US Rural Surgeons Leading During COVID-19: Where Are They Now?

Rural surgeons from disparate areas of the United States report on the effects of the COVID-19 pandemic in their communities as the virus has spread across the country. The pandemic has brought significant changes to the professional, economic, and social lives of the individual surgeons and their communities.

Cancer among Refugees Resettled to Idaho during 2008-2019: A Proof-of-Concept Study.

BACKGROUND: Disparities in cancer burden and outcomes according to socioeconomic characteristics have been extensively characterized for US populations. The cancer experience of refugees, who may share characteristics of other socioeconomically disadvantaged populations and also experience distinct barriers to care, has not been described previously. We conducted a proof-of-concept study evaluating our ability to characterize cancer incidence in refugees resettled to Idaho via a novel linkage of cancer data and administrative data characterizing refugee arrivals to Idaho. METHODS: In July 2021, the Cancer Data Registry of Idaho probabilistically linked cancer surveillance data and refugee arrival data (2008- 2019 diagnosis and arrival years) collected through the Centers for Disease Control and Prevention's Electronic Disease Notification (EDN) System. We used SEER*Stat to calculate standardized incidence ratios (SIR) for malignant tumors and benign/borderline malignant brain and other nervous system (ONS) tumors using Idaho-specific and Surveillance, Epidemiology, and End Results (SEER) Program referent incidence rates. RESULTS: 60 malignant and 7 benign brain and ONS tumors were diagnosed among 9,499 refugees resettled to Idaho. Refugees had fewer than expected malignant tumors overall (57 observed vs 96.0 expected; SIR, 0.60; 95% CI, 0.45-0.77). An excess of tumors of the esophagus were diagnosed among Southeast Asian refugees (4 observed vs 0.64 expected; SIR, 6.3; 95% CI, 1.7-16.0). We also used EDN data to update country of birth for linked persons. CONCLUSIONS: Linking EDN refugee data to cancer surveillance data presented unique challenges. However, we used a novel data source to augment cancer data and characterize incidence in refugees, potentially improving our ability to serve this vulnerable population.

Room for Improvement: Rates of Birth Cohort Hepatitis C Screening in Primary Care Practices-A WWAMI Region Practice and Research Network Study.

Introduction: An estimated 2.4 million people in the United States live with hepatitis C. Though there are effective treatments for chronic hepatitis C, many infected individuals remain untreated because 40% to 50% of individuals with chronic hepatitis C are unaware of their hepatitis C status. In 2013, the United States Preventive Services Task Force (USPSTF) recommended that adults born between 1945 and 1965 should be offered one-time hepatitis C screening. The purpose of this study is to describe rates of birth cohort hepatitis C screening across primary care practices in the WWAMI region Practice and Research Network (WPRN). Methods: Cross-sectional observational study of adult patients born between 1945 and 1965 who also had a primary care visit at 1 of 9 participating health systems (22 primary care clinics) between July 31, 2013 and September 30, 2015. Data extracted from the electronic health record systems at each clinic were used to calculate the proportion of birth cohort eligible patients with evidence of hepatitis C screening as well as proportions of screened patients with positive hepatitis C screening test results. Results: Of the 32 139 eligible patients, only 10.9% had evidence of hepatitis C screening in the electronic health record data (range 1.2%-49.1% across organizations). Among the 4 WPRN sites that were able to report data by race and ethnicity, the rate of hepatitis C screening was higher among African Americans (39.9%) and American Indians/Alaska Natives (23.2%) compared with Caucasians (10.7%; P < .001). Discussion: Rates of birth cohort hepatitis C screening are low in primary care practices. Future research to develop and test interventions to increase rates of birth cohort hepatitis C screening in primary care settings are needed.

Quit Happens: A community clinic-based, multitiered smoking cessation intervention.

OBJECTIVES: To evaluate the "Quit Happens" program launched to reduce tobacco use in low-income populations in a federally qualified nonprofit health center with clinics in Washington and Idaho. Quit Happens was implemented in 2015 and involved a public health nurse, patient, provider, clinic, health system, and community components. DESIGN AND SAMPLE: This smoking cessation program was assessed using a pre-post evaluation design. Nine clinics in a single system of federally qualified nonprofit health centers participated in this program. INTERVENTION: The Quit Happens program was implemented across nine clinics in Washington and Idaho. A specialized public health nurse led the tobacco cessation training of all clinic staff and assisted with development of the smoking cessation program. The 5A model was used as the framework for the training. MEASUREMENTS: The proportion of patients identifying as a current or former smoker was measured using data extracted from electronic health records. RESULTS: Declines in patient reports of currently smoking were observed between 2016 and 2018. The percent of current smokers identified in electronic health records decreased 18.7% and percent of former smokers doubled. CONCLUSION: This community-based tobacco cessation program had wide clinic and community support and self-reported smoking behavior declined over time. A public health nurse's leadership in offering training and program development around tobacco cessation to a local community organization can contribute to reductions in smoking rates.

Confirmation of Echinococcus canadensis G8 and G10 in Idaho Gray Wolves ( Canis lupus) and Cervids.

We confirm the presence of Echinococcus canadensis genotypes G8 and G10 in gray wolves ( Canis lupus) and cervids in Idaho, US. Our results demonstrated that cystic echinococcosis remains a potential public health issue, indicating the need for regular deworming of domestic dogs, who often act as potential bridge hosts.

Impact of a Temporary NRT Enhancement in a State Quitline and Web-Based Program.

PURPOSE: To examine the impact of a nicotine replacement therapy (NRT) enhancement on quit outcomes. DESIGN: Observational study using an intent to treat as treated analysis. SETTING: Not available. PARTICIPANTS: A total of 4022 Idaho tobacco users aged ≥18 years who received services from the Idaho Tobacco Quitline or Idaho's web-based program. INTERVENTION: One-call phone or web-based participants were sent a single 4- or 8-week NRT shipment. Multiple-call participants were sent NRT in a single 4-week shipment or two 4-week shipments (second shipment sent only to those completing a second coaching call). MEASURES: North American Quitline Consortium recommended Minimal Data Set items collected at registration and follow-up. Thirty-day point prevalence quit rates were assessed at 7-month follow-up. ANALYSIS: Multiple logistic regression models were used to examine the effects of program type and amount of NRT sent to participants while controlling for demographic and tobacco use characteristics. RESULTS: Abstinence rates were significantly higher among 8-week versus 4-week NRT recipients (42.5% vs 33.3%). The effect was only significant between multiple-call program participants who received both 4-week NRT shipments versus only the first of 2 possible 4-week shipments (51.1% vs 31.1%). Costs per quit were lowest among web-based participants who received 4 weeks of NRT (US$183 per quit) and highest among multiple-call participants who received only 1 of 2 possible NRT shipments (US$557 per quit). CONCLUSION: To better balance cost with clinical effectiveness, funders of state-based tobacco cessation services may want to consider (1) allowing tobacco users to choose between phone- and web-based programs while (2) limiting longer NRT benefits only to multiple-call program participants.

An investigation of survivorship clinic attendance among childhood cancer survivors living in a five-state rural region.

PURPOSE: Cancer survivorship clinics manage cancer-related health complications and are available primarily in urban areas. We examine how demographic, clinical, and geographic-based characteristics are associated with attendance at the only pediatric survivorship clinic in a largely rural, multistate region. METHODS: One thousand eight hundred sixteen cancer survivors were diagnosed at age ≤ 25 from 1986 to 2005 while living in the region. Cox models incorporating death as a competing risk and generalized estimating equations calculated hazards ratios (HR) for characteristics measured at the clinic's opening. Subjects were followed from the clinic opening their first visit, death, emigration from the catchment area, or December 31, 2014. RESULTS: Five percent of survivors visited the clinic. Attendance is positively associated with a leukemia or lymphoma diagnosis (HR = 3.32, 95% confidence interval [CI] = 1.72-6.78 vs CNS tumors), previous relapse (HR = 1.78, 95% CI = 1.00-3.19), and residing >100 mi from the clinic (HR = 2.05, 95% CI 1.03-4.10). Survivors aged ≥ 31 years at clinic opening (HR = 0.19, 95% CI = 0.07-0.54) are less likely to attend than younger survivors. Residence between 16 and 100 mi had an inverse association with attendance, although not significant. CONCLUSION: Survivorship clinics are not widely attended by survivors in this catchment region. Efforts should be made to recruit survivors aged ≥ 31 and diagnosed with CNS tumors. Distance has a complex association with attendance, which could be attributed to the limited availability of preventative services in regions > 100 mi from the clinic. IMPLICATIONS FOR CANCER SURVIVORS: Survivors living in this catchment region may not be receiving care necessary to prevent severe late effects.

Missed Opportunities for Chlamydia Screening in Title X Family Planning Clinics.

BACKGROUND: Annual chlamydia (CT) screening is recommended for women younger than 25 years, yet less than half of young women seeking health care are screened annually. We analyzed Title X family planning service data from the Northwest United States to assess factors associated with missed opportunities for CT screening. Our primary hypothesis was screening coverage is higher during annual preventive health visits compared to other visit types. Study objectives were: (1) identify gaps in screening coverage by patient demographics, visit characteristics, and clinic measures; and (2) examine the association between visit type and CT screening by controlling for other covariates and stratifying by state. METHODS: Calendar year 2011 Title X visit records (n = 180,856) were aggregated to the patient level (n = 112,926) to assess CT screening coverage by all characteristics. Screening variation was explored by bivariate and multivariate Poisson regression. Adjusted models for each state estimated association between comprehensive examination and screening controlling for confounders. RESULTS: Clinic and visit characteristics were associated with CT screening. Coverage ranged from 45% in Washington to 80% in Alaska. Only 34% of patients visited for a routine comprehensive examination. Visit type was associated with screening; 75% of patients who had a comprehensive examination were screened versus 34% of those without a comprehensive examination (unadjusted PR, 2.18; 95% confidence interval, 2.16-2.21). The association between comprehensive examination and CT screening varied significantly by state (interaction term, P < 0.001). CONCLUSIONS: Missed screening opportunities are common among women who access brief appointments for specific needs but do not seek routine preventive care, particularly in some states. Structural interventions may help address these systematically missed opportunities.

Farming and ranching related injuries in Southern Idaho.

INTRODUCTION: Agriculture is an inherently dangerous industry. We sought injury data for use with the Idaho Time Sensitive Emergency (TSE) system to formulate goals and track improvements. METHODS: Registries in southern Idaho were queried for ICD-9-CM diagnoses related to agriculture in 2014. Injuries known or likely to have occurred on properties intended for farming, ranching, animal care, or milk production, and relating to those activities were included. RESULTS: Among 72 patients, injuries were related to horses (31%), machinery (17%), ATVs (17%), and hay bales/haystacks (13%). Average age was 45 (3-82), 82% male, and mean ISS of 13 (1-50). Transportation utilized air (31%) and ground (69%) methods, with an average of 35 min (9-132). There was 1 inhospital death and 4 on-scene fatalities. CONCLUSIONS: We established baseline transport and injury data for the Idaho TSE system. These results can help our TSE system track improvements intended to increase quality of care.

Two Suspected Worksite or Occupational Cancer Clusters Investigated Using the Cancer Data Registry and Multiple Primary Standardized Incidence Ratios in SEER *Stat-Idaho, 2013-2014.

BACKGROUND: Investigations of suspected cancer clusters are resource intensive and rarely identify true clusters: among 428 publicly reported US investigations during 1990-2011, only 1 etiologic cluster was identified. In 2013, the Cancer Data Registry of Idaho (CDRI) was contacted regarding a suspected cancer cluster at a worksite (Cluster A) and among an occupational cohort (Cluster B). We investigated to determine whether these were true clusters. METHODS: We derived investigation cohorts for Cluster A from facility-provided employee records and for Cluster B from professional licensing records. We used Registry PlusTM Link Plus to conduct probabilistic linkage of cohort members to the CDRI registry and completed matching through manual review by using LexisNexis®, Accurint®, and the Social Security Death Index. We calculated standardized incidence ratios (SIR) using the MP-SIR session type in SEER*Stat and Idaho and US referent populations. RESULTS: For Cluster A, we identified 34 cancer cases during 9,689 person-years; compared with Idaho and US rates, 95 percent CIs for SIRs included 1.0 for 24 of 24 primary site categories. For Cluster B, we identified 78 cancer cases during 15,154 person-years; compared with Idaho rates, 95 percent CI for SIRs included 1.0 for 23 of 24 primary site categories and was less than 1.0 for lung and bronchus cancers, and compared with US rates, 95 percent CI for SIRs included 1.0 for 22 of 24 primary site categories and was less than 1.0 for lung and bronchus and colorectal cancers. CONCLUSION: We identified no statistically significant excess in cancer incidence in either cohort. SEER*Stat's MP-SIR is an efficient tool for performing SIR assessments, a Centers for Disease Control and Prevention/Council of State and Territorial Epidemiologists-recommended step when investigating suspected cancer clusters.

Atlantic salmon, Salmo salar L. are broadly susceptible to isolates representing the North American genogroups of infectious hematopoietic necrosis virus.

Beginning in 1992, three epidemic waves of infectious hematopoietic necrosis, often with high mortality, occurred in farmed Atlantic salmon Salmo salar L. on the west coast of North America. We compared the virulence of eleven strains of infectious hematopoietic necrosis virus (IHNV), representing the U, M and L genogroups, in experimental challenges of juvenile Atlantic salmon in freshwater. All strains caused mortality and there was wide variation within genogroups: cumulative mortality for five U-group strains ranged from 20 to 100%, four M-group strains ranged 30-63% and two L-group strains varied from 41 to 81%. Thus, unlike Pacific salmonids, there was no apparent correlation of virulence in a particular host species with virus genogroup. The mortality patterns indicated two different phenotypes in terms of kinetics of disease progression and final per cent mortality, with nine strains having moderate virulence and two strains (from the U and L genogroups) having high virulence. These phenotypes were investigated by histopathology and immunohistochemistry to describe the variation in the course of IHNV disease in Atlantic salmon. The results from this study demonstrate that IHNV may become a major threat to farmed Atlantic salmon in other regions of the world where the virus has been, or may be, introduced.

Northwest Latinos' health promotion lifestyle profiles according to diabetes risk status.

A sample of 225 low income and low education, middle aged Latinos with concern about diabetes and living in a mid-size Idaho city volunteered for a physical assessment for risk status for the disease. The health promoting lifestyles of Latino congregants were measured using the Health Promoting Lifestyle Profile II. Diabetes risk was measured by clinically standard glycated hemoglobin readings. From no risk for the disease to full blown diabetes as determined by glycated hemoglobin levels, the respondents reported engaging in basically the same levels of physical activity, monitoring of nutrition and use of health care services thus evidencing no apparent understanding of the role of lifestyle in disease management. The findings point to the imperative of a broad, comprehensive and especially culturally attuned educational campaign on basic disease pathophysiology, the value of prevention for individual health, and the necessity of day-to-day self-care should diabetes be diagnosed.

Long-term trends in Chlamydia trachomatis infections and related outcomes in a U.S. managed care population.

BACKGROUND: Given recent increasing case rates of Chlamydia trachomatis infection, we evaluated trends in chlamydia rates and related health outcomes in women and men aged 15 to 44 years who were enrolled in a Pacific Northwest health plan. METHODS: We identified chlamydia, pelvic inflammatory disease (PID), ectopic pregnancy, and male urethritis cases occurring annually during 1997-2007 using computerized health plan databases, calculating rates per 100,000 person-years (py) by gender and 5-year age groups. We also calculated annual chlamydia testing rates. RESULTS: In women, chlamydia testing rates increased by approximately 23% (220 tests per 1000 py in 1997 to 270 tests per 1000 in 2007). Chlamydia diagnosis rates rose from 449 cases/100,000 py in 1997 to 806/100,000 in 2007, a 79% increase (P = 0.01). Increases were greatest during 2005-2007, also the period of major conversion to nucleic acid amplification test. PID rates in this interval declined steadily from 823 cases/100,000 py to 473/100,000 (P < 0.01). Ectopic pregnancy rates remained unchanged. In men, chlamydia testing rates increased nearly 3.5-fold, from 12 to 42 tests per 1000 py. Chlamydia rates for men also rose significantly throughout the study interval (from 91 cases/100,000 py to 218/100,000; P < 0.01) as did urethritis diagnosis rates (P < 0.01). CONCLUSION: Between 1997 and 2007, annual health plan chlamydia rates increased significantly for both women and men. These trends may be due in part to increased testing rates and increased use of more sensitive tests, but they likely do not explain the increased urethritis rates. During this same interval, we observed steady declines in PID rates, consistent with other national data sources.

Regional differences and tribal use of American Indian/Alaska Native cancer data in the Pacific Northwest.

In the Pacific Northwest, cancer is a leading cause of morbidity and mortality for American Indians and Alaska Natives (AI/AN). Misclassification of AI/AN race in state cancer registries causes cancer burden to be underestimated. Furthermore, local-level data are rarely available to individual tribes for use in health assessment and program planning. We corrected race coding in the cancer registries of Idaho, Oregon, and Washington using probabilistic record linkage to a file derived from patient registration records from Indian Health Service and a large urban clinic. We calculated cancer incidence and mortality measures by state, comparing AI/AN to non-Hispanic White (NHW) race. Record linkages identified a high prevalence of misclassified race. Differences in AI/AN cancer patterns were identified across the three state region. Compared to NHW, AI/AN experienced disproportionate late stage rates of some screen-detectable cancers. The correct classification of race is a crucial factor in cancer surveillance and can reveal regional differences even within a relatively small area. The availability of local-level cancer data can help inform tribes in appropriate intervention efforts.

Survey of pathogens in hatchery Chinook salmon with different out-migration histories through the Snake and Columbia rivers.

The operation of the Federal Columbia River Power System (FCRPS) has negatively affected threatened and endangered salmonid populations in the Pacific Northwest. Barging Snake River spring Chinook salmon Oncorhynchus tshawytscha through the FCRPS is one effort to mitigate the effect of the hydrosystem on juvenile salmon out-migration. However, little is known about the occurrence and transmission of infectious agents in barged juvenile salmon relative to juvenile salmon that remain in-river to navigate to the ocean. We conducted a survey of hatchery-reared spring Chinook salmon at various points along their out-migration path as they left their natal hatcheries and either migrated in-river or were barged through the FCRPS. Salmon kidneys were screened by polymerase chain reaction for nine pathogens and one family of water molds. Eight pathogens were detected; the most prevalent were Renibacterium salmoninarum and infectious hematopoietic necrosis virus. Species in the family Saprolegniaceae were also commonly detected. Pathogen prevalence was significantly greater in fish that were barged through the FCRPS than in fish left to out-migrate in-river. These results suggest that the transmission of infectious agents to susceptible juvenile salmon occurs during the barging process. Therefore, management activities that reduce pathogen exposure during barging may increase the survival of juvenile Chinook salmon after they are released.

Prevalence of chronic obstructive pulmonary disease and tobacco use in veterans at Boise Veterans Affairs Medical Center.

BACKGROUND: Although its prevalence is still debated, chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the United States, and smoking cessation remains the only intervention that can significantly improve the prognosis of COPD. METHODS: To determine the prevalence of COPD in a typical population seeking care at a Veterans Affairs Medical Center; the impact of smoking, age, and sex on the prevalence of COPD in this population; and how often spirometry is done in patients at risk for COPD, we extracted data from the Veterans Integrated Service Network 20 Consumer Health Information and Performance Sets database, on patients seen at the Boise Veterans Affairs Medical Center between January 1, 1999, and May 30, 2006. RESULTS: Approximately 8.8% (2,556/28,983) of all patients and 14.1% (1,152/8,149) of smokers were reported to have COPD. The odds of COPD in smokers, after adjusting for age and sex, was 3.18 (95% confidence interval 2.88-3.50) times greater than in nonsmokers. Males were 1.48 times more likely to have COPD than females, and there was an increasing risk of COPD with age. Thirty-nine percent of all veterans and 54% of those with COPD were active smokers. 273 (60%) of the 455 symptomatic smokers without a prior diagnosis of COPD were not evaluated with spirometry. CONCLUSIONS: The prevalence of COPD in patients at the Boise Veterans Affairs Medical Center was consistent with that in other United States surveys, although the underutilization of screening spirometry in those at risk for COPD may have caused underestimation of the prevalence. Smoking, age, and male sex were identified as significant risk factors for COPD, and the prevalence of active smoking remains high in this population of veterans.

Echinococcus granulosus in gray wolves and ungulates in Idaho and Montana, USA.

We evaluated the small intestines of 123 gray wolves (Canis lupus) that were collected from Idaho, USA (n=63), and Montana, USA (n=60), between 2006 and 2008 for the tapeworm Echinococcus granulosus. The tapeworm was detected in 39 of 63 wolves (62%) in Idaho, USA, and 38 of 60 wolves (63%) in Montana, USA. The detection of thousands of tapeworms per wolf was a common finding. In Idaho, USA, hydatid cysts, the intermediate form of E. granulosus, were detected in elk (Cervus elaphus), mule deer (Odocoileus hemionus), and a mountain goat (Oreamnos americanus). In Montana, USA, hydatid cysts were detected in elk. To our knowledge, this is the first report of adult E. granulosus in Idaho, USA, or Montana, USA. It is unknown whether the parasite was introduced into Idaho, USA, and southwestern Montana, USA, with the importation of wolves from Alberta, Canada, or British Columbia, Canada, into Yellowstone National Park, Wyoming, USA, and central Idaho, USA, in 1995 and 1996, or whether the parasite has always been present in other carnivore hosts, and wolves became a new definitive host. Based on our results, the parasite is now well established in wolves in these states and is documented in elk, mule deer, and a mountain goat as intermediate hosts.

Arsenic levels in ground water and cancer incidence in Idaho: an ecologic study.

PURPOSE: Long-term exposure to arsenic above 50 microg/L in drinking water has been related to multiple types of cancers. Few epidemiologic studies conducted in the US have detected an association between regional exposures below this level in drinking water and corresponding cancer occurrence rates. This county-level ecologic study evaluates arsenic levels in ground water and its association with targeted cancer incidence in Idaho, where some regions have been found to contain higher arsenic levels. METHODS: Using cancer incidence data (1991-2005) from the Cancer Data Registry of Idaho and arsenic data (1991-2005) from the Idaho Department of Environmental Quality, we calculated the age-adjusted incidence rate for cancers of the urinary bladder, kidney and renal pelvis, liver and bile duct, lung and bronchus, non-Hodgkin's lymphoma (NHL), and all malignant cancers according to arsenic levels in ground water. Multivariate regression analysis was applied to evaluate the relationship between arsenic levels in ground water and cancer incidence. RESULTS: For males, but not for females, age-adjusted incidence for lung cancer and all malignant cancers was significantly higher in the intermediate arsenic counties (2-9 microg/L, n = 16) and the high arsenic counties (>or=10 microg/L, n = 5) compared to the low arsenic counties (<2.0 microg/L, n = 23). When adjusted for race, gender, population density, smoking and body mass index (BMI), no relationship was found between arsenic levels in ground water and cancer incidence. CONCLUSIONS: In this ecological design, exposure to low-level arsenic in ground water is not associated with cancer incidence when adjusting for salient variables. For populations residing in southwestern Idaho, where arsenic has been found to exceed 10 microg/L in ground water, individual risk assessment is required in order to determine whether there is a link between long-term arsenic exposure at these levels and cancer risk.

A new species of myxozoan (Myxosporea) from the brain and spinal cord of rainbow trout (Oncorhynchus mykiss) from Idaho.

A new species of Myxosporea, Myxobolus neurotropus n. sp., is described from the brain and spinal cord of rainbow trout (Oncorhynchus mykiss) from Duncan Creek, Owyhee County, Idaho. Spores are oval, have 2 pyriform polar capsules, and possess a thick spore wall (sutural rim) with a short intracapsular offshoot. The mean spore dimensions are length 11.8 microm, width 10.8 microm, and thickness 8.8 microm. This myxozoan is compared to other described Myxobolus species found in cranial tissues of salmonids in terms of spore morphology and phylogenetic analysis. Because it is found in brain and spinal cord, it is encountered while performing screening tests for Myxobolus cerebralis, the causative agent of salmonid whirling disease. Where chronic inflammation and granulomatous lesions are associated with M. cerebralis, histological examination shows no host response to M. neurotropus n. sp. A diagnostic polymerase chain reaction (PCR) test is included as an aid in properly identifying the species.