Preexisting Diabetes and Breast Cancer Treatment Among Low-Income Women.

IMPORTANCE: Diabetes is associated with poorer prognosis of patients with breast cancer. The association between diabetes and adjuvant therapies for breast cancer remains uncertain. OBJECTIVE: To comprehensively examine the associations of preexisting diabetes with radiotherapy, chemotherapy, and endocrine therapy in low-income women with breast cancer. DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study included women younger than 65 years diagnosed with nonmetastatic breast cancer from 2007 through 2015, followed up through 2016, continuously enrolled in Medicaid, and identified from the linked Missouri Cancer Registry and Medicaid claims data set. Data were analyzed from January 2022 to October 2023. EXPOSURE: Preexisting diabetes. MAIN OUTCOMES AND MEASURES: Logistic regression was used to estimate odds ratios (ORs) of utilization (yes/no), timely initiation (≤90 days postsurgery), and completion of radiotherapy and chemotherapy, as well as adherence (medication possession ratio ≥80%) and persistence (<90-consecutive day gap) of endocrine therapy in the first year of treatment for women with diabetes compared with women without diabetes. Analyses were adjusted for sociodemographic and tumor factors. RESULTS: Among 3704 women undergoing definitive surgery, the mean (SD) age was 51.4 (8.6) years, 1038 (28.1%) were non-Hispanic Black, 2598 (70.1%) were non-Hispanic White, 765 (20.7%) had a diabetes history, 2369 (64.0%) received radiotherapy, 2237 (60.4%) had chemotherapy, and 2505 (67.6%) took endocrine therapy. Compared with women without diabetes, women with diabetes were less likely to utilize radiotherapy (OR, 0.67; 95% CI, 0.53-0.86), receive chemotherapy (OR, 0.67; 95% CI, 0.48-0.93), complete chemotherapy (OR, 0.71; 95% CI, 0.50-0.99), and be adherent to endocrine therapy (OR, 0.71; 95% CI, 0.56-0.91). There were no significant associations of diabetes with utilization (OR, 0.95; 95% CI, 0.71-1.28) and persistence (OR, 1.09; 95% CI, 0.88-1.36) of endocrine therapy, timely initiation of radiotherapy (OR, 1.09; 95% CI, 0.86-1.38) and chemotherapy (OR, 1.09; 95% CI, 0.77-1.55), or completion of radiotherapy (OR, 1.25; 95% CI, 0.91-1.71). CONCLUSIONS AND RELEVANCE: In this cohort study, preexisting diabetes was associated with subpar adjuvant therapies for breast cancer among low-income women. Improving diabetes management during cancer treatment is particularly important for low-income women with breast cancer who may have been disproportionately affected by diabetes and are likely to experience disparities in cancer treatment and outcomes.

Emergency department visits for dog bite injuries in Missouri municipalities with and without breed-specific legislation: a propensity score-matched analysis.

Breed-Specific Legislation is a type of law that bans or restricts ownership of specific dog breeds. Some local governments - including over seventy municipalities in the state of Missouri - have enacted Breed-Specific Legislation to prevent injuries from dog bites. Several studies from the peer-reviewed literature have found that aggressive behavior is not associated with any particular dog breeds and, since 2018, at least a dozen municipalities in Missouri have repealed these laws. To evaluate the impact of Breed-Specific Legislation on public safety, the 2010-2015 rates of emergency department visits for dog bite-related injuries in Missouri municipalities with and without Breed-Specific Legislation were compared. Propensity-score matched negative binomial regression models were used to assess the effect of breed restrictions on injury rates while balancing the samples on population characteristics and estimates of dog ownership. After matching the sample on population, housing and dog ownership estimates, no association was found between emergency department visits for dog bite injuries and whether the municipality enacted Breed-Specific Legislation. However, the incidence rate ratio of emergency room visits for dog bite-related injuries increased by 13.8% for every 1% increase in the percentage of males aged 5 to 9 in the population (p < 0.01). This study has found breed discriminatory laws have not reduced the risk of emergency department visits for injury from dog bites in Missouri. There appears to be no greater risk to public safety as local governments move to repeal existing breed bans.

Modeling county level COVID-19 transmission in the greater St. Louis area: Challenges of uncertainty and identifiability when fitting mechanistic models to time-varying processes.

We use a compartmental model with a time-varying transmission parameter to describe county level COVID-19 transmission in the greater St. Louis area of Missouri and investigate the challenges in fitting such a model to time-varying processes. We fit this model to synthetic and real confirmed case and hospital discharge data from May to December 2020 and calculate uncertainties in the resulting parameter estimates. We also explore non-identifiability within the estimated parameter set. We find that the death rate of infectious non-hospitalized individuals, the testing parameter and the initial number of exposed individuals are not identifiable based on an investigation of correlation coefficients between pairs of parameter estimates. We also explore how this non-identifiability ties back into uncertainties in the estimated parameters and find that it inflates uncertainty in the estimates of our time-varying transmission parameter. However, we do find that R0 is not highly affected by non-identifiability of its constituent components and the uncertainties associated with the quantity are smaller than those of the estimated parameters. Parameter values estimated from data will always be associated with some uncertainty and our work highlights the importance of conducting these analyses when fitting such models to real data. Exploring identifiability and uncertainty is crucial in revealing how much we can trust the parameter estimates.

Geographic disparities and predictors of COVID-19 vaccination in Missouri: a retrospective ecological study.

Background: Limited information is available on geographic disparities of COVID-19 vaccination in Missouri and yet this information is essential for guiding efforts to improve vaccination coverage. Therefore, the objectives of this study were to (a) investigate geographic disparities in the proportion of the population vaccinated against COVID-19 in Missouri and (b) identify socioeconomic and demographic predictors of the identified disparities. Methods: The COVID-19 vaccination data for time period January 1 to December 31, 2021 were obtained from the Missouri Department of Health. County-level data on socioeconomic and demographic factors were downloaded from the 2020 American Community Survey. Proportions of county population vaccinated against COVID-19 were computed and displayed on choropleth maps. Global ordinary least square regression model and local geographically weighted regression model were used to identify predictors of proportions of COVID-19 vaccinated population. Results: Counties located in eastern Missouri tended to have high proportions of COVID-19 vaccinated population while low proportions were observed in the southernmost part of the state. Counties with low proportions of population vaccinated against COVID-19 tended to have high percentages of Hispanic/Latino population (p = 0.046), individuals living below the poverty level (p = 0.049), and uninsured (p = 0.015) populations. The strength of association between proportion of COVID-19 vaccinated population and percentage of Hispanic/Latino population varied by geographic location. Conclusion: The study findings confirm geographic disparities of proportions of COVID-19 vaccinated population in Missouri. Study findings are useful for guiding programs geared at improving vaccination coverage and uptake by targeting resources to areas with low proportions of vaccinated individuals.

Assessment of census-tract level socioeconomic position as a modifier of the relationship between short-term PM2.5 exposure and cardiovascular emergency department visits in Missouri.

INTRODUCTION: Ambient particulate matter ≤ 2.5 µm in aerodynamic diameter (PM2.5) exposure elevates the risk for cardiovascular disease morbidity (CVDM). The aim of this study is to characterise which area-level measures of socioeconomic position (SEP) modify the relationship between PM2.5 exposure and CVDM in Missouri at the census-tract (CT) level. METHODS: We use individual level Missouri emergency department (ED) admissions data (n=3 284 956), modelled PM2.5 data, and yearly CT data from 2012 to 2016 to conduct a two-stage analysis. Stage one uses a case-crossover approach with conditional logistic regression to establish the baseline risk of ED visits associated with IQR changes in PM2.5. In the second stage, we use multivariate metaregression to examine how CT-level SEP modifies the relationship between ambient PM2.5 exposure and CVDM. RESULTS: We find that overall, ambient PM2.5 exposure is associated with increased risk for CVDM. We test effect modification in statewide and urban CTs, and in the warm season only. Effect modification results suggest that among SEP measures, poverty is most consistently associated with increased risk for CVDM. For example, across Missouri, the highest poverty CTs are at an elevated risk for CVDM (OR=1.010 (95% CI 1.007 to 1.014)) compared with the lowest poverty CTs (OR=1.004 (95% CI 1.000 to 1.008)). Other SEP modifiers generally display an inconsistent or null effect. CONCLUSION: Overall, we find some evidence that area-level SEP modifies the relationship between ambient PM2.5 exposure and CVDM, and suggest that the relationship between air-pollution, area-level SEP and CVDM may be sensitive to spatial scale.

Opioid Use Disorder in Missouri: An Evidence-Based, Public Health-Oriented Approach.

Opioid use disorder (OUD) represents a growing public health crisis in Missouri and nationwide. Reversing the trend of rising OUD-associated morbidity and mortality will require implementing evidence-based approaches grounded in public health principles. Key evidence-based interventions include medications for opioid use disorder, naloxone distribution, overdose education, and syringe services programs. The increasing presence of fentanyl and xylazine in the drug supply represent new challenges to the OUD crisis in Missouri. Optimal implementation of evidence-based interventions will require action at the individual physician, community, and state policy level.

Cardiovascular disease and maternal mortality: perceptions in a Midwest birthing population.

BACKGROUND: Missouri has one of the highest rates of maternal mortality in the United States. To date, there are currently no studies describing birthing peoples' knowledge or perceptions of contributing causes of maternal mortality. An improved understanding of population-specific knowledge can help to define how best to design targeted interventions to reduce disease-specific causes of maternal mortality. OBJECTIVE: This study aimed to examine the knowledge and understanding of maternal mortality in a Missouri birthing population. STUDY DESIGN: A 46-question, cross-sectional survey to assess the familiarity with local maternal mortality rates, groups affected, and causality was developed by the Missouri Perinatal Quality Collaborative and the Maternal-Child Learning and Action Network and emailed to a random sample of birthing people across Missouri. Those who identified as someone with birthing potential with a Missouri zip code and who were ≥18 years of age were eligible for inclusion. Unadjusted descriptive statistics were generated and stratified by age, race, and region. RESULTS: Among 2196 surveys sent, 1738 people completed the survey. Of those who responded, 78.2% were aware of the risk of pregnancy-related death with 14.7% reporting that they intimately knew someone who died. When asked if a certain group is affected disproportionately more, 66.4% responded affirmatively. Black (58.7%), uninsured (61.8%), poor (71.0%), those with substance abuse disorders (57.4%), and Native American (28.8%) birthing people were identified as groups that were perceived as suffering higher rates of maternal death. When polled on etiology, severe bleeding (56.9%) was believed to be the leading cause of death, and the second stage of labor was thought to be the period of highest risk (42.3%). Beliefs about the timing of death differed by age (P=.042) but not race (P=.81) or region (P=.191). CONCLUSION: Missouri birthing people are cognizant of the social factors associated with increased maternal mortality but are unaware of the leading causes of death, namely cardiovascular disease and mental health conditions. Future Perinatal Quality Collaborative work should focus on campaigns that raise public awareness about cardiovascular disease and mental health-related birthing risks and the importance of monitoring early warning signs after delivery.

The Relationship of Vaccine Uptake and COVID-19 Infections Among Nursing Home Staff and Residents in Missouri: A Measure of Risk by Community Mobility.

BACKGROUND: As the COVID-19 pandemic progressed across the United States, older adults living in nursing home (NH) facilities were disproportionately affected because of living in communal spaces with close proximity to others, age-related medical conditions, and constant contact with staff who may support multiple clients and facilities. While these populations are particularly at risk, there has been limited research focused on the management of the potential vectors of COVID-19 infection. METHODS: Data from the Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting system assessing weekly observations of COVID-19 case counts among NH residents and COVID-19 vaccination rates among NH staff and residents in the states of Missouri and Illinois (n = 877) from May 24, 2021, to August 28, 2021, were used. This ecological study, using results from the CMS COVID-19 reporting system, local COVID-19 rates, and NH-level demographic characteristics, conducted a zero inflation mode to determine the association between NH staff vaccine uptake and COVID-19 cases among NH residents. RESULTS: Among the total 11 195 weekly observations within the NH facilities, zero cases of COVID-19 were reported during 10 683 (95%) of those weeks, supporting the use of a zero-inflated model. Results show that staff vaccination rates were significantly associated with a decrease in COVID-19 mortality. This study identified that for every percentage increase in staff vaccine coverage, the rate of COVID-19 among residents decreased by 2%. DISCUSSION: These findings suggest that NH staff vaccination rates are significantly associated with the rate of COVID-19 outbreaks among NH residents. Community median income was associated with an increased likelihood of infection. Future research that explores associations with employment benefits and staff mobility, particularly in vulnerable populations, should be implemented in future vaccination strategic planning.

Ranavirus (Frog Virus 3) Infection in Free-Living Three-Toed Box Turtles (Terrapene mexicana triunguis) in Missouri, USA.

Frog virus 3 (FV3) and related ranaviruses are emerging infectious disease threats to ectothermic vertebrate species globally. Although the impact of these viruses on amphibian health is relatively well studied, less is understood about their effects on reptile health. We report two cases of FV3 infection, 11 mo apart, in three-toed box turtles (Terrapene mexicana triunguis) from a wildlife rehabilitation center. Case 1 had upper respiratory signs upon intake but had no clinical signs at the time of euthanasia 1 mo later. Case 2 presented for vehicular trauma, had ulcerative pharyngitis and glossitis, and died overnight. In case 1, we detected FV3 nucleic acid with qPCR in oral swabs, kidney, liver, spleen, and tongue. In case 2, we detected FV3 in an oral swab, an oral plaque, heart, kidney, lung, liver, spleen, and tongue. We also detected FV3 nucleic acid with in situ hybridization for case 2. For both cases, FV3 was isolated in cell culture and identified with DNA sequencing. Histopathologic examination of postmortem tissue from case 1 was unremarkable, whereas acute hemorrhagic pneumonia and splenic necrosis were noted in case 2. The difference in clinical signs between the two cases may have been due to differences in the temporal course of FV3 disease at the time of necropsy. Failure to detect this infection previously in Missouri reptiles may be due to lack of surveillance, although cases may also represent a novel spillover to box turtles in Missouri. Our findings reiterate previous suggestions that the range of FV3 infection may be greater than previously documented and that infection may occur in host species yet to be tested.

Continued selection on cryptic SARS-CoV-2 observed in Missouri wastewater.

Deep sequencing of wastewater to detect SARS-CoV-2 has been used during the COVID-19 pandemic to monitor viral variants as they appear and circulate in communities. SARS-CoV-2 lineages of an unknown source that have not been detected in clinical samples, referred to as cryptic lineages, are sometimes repeatedly detected from specific locations. We have continued to detect one such lineage previously seen in a Missouri site. This cryptic lineage has continued to evolve, indicating continued selective pressure similar to that observed in Omicron lineages.

Firearm injuries in Missouri.

Firearm deaths continue to be a major public health problem, but the number of non-fatal firearm injuries and the characteristics of patients and injuries is not well known. The American College of Surgeons Committee on Trauma, with support from the National Collaborative on Gun Violence Research, leveraged an existing data system to capture lethal and non-lethal injuries, including patients treated and discharged from the emergency department and collect additional data on firearm injuries that present to trauma centers. In 2020, Missouri had the 4th highest firearm mortality rate in the country at 23.75/100,000 population compared to 13.58/100,000 for the US overall. We examined the characteristics of patients from Missouri with firearm injuries in this cross-sectional study. Of the overall 17,395 patients, 1,336 (7.7%) were treated at one of the 11 participating trauma centers in Missouri during the 12-month study period. Patients were mostly male and much more likely to be Black and uninsured than residents in the state as a whole. Nearly three-fourths of the injuries were due to assaults, and overall 7.7% died. Few patients received post-discharge services.

Supporting the Resilience and Mental Health of Missouri Healthcare Workers Through COVID-19 and Beyond: the Gateway2Wellness Program.

The COVID-19 pandemic is over, but US healthcare workers (HCWs) continue to report high levels of work-related exhaustion and burnout but are unlikely to seek help. Digital tools offer a scalable solution. Between February and June 2022, we surveyed Missouri hospital administrators to assess HCW mental health and identify related evidence-based or evidence-informed resources. Simultaneously, we conducted a digital survey and focus groups with HCWs and leaders at Washington University School of Medicine (WUSOM) in St. Louis to evaluate HCW mental health needs, and preferences for digital support. Here, we describe the results and subsequent development of the Gateway to Wellness (G2W) program, a digital precision engagement platform that links HCWs to the most effective tailored resources for their mental health needs.

Associations between rurality and regional differences in sociodemographic factors and the 1918-20 influenza and 2020-21 COVID-19 pandemics in Missouri counties: An ecological study.

This study compares pandemic experiences of Missouri's 115 counties based on rurality and sociodemographic characteristics during the 1918-20 influenza and 2020-21 COVID-19 pandemics. The state's counties and overall population distribution have remained relatively stable over the last century, which enables identification of long-lasting pandemic attributes. Sociodemographic data available at the county level for both time periods were taken from U.S. census data and used to create clusters of similar counties. Counties were also grouped by rural status (RSU), including fully (100%) rural, semirural (1-49% living in urban areas), and urban (>50% of the population living in urban areas). Deaths from 1918 through 1920 were collated from the Missouri Digital Heritage database and COVID-19 cases and deaths were downloaded from the Missouri COVID-19 dashboard. Results from sociodemographic analyses indicate that, during both time periods, average farm value, proportion White, and literacy were the most important determinants of sociodemographic clusters. Furthermore, the Urban/Central and Southeastern regions experienced higher mortality during both pandemics than did the North and South. Analyses comparing county groups by rurality indicated that throughout the 1918-20 influenza pandemic, urban counties had the highest and rural had the lowest mortality rates. Early in the 2020-21 COVID-19 pandemic, urban counties saw the most extensive epidemic spread and highest mortality, but as the epidemic progressed, cumulative mortality became highest in semirural counties. Additional results highlight the greater effects both pandemics had on county groups with lower rates of education and a lower proportion of Whites in the population. This was especially true for the far southeastern counties of Missouri ("the Bootheel") during the COVID-19 pandemic. These results indicate that rural-urban and socioeconomic differences in health outcomes are long-standing problems that continue to be of significant importance, even though the overall quality of health care is substantially better in the 21st century.

Understanding disruptions in cancer care to reduce increased cancer burden.

Background: This study seeks to understand how and for whom COVID-19 disrupted cancer care to understand the potential for cancer health disparities across the cancer prevention and control continuum. Methods: In this cross-sectional study, participants age 30+residing in an 82-county region in Missouri and Illinois completed an online survey from June-August 2020. Descriptive statistics were calculated for all variables separately and by care disruption status. Logistic regression modeling was conducted to determine the correlates of care disruption. Results: Participants (N=680) reported 21% to 57% of cancer screening or treatment appointments were canceled/postponed from March 2020 through the end of 2020. Approximately 34% of residents stated they would need to know if their doctor's office is taking the appropriate COVID-related safety precautions to return to care. Higher education (OR = 1.26, 95% CI:1.11-1.43), identifying as female (OR = 1.60, 95% CI:1.12-2.30), experiencing more discrimination in healthcare settings (OR = 1.40, 95% CI:1.13-1.72), and having scheduled a telehealth appointment (OR = 1.51, 95% CI:1.07-2.15) were associated with higher odds of care disruption. Factors associated with care disruption were not consistent across races. Higher odds of care disruption for White residents were associated with higher education, female identity, older age, and having scheduled a telehealth appointment, while higher odds of care disruption for Black residents were associated only with higher education. Conclusions: This study provides an understanding of the factors associated with cancer care disruption and what patients need to return to care. Results may inform outreach and engagement strategies to reduce delayed cancer screenings and encourage returning to cancer care. Funding: This study was supported by the National Cancer Institute's Administrative Supplements for P30 Cancer Center Support Grants (P30CA091842-18S2 and P30CA091842-19S4). Kia L. Davis, Lisa Klesges, Sarah Humble, and Bettina Drake were supported by the National Cancer Institute's P50CA244431 and Kia L. Davis was also supported by the Breast Cancer Research Foundation. Callie Walsh-Bailey was supported by NIMHD T37 MD014218. The content does not necessarily represent the official view of these funding agencies and is solely the responsibility of the authors.

Spatial Epidemiologic Analysis and Risk Factors for Nontuberculous Mycobacteria Infections, Missouri, USA, 2008-2019.

Nontuberculous mycobacteria (NTM) infections are caused by environmental exposure. We describe spatial distribution of NTM infections and associations with sociodemographic factors and flooding in Missouri, USA. Our retrospective analysis of mycobacterial cultures reported to the Missouri Department of Health and Social Services surveillance system during January 1, 2008-December 31, 2019, detected geographic clusters of infection. Multilevel Poisson regression quantified small-area geographic variations and identified characteristics associated with risk for infection. Median county-level NTM infection rate was 66.33 (interquartile range 51-91)/100,000 persons. Risk of clustering was significantly higher in rural areas (rate ratio 2.82, 95% CI 1.90-4.19) and in counties with >5 floodings per year versus no flooding (rate ratio 1.38, 95% CI 1.26-1.52). Higher risk for NTM infection was associated with older age, rurality, and more flooding. Clinicians and public health professionals should be aware of increased risk for NTM infections, especially in similar environments.

Examining a Hypothesized Causal Chain for the Effects of the 2007 Repeal of the Permit-to-Purchase Licensing Law in Missouri: Homicide Guns Recovered in State and within a Year of Purchase.

Firearm-related deaths are a leading cause of death in the USA. Webster et al. (2014) found an association between Missouri's repeal of a permit-to-purchase handgun licensing law and an increase in firearm-related homicides. The evidence for causality of this association would be strengthened by finding that the increase occurred through the hypothesized mechanism of increasing the ease with which those with violent intent could obtain guns. This study examines two measures: (1) proportion of guns recovered and purchased in-state and (2) time between firearm purchase and recovery by police following criminal use. The repeal was associated from 2008 to 2019 with a 0.05 increase in the proportion own-state gun trace (p < 0.0001, 95% confidence interval: 0.08,0.13) and a 0.10 increase in the proportion of guns recovered prior to 1 year after purchase (p = 0.01, 95% confidence interval: 1.20, 1.90). Our study provides supportive evidence for the repeal increasing firearm-related homicides.

Examining Increasing Racial Inequities in Opioid Overdose Deaths: a Spatiotemporal Analysis of Black and White Decedents in St. Louis, Missouri, 2011-2021.

The third wave of the opioid overdose crisis-defined by the proliferation of illicit fentanyl and its analogs-has not only led to record numbers of overdose deaths but also to unprecedented racial inequities in overdose deaths impacting Black Americans. Despite this racialized shift in opioid availability, little research has examined how the spatial epidemiology of opioid overdose death has also shifted. The current study examines the differential geography of OOD by race and time (i.e., pre-fentanyl versus fentanyl era) in St. Louis, Missouri. Data included decedent records from the local medical examiners suspected to involve opioid overdose (N = 4420). Analyses included calculating spatial descriptive analyses and conducting hotspot analyses (i.e., Gettis-Ord Gi*) stratified by race (Black versus White) and time (2011-2015 versus 2016-2021). Results indicated that fentanyl era overdose deaths were more densely clustered than pre-fentanyl era deaths, particularly those among Black decedents. Although hotspots of overdose death were racially distinct pre-fentanyl, they substantially overlapped in the fentanyl era, with both Black and White deaths clustering in predominantly Black neighborhoods. Racial differences were observed in substances involved in cause of death and other overdose characteristics. The third wave of the opioid crisis appears to involve a geographic shift from areas where White individuals live to those where Black individuals live. Findings demonstrate racial differences in the epidemiology of overdose deaths that point to built environment determinants for future examination. Policy interventions targeting high-deprivation communities are needed to reduce the burden of opioid overdose on Black communities.