millions and poor maintenance of diabetes can lead to preventable complications, which is why achieving and maintaining target A1C levels is critical. Thus, we aimed to examine inequities in A1C over time, place, and individual characteristics, given known inequities across these indicators and the need to provide continued surveillance. METHODS: Secondary de-identified data from medical claims from a single payer in Texas was merged with population health data. Generalized Estimating Equations were utilized to assess multiple years of data examining the likelihood of having non-target (>7% and ≥7%, two slightly different cut points based on different sources) and separately uncontrolled (>9%) A1C. Adults in Texas, with a Type 2 Diabetes (T2D) flag and with A1C reported in first quarter of the year using data from 2016 and 2019 were included in analyses. RESULTS: Approximately 50% had A1Cs within target ranges (<7% and ≤7%), with 50% considered having non-target (>7% and ≥7%) A1Cs; with 83% within the controlled ranges (≤9%) as compared to approximately 17% having uncontrolled (>9%) A1Cs. The likelihood of non-target A1C was higher among those individuals residing in rural (vs urban) areas (P < .0001); similar for the likelihood of reporting uncontrolled A1C, where those in rural areas were more likely to report uncontrolled A1C (P < .0001). In adjusted analysis, ACA enrollees in 2016 were approx. 5% more likely (OR = 1.049, 95% CI = 1.002-1.099) to have non-target A1C (≥7%) compared to 2019; in contrast non-ACA enrollees were approx. 4% more likely to have non-target A1C (≥7%) in 2019 compared to 2016 (OR = 1.039, 95% CI = 1.001-1.079). In adjusted analysis, ACA enrollees in 2016 were 9% more likely (OR = 1.093, 95% CI = 1.025-1.164) to have uncontrolled A1C compared to 2019; whereas there was no significant change among non-ACA enrollees. CONCLUSIONS: This study can inform health care interactions in diabetes care settings and help health policy makers explore strategies to reduce health inequities among patients with diabetes. Key partners should consider interventions to aid those enrolled in ACA plans, those in rural and border areas, and who may have coexisting health inequities.

A Retrospective Study Comparing Mortality Rates between Vaccinated and Unvaccinated Kidney Transplant Recipients.

Background: With the emergence of vaccines for COVID-19, mortality and severity of disease have decreased. However, patients with certain comorbidities, such as immunosuppression, CKD, and renal transplant, still have higher mortality rates as compared to the general population. Current data suggests that the risk of developing COVID-19 among transplant patients was reported to be about 5%, which is significantly higher than the risk rate of 0.3% in the general population. Studies utilizing larger sample sizes (i.e., multiple cohorts, sites, hospitals) comparing COVID-19 outcomes among renal transplant patients with a control group are lacking.

Objective: The purpose of this descriptive study was to compare the mortality rate between vaccinated and unvaccinated kidney transplant recipients.

Methods: Participants were recruited at a community-based transplant clinic in West Texas.

Results: Among the group of participants who tested positive for COVID-19 between 2020 and 2022, higher mortality rates and longer hospital stays were noted among those unvaccinated (72% unvaccinated had greater than 5-day length of stay vs. 33% vaccinated).

Conclusion: Our study suggests that vaccination against COVID-19 decreases mortality rates in kidney transplant recipients.

Examining within-person associations between alcohol and cannabis use and hooking up among adolescents and young adults in the United States.

OBJECTIVE: This study examined daily associations between alcohol use, cannabis use, and simultaneous alcohol and cannabis/marijuana (SAM) use with the likelihood of hooking up (uncommitted sexual encounter that may or may not include intercourse). METHOD: We used a longitudinal measurement burst ecological momentary assessment (EMA) design with 3-week EMA bursts with daily measurements repeated quarterly across 12 months. 1,009 (57 % female, Mean age = 20.00 [SD = 3.21]) Texan adolescents and young adults ages 15-25 participated in the study. Mixed effects logistic regression models were estimated using maximum likelihood estimation to evaluate the associations between substance use and hooking up. RESULTS: Within-person results indicated that participants were more likely to hook up on days with alcohol use and on days with cannabis use, but not on days with SAM use. Participants were also more likely to hook up on drinking days with higher-than-usual alcohol use. Between-person results indicated that participants who used alcohol more often or cannabis more often on average were more likely to hook up, and participants who tended to drink more on drinking days were more likely to hook up. CONCLUSIONS: Given the significant daily-level associations between alcohol and cannabis use and hooking up behavior, public health initiatives should focus on developing interventions to reduce alcohol and cannabis use and promote safer hooking up behavior among adolescents and young adults.

Coccidioidomycosis-Related Hospital Visits, Texas, USA, 2016-2021.

We analyzed hospital discharge records of patients with coccidioidomycosis-related codes from the International Classification of Diseases, 10th revision, Clinical Modification, to estimate the prevalence of hospital visits associated with the disease in Texas, USA. Using Texas Health Care Information Collection data for 2016-2021, we investigated the demographic characteristics and geographic distribution of the affected population, assessed prevalence of hospital visits for coccidioidomycosis, and examined how prevalence varied by demographic and geographic factors. In Texas, 709 coccidioidomycosis-related inpatient and outpatient hospital visits occurred in 2021; prevalence was 3.17 cases per 100,000 total hospital visits in 2020. Geographic location, patient sex, and race/ethnicity were associated with increases in coccidioidomycosis-related hospital visits; male, non-Hispanic Black, and Hispanic patients had the highest prevalence of coccidioidomycosis compared with other groups. Increased surveillance and healthcare provider education and outreach are needed to ensure timely and accurate diagnosis and treatment of coccidioidomycosis in Texas and elsewhere.

Investigation of Factors Associated with Subclinical Infections of Giardia duodenalis and Cryptosporidium canis in Kennel-Housed Dogs (Canis lupus familiaris).

Giardia duodenalis and Cryptosporidium spp. are zoonotic protozoal pathogens, spread by a fecal-oral route, which can infect a wide range of hosts including but not limited to dogs and humans. Giardia was recently estimated to be present in 37% to 50% of kennel-housed dogs. Cryptosporidium infections in kennel-housed dogs have been reported in 7% to 21% of the population. The goal of this study was to define demographic factors and fecal scores associated with positive screening test cases of Giardia and Cryptosporidium in kennel-housed laboratory dogs in the state of Texas. Fecal samples were collected from 153 clinically normal laboratory dogs at an academic research facility and a local laboratory dog supplier. We used 3 diagnostic tests evaluated in parallel to determine test positivity to each organism: a human point-of-care coproantigen test, a direct immunofluorescent assay, and an in-house polymerase chain reaction. Dogs were significantly more likely to test positive for Giardia (45%) than Cryptosporidium (7%) (P < 0.01). Dogs that were 18 mo of age or younger had 3 times the odds (P = 0.009) of subclinical Giardia infection compared with older dogs. We found no significant relationship between age and Cryptosporidium prevalence. Dogs with hard feces (fecal score 1-2) at the time of screening had 0.34 times lower odds ( P = 0.049) of testing positive for Giardia than dogs with normal feces, but no statistically significant relationship was found between fecal score and Cryptosporidium -positive test status. With these findings, we demonstrated the value of considering age and fecal score when choosing which dogs to screen for subclinical Giardia. Additional studies with larger sample sizes should be conducted to determine the relationship between age and fecal score and subclinical Cryptosporidium infection.

Examining the Role of Self-Harm in the Relationship between Emergency Department Service Utilization and Trauma-Induced Homelessness among Homeless Individuals in Texas.

Homelessness is a complex public health problem in the United States. Current or ongoing history of trauma among individuals adds to the complexity and challenges of homelessness. Our study assessed the moderating role of self-harm in the association between emergency department (ED) service utilization and trauma-induced homelessness (TIH) among adults in Texas. Homeless adults (N = 282) who completed their baseline Vulnerability Index Service Prioritization Decision Assistance Prescreen Tool survey between February 2021 and February 2022 at a Local Mental Health Authority in Texas were selected. The outcome variable, TIH, was assessed by current period of homelessness due to experiencing trauma or abuse. The main independent variable was ED utilization, while self-harm in the past year was assessed as the moderating variable. A multivariate logistic regression with a moderation analysis was conducted while adjusting for the covariates. Individuals who utilized ED services and engaged in self-harm and risky behaviors had greater odds of experiencing current period of TIH. Male respondents were less likely to experience TIH. Finally, engaging in self-harm significantly moderated the association between ED service use and TIH. This study may help inform efforts to develop tailored interventions and promote resilience-based approaches to improve health outcomes among individuals experiencing homelessness due to TIH.

Co-action and changes in alcohol use during a smoking cessation attempt.

AIMS: Three smoking cessation studies (CARE, Break Free, Por Nuestra Salud [PNS]) were used to measure changes in average alcohol consumption, binge drinking and alcohol-related problems during a smoking cessation attempt and to explore co-action with smoking abstinence. DESIGN: CARE and PNS were longitudinal cohort cessation studies; Break Free was a two-arm randomized clinical trial. SETTING: Texas, USA. PARTICIPANTS: Participants were current smokers who were recruited from the community and received smoking cessation interventions. All participants received nicotine replacement therapy and smoking cessation counseling. CARE included 424 smokers (1/3 White, 1/3 African American and 1/3 Latino); Break Free included 399 African American smokers; PNS included 199 Spanish-speaking Mexican-American smokers. MEASUREMENTS: Weekly alcohol consumption was collected multiple times pre and post-quit, and binge drinking and alcohol-related problems were collected at baseline and 26 weeks post-quit. Analyses included only those who indicated current alcohol use. FINDINGS: Average alcohol consumption decreased from baseline to 26 weeks post-quit in CARE (F = 17.09, P < 0.001), Break Free (F = 12.08, P < 0.001) and PNS (F = 10.21, P < 0.001). Binge drinking decreased from baseline to 26 weeks post-quit in CARE (F = 3.94, P = 0.04) and Break Free (F = 10.41, P < 0.001) but not PNS. Alcohol-related problems decreased from baseline to 26 weeks post-quit in CARE (Chi-sq = 6.41, P = 0.010) and Break Free (Chi sq = 14.44, P = 0.001), but not PNS. CONCLUSIONS: Among current drinkers, alcohol use/problems appear to decrease during a smoking cessation attempt and remain low through 26 weeks after the quit attempt. Little evidence was found for co-action, with smoking abstainers and relapsers showing similar change in alcohol use/problems.

Facilitators of and barriers to gastric cancer and precursor diagnosis among South Texas residents: Social determinants of health.

BACKGROUND: Latinos/Hispanics are at higher risk for developing gastric cancer (GC) compared with non-Hispanic whites, and social determinants of health (SDoH) are thought to contribute. AIMS/MATERIALS AND METHODS: This study addressed SDoH and their interactions contributing to disparities in the testing and treatment of Helicobacter pylori (HP) infection and diagnosis of GC and its known precursors, among Latinos/Hispanics relative to non-Latinos at two affiliated but independent health systems in San Antonio, Texas, using a mixed methods approach. RESULTS: Secondary data abstraction and analysis showed that GCs represented 2.6% (n = 600) of our population. Men and older individuals were at higher GC risk. Individuals with military insurance were 2.7 times as likely to be diagnosed as private insurance. Latinos/Hispanics had significantly (24%) higher GC risk than Whites. Poverty and lack of insurance contributed to GC risk among the minorities classified as other (Asians, Native Americans, Multiracial; all p < 0.01). All SDoH were associated with H. pylori infection (p < 0.001). Qualitative analysis of patient and provider interviews showed providers reporting insurance as a major care barrier; patients reported appointment delays, and lack of clinic staff. Providers universally agreed treatment of H. pylori was necessary, but disagreed on its prevalence. Patients did not report discussing H. pylori or its cancer risk with providers. DISCUSSION/CONCLUSION: These data indicate the importance of considering SDoH in diagnosis and treatment of GC and its precursors, and educating providers and patients on H. pylori risks for GC.

Trypanosoma Cruzi antibody screening in North Texas client owned dogs.

Despite multiple screening efforts to identify exposures to Trypanosoma cruzi, in dogs across southern USA, no published studies could be found involving client owned dogs in the North Texas Metroplex area. Therefore, a limited screen was conducted for client owned dogs, seeking routine or preventative care, from participating veterinary practices in the greater Dallas-Fort Worth (DFW) Metroplex from 2019 to 2021. Participants, with owner consent, ranged in age, breed, and length of time at recorded residence. Ninety-nine samples were acquired from participating veterinary practices, initially assessed with the Chagas StatPak, and positive samples were confirmed with IFA (indirect fluorescent antibody test) at the Texas Veterinary Medical Diagnostic Lab (TVMDL), College Station, Texas. Six samples were positive with the StatPak and only two were confirmed positive with IFA. Both animals were senior (10 and 8 years) with no owner reports of previous cardiac issues. The results appear reasonable within the context of previous studies and the seropositivity rate of 2% (n = 99) for client owned dogs included in this study are lower than previously reported rates for shelter dogs from the North Texas area.

Cutaneous Leishmania mexicana infections in the United States: defining strains through endemic human pediatric cases in northern Texas.

Over a 6-month span, three patients under 5 years old with cutaneous leishmaniasis presented to the Pediatric Infectious Diseases Clinic at the University of Texas Southwestern Medical Center/Children's Health Dallas. None had traveled outside of northern Texas/southern Oklahoma; all had Leishmania mexicana infections confirmed by PCR. We provide case descriptions and images to increase the awareness of this disease among United States (US) physicians and scientists. Two patients responded to fluconazole, but the youngest required topical paromomycin. Combining these cases with guidelines and our literature review, we suggest that (i) higher doses (10-12 mg/kg/day) of fluconazole should be considered in young children to maximize likelihood and rapidity of response and (ii) patients should transition to alternate agents if they do not respond to high-dose fluconazole within 6 weeks. Furthermore, and of particular interest to the broad microbiology community, we used samples from these cases as a proof of concept to propose a mechanism to strain-type US-endemic L. mexicana. For our analysis, we sequenced three housekeeping genes and the internal transcribed sequence 2 of the ribosomal RNA gene. We identified genetic changes that not only allow us to distinguish US-based L. mexicana strains from strains found in other areas of the Americas but also establish polymorphisms that differ between US isolates. These techniques will allow documentation of genetic changes in this parasite as its range expands. Hence, our cases of cutaneous leishmaniasis provide significant evolutionary, treatment, and public health implications as climate change increases exposure to formerly tropical diseases in previously non-endemic areas. IMPORTANCE: Leishmaniasis is a parasitic disease that typically affects tropical regions worldwide. However, the vector that carries Leishmania is spreading northward into the United States (US). Within a 6-month period, three young cutaneous leishmaniasis patients were seen at the Pediatric Infectious Diseases Clinic at the University of Texas Southwestern Medical Center/Children's Health Dallas. None had traveled outside of northern Texas and southern Oklahoma. We document their presentations, treatments, and outcomes and compare their management to clinical practice guidelines for leishmaniasis. We also analyzed the sequences of three critical genes in Leishmania mexicana isolated from these patients. We found changes that not only distinguish US-based strains from strains found elsewhere but also differ between US isolates. Monitoring these sequences will allow tracking of genetic changes in parasites over time. Our findings have significant US public health implications as people are increasingly likely to be exposed to what were once tropical diseases.

Natural history of cancer-associated splanchnic vein thrombosis.

BACKGROUND: There is uncertainty in the management of cancer-associated isolated splanchnic vein thrombosis (SpVT). OBJECTIVES: To describe the natural history of SpVT by cancer type and thrombus composition and to review anticoagulation (AC) practices and associated rates of usual-site venous thromboembolism (VTE), major and clinically relevant nonmajor bleeding (MB/CRNMB), recanalization/progression, and mortality. METHODS: We performed a retrospective cohort study in patients with SpVT at 2 cancer care centers in Houston, Texas. We estimated the incidence of usual-site VTE and MB/CRNMB at 6 months using competing risk methods and examined venous patency in a subset of patients with repeat imaging. We assessed associations with mortality using Cox regression. RESULTS: Among 15 342 patients with an incident cancer diagnosis from 2011 to 2020, we identified 298 with isolated SpVT. Patients with hepatocellular carcinoma (HCC) and SpVT (n = 146) had the highest disease prevalence (20%), lowest rate of AC treatment (2%), and similar rate of usual-site VTE (4.2%) vs those without SpVT (5.2%) at 6 months, though tumor thrombus vs bland was associated with worse overall survival. In patients with non-HCC bland SpVT (n = 114), AC (n = 37) was more common in those with non-upper gastrointestinal cancers and fewer comorbidities. AC was associated with more recanalization (44% vs 15%, P = .041) but no differences in usual-site VTE, MB/CRNMB, or mortality at 6 months. CONCLUSION: Cancer-associated isolated SpVT is a common but heterogeneous thrombotic disease that is treated differently from usual-site VTE. Tumor thrombus is a negative prognostic factor. Initiation of AC in bland thrombi requires judicious consideration of thrombotic and bleeding risk.

Factors associated with longer survival among older medicare patients after diagnosis of supratentorial primary brain malignancies: a retrospective cohort study.

OBJECTIVES: Despite recent advances, the prognosis for primary malignant brain tumors (PMBTs) remains poor. Some commonly prescribed medications may exhibit anti-tumor properties in various cancers, and neurodegenerative diseases may activate pathways that counteract gliomagenesis. Our study is focused on determining if there is a correlation between the use of metformin, beta-blockers, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs), or the presence of Parkinson's disease (PD), and the survival rates following a diagnosis of a PMBT. METHODS: This analysis of the 100% Texas Medicare Database identified patients aged 66+ years diagnosed with a supratentorial PMBT from 2014-2017. Cox proportional hazards regression was employed to analyze survival following diagnosis and associations of survival with surgical intervention, radiation, PD diagnosis, and prescription of metformin, beta-blockers, ACEIs, or ARBs. RESULTS: There were 1,943 patients who met study criteria, and the median age was 74 years. When medication utilization was stratified by none, pre-diagnosis only, post-diagnosis only, or both pre- and post-diagnosis (continuous), continuous utilization of metformin, beta-blockers, ACEIs, or ARBs was associated with prolonged survival compared to no utilization (hazard ratio [HR]:0.45, 95% CI:0.33-0.62; HR:0.71. 95% CI:0.59-0.86; HR:0.59, 95% CI:0.48-0.72; and HR:0.45, 95% CI:0.35-0.58 respectively). PD was also associated with longer survival (HR:0.59-0.63 across the four models). DISCUSSION: Our study suggests that metformin, beta-blockers, ACEIs, ARBs, and comorbid PD are associated with a survival benefit among geriatric Medicare patients with supratentorial PMBTs.

Preventing malaria spread in the US.

ABSTRACT: Locally acquired malaria is rare in the US; however, in 2023, cases were reported in Florida, Texas, Maryland, and Arkansas. Prompt diagnosis and treatment of malaria are essential to prevent severe malaria disease. This article details malaria and offers treatment guidelines.

Hospital-Level NICU Capacity, Utilization, and 30-Day Outcomes in Texas.

Importance: Risk-adjusted neonatal intensive care unit (NICU) utilization and outcomes vary markedly across regions and hospitals. The causes of this variation are poorly understood. Objective: To assess the association of hospital-level NICU bed capacity with utilization and outcomes in newborn cohorts with differing levels of health risk. Design, Setting, and Participants: This population-based retrospective cohort study included all Medicaid-insured live births in Texas from 2010 to 2014 using linked vital records and maternal and newborn claims data. Participants were Medicaid-insured singleton live births (LBs) with birth weights of at least 400 g and gestational ages between 22 and 44 weeks. Newborns were grouped into 3 cohorts: very low birth weight (VLBW; <1500 g), late preterm (LPT; 34-36 weeks' gestation), and nonpreterm newborns (NPT; ≥37 weeks' gestation). Data analysis was conducted from January 2022 to October 2023. Exposure: Hospital NICU capacity measured as reported NICU beds/100 LBs, adjusted (ie, allocated) for transfers. Main Outcomes and Measures: NICU admissions and special care days; inpatient mortality and 30-day postdischarge adverse events (ie, mortality, emergency department visit, admission, observation stay). Results: The overall cohort of 874 280 single LBs included 9938 VLBW (5054 [50.9%] female; mean [SD] birth weight, 1028.9 [289.6] g; mean [SD] gestational age, 27.6 [2.6] wk), 63 160 LPT (33 684 [53.3%] female; mean [SD] birth weight, 2664.0 [409.4] g; mean [SD] gestational age, 35.4 [0.8] wk), and 801 182 NPT (407 977 [50.9%] female; mean [SD] birth weight, 3318.7 [383.4] g; mean [SD] gestational age, 38.9 [1.0] wk) LBs. Median (IQR) NICU capacity was 0.84 (0.57-1.30) allocated beds/100 LB/year. For VLBW newborns, NICU capacity was not associated with the risk of NICU admission or number of special care days. For LPT newborns, birth in hospitals with the highest compared with the lowest category of capacity was associated with a 17% higher risk of NICU admission (adjusted risk ratio [aRR], 1.17; 95% CI, 1.01-1.33). For NPT newborns, risk of NICU admission was 55% higher (aRR, 1.55; 95% CI, 1.22-1.97) in the highest- vs the lowest-capacity hospitals. The number of special care days for LPT and NPT newborns was 21% (aRR, 1.21; 95% CI,1.08-1.36) and 37% (aRR, 1.37; 95% CI, 1.08-1.74) higher in the highest vs lowest capacity hospitals, respectively. Among LPT and NPT newborns, NICU capacity was associated with higher inpatient mortality and 30-day postdischarge adverse events. Conclusions and Relevance: In this cohort study of Medicaid-insured newborns in Texas, greater hospital NICU bed supply was associated with increased NICU utilization in newborns born LPT and NPT. Higher capacity was not associated with lower risk of adverse events. These findings raise important questions about how the NICU is used for newborns with lower risk.

Nature and Mental Health in Urban Texas: A NatureScore-Based Study.

In this cross-sectional study, we examined the impact of access to nature on mental health utilization in urban neighborhoods using Texas outpatient encounters data merged with NatureScoreTM (0-100; low to high nature levels) and US census data (household income, education, employment, poverty, and insurance coverage) at the zipcode level. Our sample size included 61 million outpatient encounters across 1169 zipcodes, with 63% women and 30% elderly. A total of 369,344 mental health encounters were identified, with anxiety/stress and depression encounters representing 68.3% and 23.6%, respectively. We found that neighborhoods with a NatureScore of 60+ had lower overall mental health utilization than those below 40 (RR 0.51, 95%CI 0.38-0.69). This relationship persisted for depression, bipolar disorder, and anxiety/stress and in neighborhoods with a NatureScore above 80 (p < 0.001). Compared to neighborhoods with a NatureScore below 40, those above 80 had significantly lower depression (aRR 0.68, 95%CI 0.49-0.95) and bipolar (aRR 0.59, 95%CI 0.36-0.99) health encounters after adjusting for demographic and socioeconomic factors. This novel approach, utilizing NatureScore as a proxy for urban greenness, demonstrates the correlation between a higher NatureScore and reduced mental health utilization. Our findings highlight the importance of integrating nature into our healthcare strategies to promote well-being and mental health.

Prevalence and descriptive epidemiology of choanal atresia and stenosis in Texas, 1999-2018.

Choanal atresia and stenosis are common causes of congenital nasal obstruction, but their epidemiology is poorly understood. Compared to bilateral choanal atresia/stenosis, unilateral choanal atresia/stenosis is generally diagnosed later and might be under-ascertained in birth defect registries. Data from the population-based Texas Birth Defects Registry and Texas vital records, 1999-2018, were used to assess the prevalence of choanal atresia/stenosis. Poisson regression models were used to evaluate associations with infant and maternal characteristics in two analytic groups: isolated choanal atresia/stenosis (n = 286) and isolated, bilateral choanal atresia/stenosis (n = 105). The overall prevalence of choanal atresia/stenosis was 0.92/10,000, and the prevalence of isolated choanal atresia/stenosis was 0.37/10,000 livebirths. Variables associated with choanal atresia/stenosis in one or both analytic groups included infant sex, pregnancy plurality, maternal race/ethnicity, maternal age, and maternal residence on the Texas-Mexico border. In general, adjusted prevalence ratios estimated from the two analytic groups were in the same direction but tended to be stronger in the analyses restricted to isolated, bilateral defects. Epidemiologic studies of isolated choanal atresia/stenosis should consider focusing on cases with bilateral defects, and prioritizing analyses of environmental, social, and structural factors that could account for the association with maternal residence on the Texas-Mexico border.

Sacral Ulcer Development Risk Among Older Adult Patients in North Texas Rehabilitation Hospitals: Role of Comorbidities, Lifestyle, and Personal Factors.

PURPOSE: Sacral ulcers are a serious mortality risk for older adults; thus, we aimed to determine sacral ulcer risk factors among older adults who were recently admitted to rehabilitation hospitals. METHOD: We conducted a retrospective cohort study using the Texas Inpatient Discharge database (2021). The study included 1,290 rehabilitation hospital patients aged ≥60 years diagnosed with sacral ulcers. The control group comprised 37,626 rehabilitation hospital patients aged ≥60 years without sacral ulcers. Binary logistic regression was used to identify risks for sacral ulcer development adjusting for patient demographics, insurance type, and lifestyle. RESULTS: Comorbidities of dementia, Parkinson's disease, type 2 diabetes, and cardiac dysrhythmias were significantly associated with increased risk of sacral ulcers. Longer length of stay, Medicare, and Medicare HMO were also associated with sacral ulcers. Demographically, older age, male sex, identifying as African American, and having malnutrition all had a 50% increased prevalence of sacral ulcers. CONCLUSION: Findings indicate a need to proactively treat chronic comorbidities in vulnerable populations to reduce their possible risk for hospital-acquired infections and excess mortality from sacral ulcers. [Journal of Gerontological Nursing, 50(2), 32-41.].