Manure nutrient cycling in US animal agriculture basins-North Carolina case study.

Nutrient cycling in crop-animal production is impacted by changes in both systems, with imbalance hotspots in concentrated animal production regions severely impacting water quality. This study assesses manure-crop nutrient balances in five river basins in North Carolina and demonstrates a new approach for partial nutrient balances along hydrological boundaries. County-level crop production data were combined with crop-type spatial distribution data to derive spatially referenced nutrient uptake and removal. Similarly, spatially referred animal production inventory data were used to derive excreted and recovered manure nutrients. Partial nutrient balances were developed for both N and P in basins and hydrologic units. Excreted manure N and P were 139% and 159% of respective plant N and P removal at harvest across the five basins. Finer geographical scales revealed hotspots for manure surplus, particularly within the Cape Fear basin (up to 96% N and 97% P). Despite N hotspots, plant-available manure N met only 38% of crop N demand due to significant losses during storage. Plant-available manure P exceeded crop P removal by 54% over the entire area. Cape Fear showed the greatest P excess, 76% greater than crop removal. This study contributes to nutrient cycling improvements by connecting crop-animal nutrient budgets to hydrologic resources. Furthermore, we show the value of finer spatial scales to identify hotspots that play a significant role in nutrient losses. We conclude that nutrient-surplus basins require, in addition to manure nutrient conservation, a basin-wide redistribution and export strategies to address nutrient excesses and water quality impacts.

Insect frass composition and potential use as an organic fertilizer in circular economies.

Insect manure or "frass" has emerged as an alternative nutrient source for alleviating the dependence on fossil fuel-based fertilizers, reducing food waste, and promoting food security. Yet, research on insect frass chemical composition is in its infancy. Here, we assessed the chemical properties of yellow mealworm (Tenebrio molitor L.) frass compared with poultry litter (PL). Insect frass was obtained from the National Biological Control Laboratory (NBCL; IF-L) and an insect-rearing company (IF-C). PL was collected from facilities in Arkansas (PL-AR) and North Carolina (PL-NC). Samples were analyzed for pH, electrical conductivity, macro- and micronutrients, heavy metals, pathogens, and indicator microorganisms. On average, insect frass had 43% and 47% higher C and N than PL, respectively (P < 0.05). Considering a 5 mg/ha application rate, IF-C can supply 159 kg N/ha, twice the N supply of PL-AR (78 kg/ha). IF-L had a 53% higher P supply than PL-NC. Mean K, Ca, S, and micronutrient contents were higher in PL than in frass (P < 0.05), whereas As, Cd, Cr, and Pb were nearly absent in frass. Chemical composition and pathogens in fertilizer sources were largely affected by insect-rearing substrate and supplements used in poultry and insect production. Insect frass utilized in this study had optimum C and N rates relative to PL, suggesting a promising soil amendment for improving soil health and C sequestration, thus contributing to sustainable agricultural intensification and reuse of food waste in circular economies.

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.

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).

Racial and ethnic disparities in motor vehicle crash-related outcomes in North Carolina surrounding the COVID-19 pandemic.

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.

Dietary omega-6/omega-3 fatty acids and risk of prostate cancer; Is there any potential interaction by organophosphate insecticides among the agricultural health study population.

BACKGROUND: In the United States (US), the average annual increase in the incidence of prostate cancer (PCa) has been 0.5% between 2013 and 2017. Although some modifiable factors have been identified as the risk factors for PCa, the effect of lower ratio of omega-6 to omega-3 fatty acids intake (N-6/N-3) remains unknown. Previous studies of the Agricultural Health Study (AHS) reported a significant positive association between PCa and selected organophosphate pesticides (OPs) including terbufos and fonofos. OBJECTIVE: The aim of this study was to evaluate the association between N-6/N-3 and PCa and any interaction between N-6/N-3 and 2 selected OPs (i.e., terbufos and fonofos) exposure. DESIGN AND PARTICIPANTS: This case-control study, nested within a prospective cohort study, was conducted on a subgroup of the AHS population (1193 PCa cases and 14,872 controls) who returned their dietary questionnaire between 1999 and 2003 MAIN OUTCOME MEASURES: PCa was coded based on the International Classification of Diseases of Oncology (ICD-O-3) definitions and obtained from the statewide cancer registries of Iowa (2003-2017) and North Carolina (2003-2014). STATISTICAL ANALYSIS: Multivariate logistic regression analysis was applied to obtain the odds ratios adjusted (aORs) for age at dietary assessment (years), race/ethnicity (white, African American, other), physical activity (hours/week), smoking (yes/no), terbufos (yes/no), fonofos (yes/no), diabetes, lycopene intake (milligrams/day), family history of PCa, and the interaction of N-6/N-3 with age, terbufos and fonofos. Pesticide exposure was assessed by self-administrated questionnaires collecting data on ever/never use of mentioned pesticides during lifetime as a yes/no variable. Assessing the P value for the interaction between pesticides and N-6/N-3, we used the continuous variable of "intensity adjusted cumulative exposure" to terbufos and fonofos. This exposure score was based on duration, intensity and frequency of exposure. We also conducted a stratified regression analysis by quartiles of age. RESULTS: Relative to the highest N-6/N-3 quartile, the lowest quartile was significantly associated with a decreased risk of PCa (aOR=0.61, 95% CI: 0.41-0.90), and quartile-specific aORs decreased toward the lowest quartile (Ptrend=<0.01). Based on the age-stratified analysis, the protective effect was only significant for the lowest quartile of N-6/N-3 among those aged between 48 and 55 years old (aORs=0.97, 95% CI, 0.45-0.55). Among those who were exposed to terbufos (ever exposure reported as yes in the self-report questionnaires), lower quartiles of N-6/N-3 were protective albeit nonsignificant (aORs: 0.86, 0.92, 0.91 in quartiles 1,2, and 3, respectively). No meaningful findings were observed for fonofos and N-6/N-3 interaction. CONCLUSION: Findings showed that lower N-6/N-3 may decrease risk of PCa among farmers. However, no significant interaction was found between selected organophosphate pesticides and N-6/N-3.

The Selah Pilot Study of Spiritual, Mindfulness, and Stress Inoculation Practices on Stress-Related Outcomes Among United Methodist Clergy in the United States.

The job-demand-control-support model indicates that clergy are at high risk for chronic stress and adverse health outcomes. A multi-group pre-test-post-test design was used to evaluate the feasibility, acceptability, and range of outcome effect sizes for four potentially stress-reducing interventions: stress inoculation training, mindfulness-based stress reduction (MBSR), the Daily Examen, and Centering Prayer. All United Methodist clergy in North Carolina were eligible and recruited via email to attend their preferred intervention. Surveys at 0, 3, and 12 weeks assessed symptoms of stress, anxiety, and perceived stress reactivity. Heart rate variability (HRV) was assessed at baseline and 12 weeks using 24 h ambulatory heart rate monitoring data. A subset of participants completed in-depth interviews and reported skill practice using daily text messages. Standardized mean differences with 95% and 75% confidence intervals were calculated for the change observed in each intervention from baseline to 3 and 12 weeks post-baseline to determine the range of effect sizes likely to be observed in a definitive trial. 71 clergy participated in an intervention. The daily percentage of participants engaging in stress management practices ranged from 47% (MBSR) to 69% (Examen). Results suggest that participation in Daily Examen, stress inoculation, or MBSR interventions could plausibly result in improvement in stress and anxiety at 12 weeks with small-to-large effect sizes. Small effect sizes on change in HRV were plausible for MBSR and Centering Prayer from baseline to 12 weeks. All four interventions were feasible and acceptable, although Centering Prayer had lower enrollment and mixed results.

Generation of the Chemical and Social Stressors Integration Technique (CASS-IT) to identify areas of holistic public health concern: An application to North Carolina.

Due to structural racism and income inequality, exposure to environmental chemicals is tightly linked to socioeconomic factors. In addition, exposure to psychosocial stressors, such as racial discrimination, as well as having limited resources, can increase susceptibility to environmentally induced disease. Yet, studies are often conducted separately in fields of social science and environmental science, reducing the potential for holistic risk estimates. To tackle this gap, we developed the Chemical and Social Stressors Integration Technique (CASS-IT) to integrate environmental chemical and social stressor datasets. The CASS-IT provides a framework to identify distinct geographic areas based on combinations of environmental chemical exposure, social vulnerability, and access to resources. It incorporates two data dimension reduction tools: k-means clustering and latent profile analysis. Here, the CASS-IT was applied to North Carolina (NC) as a case study. Environmental chemical data included toxic metals - arsenic, manganese, and lead - in private drinking well water. Social stressor data were captured by the CDC's social vulnerability index's four domains: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. Data on resources were derived from Federal Emergency Management Agency (FEMA's) Resilience and Analysis Planning Tool, which generated measures of health resources, social resources, and information resources. The results highlighted 31 NC counties where exposure to both toxic metals and social stressors are elevated, and health resources are minimal; these are counties in which environmental justice is of utmost concern. A census-tract level analysis was also conducted to demonstrate the utility of CASS-IT at different geographical scales. The tract-level analysis highlighted specific tracts within counties of concern that are particularly high priority. In future research, the CASS-IT can be used to analyze United States-wide environmental datasets providing guidance for targeted public health interventions and reducing environmental disparities.

Exploring North Carolina's Transition to Whole-Person, Integrated Care From the Provider Perspective: Results From an Exploratory Survey.

BACKGROUND For quite some time, many North Carolina practitioners and health care leaders have advocated for whole-person care. There has been significant movement toward a whole-person approach to health in the state; however, challenges remain despite continuous momentum building over the years. This article reports an exploratory survey with North Carolina primary care and behavioral health providers.METHODS Providers were recruited statewide through professional associations and networks to participate in a survey regarding their experience delivering whole-person care. The survey included demographic, provider, and clinic type information; professional experience; and 46 questions focused on whole-person care practice.RESULTS The results of the survey demonstrated that providers report more acknowledgment and attempted practice of whole-person care, but there are still barriers to overcome, such as relieving the administrative burden of changing or expanding services, understanding reimbursement for integrated services, and difficulty recruiting and retaining providers.LIMITATIONS The sample included more nurse practitioners than other primary care and behavioral health disciplines. Thus, the information gathered in this survey may be more representative of the training and experience of nurse practitioners than of a paradigm shift in North Carolina in the delivery of care. Additionally, while researchers made every attempt to distribute the survey statewide, some areas of the state were more represented than others.CONCLUSION Obstacles to seamlessly providing whole person care remain. State health leaders, providers, and North Carolina communities will need to work together to reduce or eliminate these obstacles and ensure the delivery of integrated behavioral health and whole-person care.

Assessing Breast Cancer Risks to Improve Care for an Increased-Risk Population within Eastern North Carolina.

BACKGROUND The average lifetime risk of breast cancer for an American woman is 12.5%, but individual risks vary significantly. Risk modeling is a standard of care for breast cancer screening and prevention with recommended tools to stratify individual risks based on age, family history, breast density, and a host of other known risk factors. Because of a lack of resources rurally, we have not consistently met this standard of care within all of North Carolina.METHODS We implemented a quality improvement project to assess the risk for breast cancer by gathering data on community risks. We implemented an evidence-based tool (Tyrer-Cuzick) for quantifying risk within a mostly rural population of Eastern North Carolina and developed customized services for women meeting elevated-risk definition. These services included additional imaging for elevated-risk women and a risk-reduction program. We also assessed genetic risks for hereditary breast and ovarian cancer in our at-risk population using National Comprehensive Cancer Network (NCCN) guidelines based on family history and added local genetics extenders to help test more women. We analyzed data regularly using Plan-Do-Study-Act methods to improve outcomes over 1 year.RESULTS We screened a population of 4500 women at a community hospital over a 1-year period for their individual lifetime cancer risk and genetic risk. Breast cancer risk was quantitated at the time of mammography, and women were stratified into 3 groups for risk management. Within our screening population, 6.3% of women were at high risk (defined by a lifetime breast cancer risk greater than or equal to 20%) and another 8.1% were above-average risk (defined by a lifetime breast cancer risk of 15%-20%). These women (14.4%) could potentially benefit from additional risk-management strategies. Additionally, 20% of all unaffected women within a typical screening population of Eastern North Carolina met NCCN guidelines for hereditary breast cancer and ovarian cancer testing independent of their cancer risk score. Using a model of targeted intervention within a population with elevated risks can be helpful in improving outcomes.LIMITATIONS This population within Eastern North Carolina is mostly rural and represents a potentially biased population, as it involves older women undergoing annual mammography. It may not be broadly applicable to the entire population based on age, geography, and other risks.CONCLUSIONS This model for improving cancer risk assessment and testing at a small community hospital in Eastern North Carolina was successful and addressed a community need. We discovered a high rate of increased-risk women who can benefit from individualized risk management, and a higher percentage of women who potentially benefit from genetic testing. These higher cumulative risks may in part explain some of the disparities seen for breast-cancer-specific outcomes in some parts of the state.

Opportunities to implement manureshed management in the Iowa, North Carolina, and Pennsylvania swine industry.

The U.S. swine industry is diverse, but opportunities exist to strategically improve manure management, especially given much of the industry's vertical integration. We investigate opportunities for improving manureshed management, using swine production examples in Iowa, North Carolina, and Pennsylvania as a lens into historical trends and the current range of management conditions. Manure management reflects regional differences and the specialized nature of hog farms, resulting in a large range of land bases required to assimilate manure generated by these operations. Selected representative farm scenarios were evaluated on an annual basis; farm-level manuresheds were largest for Pennsylvania sow farms and smallest for North Carolina nursery farms. Compared with nitrogen-based manuresheds, phosphorus-based manuresheds were up to 12.5 times larger. Technology advancements are needed to promote export of concentrated nutrients, especially phosphorus, from existing "source" manuresheds to suitable croplands. The industry is dynamic, as revealed by historical analysis of the siting of hog barns in Pennsylvania, which are currently trending toward the north and west where there is greater isolation to prevent the spread of disease and a larger land base to assimilate manure. Industry expansion should focus on locating animals in nutrient "sink" areas.

Variations in Receipt of Contraceptives by Insurance Status and Race/Ethnicity.

BACKGROUND Although use of contraceptives has increased among young women in the United States, more than half of pregnancies remain unplanned. The goal of this study was to examine the association between insurance status and receipt of contraceptives among young women receiving care within a large integrated health care system in the Southeastern United States to better inform strategies for increasing access to contraception.METHODS This retrospective study used electronic medical record data from an integrated health care system based in Charlotte, North Carolina. Data were analyzed for 51,900 women aged 18-29 who lived in Mecklenburg County and had at least 1 primary care visit between 2014 and 2016. Contraceptive orders were identified by service and procedure codes and grouped into long-acting reversible contraceptives (LARC) and non-LARC categories. Adjusted multinomial logistic regression models were used to assess the association between receipt of contraceptives and insurance status.RESULTS Compared to non-Hispanic White women with commercial insurance, non-Hispanic Black (OR = 1.25; 95% CI, 1.13-1.38) and Hispanic (OR = 2.25; 95% CI, 1.93-2.61) women with Medicaid had higher odds of receiving LARC. Similar variations by insurance and race/ethnicity were observed for the non-LARC group.LIMITATIONS Data were limited to a single health care system and did not capture contraceptive orders by unaffiliated providers. Analyses used the most frequent payor and did not account for changes in insurance status.CONCLUSION Findings indicate an important role of race/ethnicity and insurance coverage in contraceptive care. Higher receipt of LARC among Black and Hispanic women also suggests that implicit biases may influence contraception counseling and promotion practices. Future study is warranted to further delineate these relationships.

Associations Among Food Security, Diet Quality, and Dietary Intake During Pregnancy in a Predominantly African American Group of Women from North Carolina.

BACKGROUND: Low food security during pregnancy can negatively affect women's physical and mental health. Although many women make a greater effort to eat a healthy diet during pregnancy, the influence of low food security during pregnancy on maternal diet is not well understood. OBJECTIVE: This study aimed to assess the association between adult food security and maternal diet during pregnancy in a sample from North Carolina. DESIGN: This was a cross-sectional, secondary data analysis of food security (marginal, low, and very low vs high) and maternal diet during pregnancy. PARTICIPANTS AND SETTING: This study included 468 predominantly Black/African American women during pregnancy from the Nurture cohort, enrolled through prenatal clinics in central North Carolina between 2013 and 2016. MAIN OUTCOME MEASURE: Diet quality was assessed using the Alternate Healthy Eating Index-Pregnancy and the Mediterranean Diet Score. Dietary intake from seven food groups included in the Alternate Healthy Eating Index-Pregnancy and/or Mediterranean Diet Score was assessed as well. STATISTICAL ANALYSIS PERFORMED: Multiple linear regression models were used to examine the association between food security and diet quality and dietary intake during pregnancy, adjusting for race/ethnicity; participation in the Special Supplemental Nutrition Program for Women, Infants, and Children; education; prepregnancy body mass index; age; parity; and mean daily energy intake. RESULTS: In this study, there was no association between maternal food security status and diet quality during pregnancy. However, researchers observed an association between low and marginal food security and greater intake of red and processed meats (marginal: ß = 2.20 [P = 0.03]; low: ß = 2.28 [P = 0.04]), as well as an association between very low food security and decreased vegetable consumption (ß = -.43; P = 0.03). CONCLUSIONS: Very low food security was associated with reduced vegetable intake. In addition, low and marginal food security were associated with greater red and processed meat intake. Future research should focus on nationally representative populations and include longitudinal assessments to allow for the study of the influence of food security on health during pregnancy.

The Care of American Indian Children in North Carolina: Protecting Our Future and Our Heritage.

Native American children face many different challenges when it comes to their health. They are predisposed to an increased rate of diseases such as diabetes and asthma. Traditional medicine is still practiced in many Native communities. As health care professionals, we must be culturally sensitive to their needs. One way to improve Native health care is to increase the number of Native physicians practicing in their communities.

Genetic diversity and population structure of Alternaria species from tomato and potato in North Carolina and Wisconsin.

Early blight (EB) caused by Alternaria linariae or Alternaria solani and leaf blight (LB) caused by A. alternata are economically important diseases of tomato and potato. Little is known about the genetic diversity and population structure of these pathogens in the United States. A total of 214 isolates of A. alternata (n = 61), A. linariae (n = 96), and A. solani (n = 57) were collected from tomato and potato in North Carolina and Wisconsin and grouped into populations based on geographic locations and tomato varieties. We exploited 220 single nucleotide polymorphisms derived from DNA sequences of 10 microsatellite loci to analyse the population genetic structure between species and between populations within species and infer the mode of reproduction. High genetic variation and genotypic diversity were observed in all the populations analysed. The null hypothesis of the clonality test based on the index of association [Formula: see text] was rejected, and equal frequencies of mating types under random mating were detected in some studied populations of Alternaria spp., suggesting that recombination can play an important role in the evolution of these pathogens. Most genetic differences were found between species, and the results showed three distinct genetic clusters corresponding to the three Alternaria spp. We found no evidence for clustering of geographic location populations or tomato variety populations. Analyses of molecular variance revealed high (> 85%) genetic variation within individuals in a population, confirming a lack of population subdivision within species. Alternaria linariae populations harboured more multilocus genotypes (MLGs) than A. alternata and A. solani populations and shared the same MLG between populations within a species, which was suggestive of gene flow and population expansion. Although both A. linariae and A. solani can cause EB on tomatoes and potatoes, these two species are genetically differentiated. Our results provide new insights into the evolution and structure of Alternaria spp. and can lead to new directions in optimizing management strategies to mitigate the impact of these pathogens on tomato and potato production in North Carolina and Wisconsin.

St. Luke's International University and University of North Carolina at Chapel Hill collaboration project to develop the first DNP program in Japan.

We report an international collaborative project to develop the first Doctor of Nursing Practice (DNP) program in Japan. We described the development and implementation of the first DNP program at the St. Luke's International University in Tokyo and the collaboration with the University of North Carolina at Chapel Hill in the United States. Faculty perceptions in both parties gradually evolved from the traditional perspective of international collaboration to the transitional and the beginning of the holistic partnership perspectives. The collaboration resulted in an innovative DNP program that directly addressed the gap between nursing education programs and Japan's clinical needs. The collaborative project cultivated a holistic international partnership. Rather than reporting a manual for international collaboration, we present our reflections and outcomes as narratives that others could use to achieve a holistic global partnership.

Ambulatory care, insurance, and avoidable emergency department utilization in North Carolina.

OBJECTIVE: To examine whether and how avoidable emergency department (ED) utilization is associated with ambulatory or primary care (APC) utilization, insurance, and interaction effects. DESIGN AND SAMPLE: A cross-sectional analysis of electronic health records from 70,870 adults residing in Mecklenburg County, North Carolina, who visited an ED within a large integrated healthcare system in 2017. METHODS: APC utilization was measured as total visits, categorized as: 0, 1, and > 1. Insurance was defined as the method of payment for the ED visit as: Medicaid, Medicare, private, or uninsured. Avoidable ED utilization was quantified as a score (aED), calculated as the sum of New York University Algorithm probabilities multiplied by 100. Quantile regression models were used to predict the 25th, 50th, 75th, 95th, and 99th percentiles of avoidable ED scores with APC visits and insurance as predictors (Model 1) and with an interaction term (Model 2). RESULTS: Having >1 APC visit was negatively associated with aED at the lower percentiles and positively associated at higher percentiles. A higher aED was associated with having Medicaid insurance and a lower aED was associated with having private insurance, compared to being uninsured. In stratified models, having >1 APC visit was negatively associated with aED at the 25th percentile for the uninsured and privately insured, but positively associated with aED at higher percentiles among the uninsured, Medicaid-insured, and privately insured. CONCLUSIONS: The association between APC utilization and avoidable ED utilization varied based on segments of the distribution of ED score and differed significantly by insurance type.

Exploring nutrient and light limitation of algal production in a shallow turbid reservoir.

Harmful algal blooms are increasingly recognized as a threat to the integrity of freshwater reservoirs, which serve as water supplies, wildlife habitats, and recreational attractions. While algal growth and accumulation is controlled by many environmental factors, the relative importance of these factors is unclear, particularly for turbid eutrophic systems. Here we develop and compare two models that test the relative importance of vertical mixing, light, and nutrients for explaining chlorophyll-a variability in shallow (2-3 m) embayments of a eutrophic reservoir, Jordan Lake, North Carolina. One is a multiple linear regression (statistical) model and the other is a process-based (mechanistic) model. Both models are calibrated using a 15-year data record of chlorophyll-a concentration (2003-2018) for the seasonal period of cyanobacteria dominance (June-October). The mechanistic model includes a novel representation of vertical mixing and is calibrated in a Bayesian framework, which allows for data-driven inference of important process rates. Both models show that chlorophyll-a concentration is much more responsive to nutrient variability than mixing, light, or temperature. While both models explain approximately 60% of the variability in chlorophyll-a, the mechanistic model is more robust in cross-validation and provides a more comprehensive assessment of algal drivers. Overall, these models indicate that nutrient reductions, rather than changes in mixing or background turbidity, are critical to controlling cyanobacteria in a shallow eutrophic freshwater system.

Prevalence and Predictors of Moral Injury Symptoms in Health Care Professionals.

ABSTRACT: This study examined the prevalence and predictors of moral injury (MI) symptoms in 181 health care professionals (HPs; 71% physicians) recruited from Duke University Health Systems in Durham, NC. Participants completed an online questionnaire between November 13, 2019, and March 12, 2020. Sociodemographic, clinical, religious, depression/anxiety, and clinician burnout were examined as predictors of MI symptoms, assessed by the Moral Injury Symptoms Scale-Health Professional, in bivariate and stepwise multivariate analyses. The prevalence of MI symptoms causing at least moderate functional impairment was 23.9%. Younger age, shorter time in practice, committing medical errors, greater depressive or anxiety symptoms, greater clinician burnout, no religious affiliation, and lower religiosity correlated with MI symptoms in bivariate analyses. Independent predictors in multivariate analyses were the commission of medical errors in the past month, lower religiosity, and, especially, severity of clinician burnout. Functionally limiting MI symptoms are present in a significant proportion of HPs and are associated with medical errors and clinician burnout.

Outreach to new mothers through direct mail and email: recruitment in the Early Check research study.

Meeting recruitment targets for clinical trials and health research studies is a notable challenge. Unsuccessful efforts to recruit participants from traditionally underserved populations can limit who benefits from scientific discovery, thus perpetuating inequities in health outcomes and access to care. In this study, we evaluated direct mail and email outreach campaigns designed to recruit women who gave birth in North Carolina for a statewide research study offering expanded newborn screening for a panel of rare health conditions. Of the 54,887 women who gave birth in North Carolina from September 28, 2018, through March 19, 2019, and were eligible to be included on the study's contact lists, we had access to a mailing address for 97.9% and an email address for 6.3%. Rural women were less likely to have sufficient contact information available, but this amounted to less than a one percentage point difference by urbanicity. Native American women were less likely to have an email address on record; however, we did not find a similar disparity when recruitment using direct-mail letters and postcards was concerned. Although we sent letters and emails in roughly equal proportion by urbanicity and race/ethnicity, we found significant differences in enrollment across demographic subgroups. Controlling for race/ethnicity and urbanicity, we found that direct-mail letters and emails were effective recruitment methods. The enrollment rate among women who were sent a recruitment letter was 4.1%, and this rate increased to 5.0% among women who were also sent an email invitation. Study Highlights WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC? Under-representation by traditionally underserved populations in clinical trials and health research is a challenge that may in part reflect inequitable opportunities to participate. WHAT QUESTION DID THIS STUDY ADDRESS? Are direct-mail and email outreach strategies effective for reaching and recruiting women from traditionally underserved and rural populations to participate in large-scale, population-based research? WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE? Despite sending recruitment letters and email invitations in roughly equal proportion by urbanicity and race/ethnicity, women living in rural areas were less likely to enroll (2.8%) than women from urban areas (4.2%). Additionally, enrollment rates decreased as the probability that women were members of a racial or ethnic minority group increased. HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE? Results from this study might encourage researchers to take a holistic and participant-centered view of barriers to study enrollment that may disproportionately affect underserved communities, including differences in willingness to participate, trust, and access to resources needed for uptake.