Assessment of the 2021 AASLD Practice Guidance for Albumin Infusion in Elective Therapeutic Paracentesis: A Regression Discontinuity Design.

INTRODUCTION: The 2021 American Association for the Study of Liver Disease (AASLD) Practice Guidance recommends albumin infusion when removing ≥5 L of ascites to prevent post-paracentesis circulatory dysfunction. However, the optimal criteria and scenarios for initiating albumin infusion subsequent to therapeutic paracentesis (TP) have been subject to limited scientific inquiry. METHODS: We conducted a retrospective cohort study at a US academic healthcare center. Participants received elective, outpatient TP between July 2019 and December 2022. Patients with spontaneous bacterial peritonitis, post-TP clinical adjustments, and/or hospitalization were excluded. The institution strictly followed the AASLD Guidance. We used a sharp regression discontinuity (RD) design to estimate the effect of albumin infusion at the AASLD Guidance-recommended cutoff of 5 L on serum creatinine and sodium trajectory after TP. RESULTS: Over the study period, 1,457 elective TPs were performed on 235 unique patients. Albumin infusion at the threshold of 5 L of ascites removal reduced serum creatinine levels by 0.046 mg/dL/d (95% confidence interval 0.003-0.116, P = 0.037) and increased serum sodium levels by 0.35 mEq/L/d (95% confidence interval 0.15-0.55, P = 0.001) compared with those who did not receive albumin infusion. The RD plots indicated worsened serum creatine/sodium levels after draining 3 L of fluid, approaching levels similar to or worse than with albumin infusion at 5 L or more. DISCUSSION: Our RD models supported the 2021 AASLD Guidance with robust estimation of causal effect sizes at the cutoff level of 5 L. Nevertheless, the findings also highlight the need to further evaluate the efficacy of albumin infusion in patients who undergo elective TP and have 3-5 L of ascites removed.

Eliminating Medicaid dental benefits and early-stage oral cancer diagnoses.

BACKGROUND: Despite the importance of regular dental visits for detecting oral cancer, millions of low-income adults lack access to dental services. In July 2009, California eliminated adult Medicaid dental benefits. We tested if this impacted oral cancer detection for Medicaid enrollees. METHODS: We analyzed Surveillance, Epidemiology, and End Results-Medicaid data, which contains verified Medicaid enrollment status, to estimate a difference-in-differences model. Our design compares the change in early-stage (Stages 0-II) diagnoses before and after dropping dental benefits in California with the change in early-stage diagnoses among eight states that did not change Medicaid dental benefits. Patients were grouped by oropharyngeal cancer (OPC) and non-OPC (oral cavity cancer), type, and the length of Medicaid enrollment. We also assessed if the effect of dropping dental benefits varied by the number of dentists per capita. RESULTS: Dropping Medicaid dental benefits was associated with a 6.5%-point decline in early-stage diagnoses of non-OPC (95% CI = -14.5, -3.2, p = 0.008). This represented a 20% relative reduction from baseline rates. The effect was highest among beneficiaries with 3 months of continuous Medicaid enrollment prior to diagnosis who resided in counties with more dentists per capita. Specifically, dropping dental coverage was associated with a 1.25%-point decline in the probability of early-stage non-OPC diagnoses for every additional dentist per 5000 population (p = 0.006). CONCLUSIONS: Eliminating Medicaid dental benefits negatively impacted early detection of cancers of the oral cavity. Continued volatility of Medicaid dental coverage and provider shortages may be further delaying oral cancer diagnoses. Alternative approaches are needed to prevent advanced stage OPC.

Revisiting the effects of state earned income tax credits on infant health: a quasi-experimental study using contiguous border counties approach.

BACKGROUND: To examine the effects of refundable state earned income tax credits (EITC) on infant health. METHODS: We use the restricted-access U.S. birth certificate data with county codes from 1989 to 2018. Birth outcomes include birth weight, low birth weight, gestational weeks, preterm birth, and the fetal growth rate. The analytical sample includes single mothers with high school education or less. Two specifications of two-way fixed effects models are employed. The first specification accounts for shared time trends across all states/counties. The second specification estimates effects based on EITC changes within contiguous counties across state borders which accounts for contemporaneous events specific to each contiguous county pair. Models are estimated pooling and stratifying by parity subgroups. RESULTS: Under the first specification, refundable state EITC is associated with improved birth outcomes. Pooling all parity, a 10%-point increase in refundable EITC is associated with an 8-gram increase in birth weight (95% CI: 2.9,14.6). The effect increases by parity. In contrast, the estimates from the second model are much smaller and statistically non-significant, both pooling and stratifying by parity. CONCLUSIONS: Comparing contiguous counties across state borders, there is no evidence that refundable state EITC affects birth outcomes. However, the estimates still do not rule out moderate to large benefits for third or higher born infants.

Children's oral health and oral health care use during the first 2 years of the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has been associated with declines in children's oral health and oral health care use in 2020. The authors examined the pandemic effects on these outcomes into 2021. METHODS: This cross-sectional study used data from the National Survey of Children's Health from 2017 through 2021. The authors compared parent's or caregiver's perceptions of the child's oral health and reported dental problems and dental visits across years, adjusting for child and household covariates and state of residence. The authors evaluated potential heterogeneity across demographic and socioeconomic subgroups. RESULTS: In 2021, parents and caregivers were still more likely to perceive children's oral health as poor (odds ratio [OR], 1.90; 95% CI, 1.28 to 2.82) and less likely to report very good or excellent oral health (OR, 0.83; 95% CI, 0.76 to 0.92) than in 2019, similar to differences between 2020 and 2019. Dental visits were also less likely in 2021 than 2019 (OR, 0.74; 95% CI, 0.66 to 0.83). These differences between 2021 and 2019 were not explained by prepandemic trends and were observed across a range of demographic and socioeconomic subgroups. CONCLUSIONS: Children's oral health as perceived by parents and caregivers and oral health care use were still worse in 2021 than before the pandemic both overall and across demographic and socioeconomic subgroups. PRACTICAL IMPLICATIONS: The persistent adverse effects of the COVID-19 pandemic on children's oral health as perceived by parents and caregivers and shown through dental visits highlight the need to improve oral health care access and use and to evaluate the long-term effects of the pandemic on children's oral health.

Changes in Children's Health Care Access and Utilization in the United States in the First 2 Years of the COVID-19 Pandemic.

OBJECTIVE: To compare children's access to and utilization of health care services in the United States during the first 2 years of the pandemic to prepandemic levels. METHODS: This cross-sectional study used data from the 2017 to 2021 National Survey of Children's Health. Access to care was measured by having a usual place for sick and preventive care, having a personal doctor or nurse, and unmet care needs. Utilization measures included preventive, mental health, specialist, and emergency department (ED) visits, and hospital admissions in the past 12months. Outcomes were reported by parents or other caregivers. Multivariate logistic regressions were employed adjusting for sociodemographic factors and state of residence. The study sample included 163,353 children aged 0 to 17years. RESULTS: Compared to 2019, there were declines in the probability of having a usual place for sick care in 2020 (-1.5 percentage-points) and a usual place for preventive care in 2021 (-2.1 percentage-points), and greater probability of unmet care needs in 2020 (+1.2 percentage-points) and 2021 (+0.8 percentage-points). The probability of having any preventive, specialist, and ED visits and hospitalizations remained lower in 2021 than 2019 (-7.5, 2.2, 5.4 and 0.9 percentage-points, respectively). These differences were not explained by prepandemic trends and were observed across a range of sociodemographic subgroups. CONCLUSIONS: Children's health care access and utilization declined noticeably over the first 2years of the pandemic. Evaluating these outcomes in subsequent years and addressing barriers to care continue to be critical to reduce unmet needs.

Association Between Gestational Age and Academic Achievement of Children Born at Term.

Importance: Differences in academic achievement by gestational age of children born at term, especially at 39 to 41 weeks, are not well understood. Objective: To examine differences in academic achievement among children born between 37 and 41 weeks' gestational age. Design, Setting, and Participants: This retrospective cohort study linked birth certificates of children born in Iowa from 1989 to 2009 with school test scores for grades 2 to 11 from 2017 to 2018. Statistical analysis was performed from January to March 2023. Exposures: Gestational age at 37, 38, 39, and 41 weeks vs 40 weeks from clinical or obstetric and calendar measures. Main Outcomes and Measures: Outcomes were scores in national percentile rankings (NPRs) on standardized school tests in math and reading. Covariates included demographic and prenatal risk factors. Results: The sample included 536 996 children (50.7% male children and 49.3% female children) with math scores (3 576 045 child-grade observations; 6.6%, 15.7%, 28.6%, 35.5%, and 13.7% born at 37, 38, 39, 40, and 41 weeks, respectively) and 537 078 children with reading scores (3 590 408 child-grade observations). Score differences for those born at 39 vs 40 weeks were -0.028 NPRs (95% CI, -0.18 to 0.12 NPRs) for math and 0.085 NPRs (95% CI, -0.067 to 0.24 NPRs) for reading using the clinical or obstetric measure and 0.03 NPRs (95% CI, -0.14 to 0.20 NPRs) for math and 0.13 NPRs (95% CI, -0.042 to 0.31 NPRs) for reading using the calendar measure. With the clinical or obstetric measure, score differences between those born at 41 and 40 weeks were 0.19 NPRs (95% CI, -0.0052 to 0.38 NPRs) for math and 0.098 NPRs (95% CI, -0.096 to 0.29 NPRs) for reading. With the calendar measure, score differences for those born at 41 weeks were -0.22 NPRs (95% CI, -0.43 to -0.013 NPRs) for math and -0.28 NPRs (95% CI, -0.49 to -0.074 NPRs) for reading. With the clinical or obstetric measure, score differences between those born at 37 and 38 weeks vs 40 weeks were -0.59 NPRs (95% CI, -0.84 to -0.33 NPRs) and -0.44 NPRs (95% CI, -0.62 to -0.26 NPRs), respectively, for math, and -0.066 NPRs (95% CI, -0.32 to 0.19 NPRs) and -0.19 NPRs (95% CI, -0.37 to 0.0038 NPRs), respectively, for reading. Conclusions and Relevance: This study suggests that there is no evidence of a difference in math and reading scores over grades 2 to 11 among children born between 39 and 40 weeks' gestation, and overall no evidence of better scores among those born at 41 weeks' gestation compared with 40 weeks' gestation. The results can further inform decisions on delivery timing at term birth by offering insights into long-term associations of delivery timing with cognitive development and school achievement.

Effects of state reinsurance programs on health insurance exchange premiums and insurer participation.

OBJECTIVE: The aim of the study was to estimate the effect of the state-based reinsurance programs through the section 1332 State Innovation Waivers on health insurance marketplace premiums and insurer participation. DATA SOURCE: 2015 to 2022 Robert Wood Johnson Foundation Health Insurance Exchange Compare Datasets. STUDY DESIGN: An event study difference-in-differences (DD) model separately for each year of implementation and a synthetic control method (SCM) are used to estimate year-by-year effects following program implementation. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Reinsurance programs were associated with a decline in premiums in the first year of implementation by 10%-13%, 5%-19%, and 11%-17% for bronze, silver, and gold plans (p < 0.05). There is a trend of sustained declines especially for states that implemented their programs in 2019 and 2020. The SCM analyses suggest some effect heterogeneity across states but also premium declines across most states. There is no evidence that reinsurance programs affected insurer participation. CONCLUSION: State-based reinsurance programs have the potential to improve the affordability of health insurance coverage. However, reinsurance programs do not appear to have had an effect on insurer participation, highlighting the need for policy makers to consider complementary strategies to encourage insurer participation.

Rare variants found in clinical gene panels illuminate the genetic and allelic architecture of orofacial clefting.

PURPOSE: Orofacial clefts (OFCs) are common birth defects including cleft lip, cleft lip and palate, and cleft palate. OFCs have heterogeneous etiologies, complicating clinical diagnostics because it is not always apparent if the cause is Mendelian, environmental, or multifactorial. Sequencing is not currently performed for isolated or sporadic OFCs; therefore, we estimated the diagnostic yield for 418 genes in 841 cases and 294 controls. METHODS: We evaluated 418 genes using genome sequencing and curated variants to assess their pathogenicity using American College of Medical Genetics criteria. RESULTS: 9.04% of cases and 1.02% of controls had "likely pathogenic" variants (P < .0001), which was almost exclusively driven by heterozygous variants in autosomal genes. Cleft palate (17.6%) and cleft lip and palate (9.09%) cases had the highest yield, whereas cleft lip cases had a 2.80% yield. Out of 39 genes with likely pathogenic variants, 9 genes, including CTNND1 and IRF6, accounted for more than half of the yield (4.64% of cases). Most variants (61.8%) were "variants of uncertain significance", occurring more frequently in cases (P = .004), but no individual gene showed a significant excess of variants of uncertain significance. CONCLUSION: These results underscore the etiological heterogeneity of OFCs and suggest sequencing could reduce the diagnostic gap in OFCs.

Rare variants found in multiplex families with orofacial clefts: Does expanding the phenotype make a difference?

Exome sequencing (ES) is now a relatively straightforward process to identify causal variants in Mendelian disorders. However, the same is not true for ES in families where the inheritance patterns are less clear, and a complex etiology is suspected. Orofacial clefts (OFCs) are highly heritable birth defects with both Mendelian and complex etiologies. The phenotypic spectrum of OFCs may include overt clefts and several subclinical phenotypes, such as discontinuities in the orbicularis oris muscle (OOM) in the upper lip, velopharyngeal insufficiency (VPI), microform clefts or bifid uvulas. We hypothesize that expanding the OFC phenotype to include these phenotypes can clarify inheritance patterns in multiplex families, making them appear more Mendelian. We performed exome sequencing to find rare, likely causal genetic variants in 31 multiplex OFC families, which included families with multiple individuals with OFCs and individuals with subclinical phenotypes. We identified likely causal variants in COL11A2, IRF6, SHROOM3, SMC3, TBX3, and TP63 in six families. Although we did not find clear evidence supporting the subclinical phenotype hypothesis, our findings support a role for rare variants in the etiology of OFCs.

Changes in birth outcomes and utilization of prenatal care during the COVID-19 pandemic in 2020: a secondary analysis of vital statistics in Colombia.

BACKGROUND: Birth outcomes could have been affected by the COVID-19 pandemic through changes in access to prenatal services and other pathways. The aim of this study was to examine the effects of the COVID-19 pandemic on fetal death, birth weight, gestational age, number of prenatal visits, and caesarean delivery in 2020 in Colombia. METHODS: We conducted a secondary analysis of data on 3,140,010 pregnancies and 2,993,534 live births from population-based birth certificate and fetal death certificate records in Colombia between 2016 and 2020. Outcomes were compared separately for each month during 2020 with the same month in 2019 and pre-pandemic trends were examined in regression models controlling for maternal age, educational level, marital status, type of health insurance, place of residence (urban/rural), municipality of birth, and the number of pregnancies the mother has had before last pregnancy. RESULTS: We found some evidence for a decline in miscarriage risk in some months after the pandemic start, while there was an apparent lagging increase in stillbirth risk, although not statistically significant after correction for multiple comparisons. Birth weight increased during the onset of the pandemic, a change that does not appear to be driven by pre-pandemic trends. Specifically, mean birth weight was higher in 2020 than 2019 for births in April through December by about 12 to 21 g (p < 0.01). There was also a lower risk of gestational age at/below 37 weeks in 2020 for two months following the pandemic (April, June), but a higher risk in October. Finally, there was a decline in prenatal visits in 2020 especially in June-October, but no evidence of a change in C-section delivery. CONCLUSIONS: The study findings suggest mixed early effects of the pandemic on perinatal outcomes and prenatal care utilization in Colombia. While there was a significant decline in prenatal visits, other factors may have had counter effects on perinatal health including an increase in birth weight on average.

Effects of the Affordable Care Act Insurance Expansions on Health Care Coverage, Access, and Health Status of 50-64-Year-Old Adults: Evidence From the First Six Years.

Individuals aged 50-64 face a higher burden of chronic conditions and an increased probability of insurance coverage loss, making them particularly vulnerable to limited access than younger adults. This study examines the effects of the Affordable Care Act (ACA) insurance expansions, including both Medicaid eligibility and other expansions, on health care coverage, access, and health status of adults aged 50-64 years over 6 years since the initial expansions in 2014. Using a triple difference-in-difference-in-differences model and nationally representative data, we find that the ACA increased private insurance and Medicaid coverage. There is evidence of improved access based on having a personal provider, completing a routine checkup, and reducing forgoing medical care due to cost. There is little evidence for the effects on self-reported health outcomes. Findings suggest that coverage expansions have improved access to care but have thus far not had discernible and consistent effects on self-reported health for 50-64-year-olds.

Effects of the Affordable Care Act Medicaid Expansions on Mental Health During the COVID-19 Pandemic in 2020-2021.

To examine whether previous Affordable Care Act (ACA) Medicaid expansions had an added effect on the mental health of low-income adults during the COVID-19 pandemic in 2020 and 2021. We use the 2017-2021 Behavioral Risk Factor Surveillance System (BRFSS) data. We use an event study difference-in-differences model to compare the number of days in poor mental health in the past 30 days and the likelihood of frequent mental distress among 18 to 64 year old individuals with household incomes below 100% of the federal poverty level who participated in BRFSS in one of the surveys from 2017 to 2021 and who resided in states that expanded Medicaid by 2016 or states that had not expanded by 2021. We also examine the heterogeneity of the expansion effects across subpopulation groups. We find some evidence that the Medicaid expansion was associated with better mental health during the pandemic for adults younger than 45, females, and non-Hispanic Black and other non-Hispanic non-White individuals. There is some evidence of an added benefit to mental health from Medicaid expansion status during the pandemic for some subgroups among low-income adults, suggesting potential health benefits from Medicaid eligibility during public health and economic crises.

Rare variants found in multiplex families with orofacial clefts: Does expanding the phenotype make a difference?

Whole-exome sequencing (WES) is now a relatively straightforward process to identify causal variants in Mendelian disorders. However, the same is not true for WES in families where the inheritance patterns are less clear, and a complex etiology is suspected. Orofacial clefts (OFCs) are highly heritable birth defects with both Mendelian and complex etiologies. The phenotypic spectrum of OFCs may include overt clefts and several subclinical phenotypes, such as discontinuities in the orbicularis oris muscle (OOM) in the upper lip, velopharyngeal insufficiency (VPI), microform clefts or bifid uvulas. We hypothesize that expanding the OFC phenotype to include these phenotypes can clarify inheritance patterns in multiplex families, making them appear more Mendelian. We performed whole-exome sequencing to find rare, likely causal genetic variants in 31 multiplex OFC families, which included families with multiple individuals with OFCs and individuals with subclinical phenotypes. We identified likely causal variants in COL11A2, IRF6, KLF4, SHROOM3, SMC3, TP63 , and TBX3 in seven families. Although we did not find clear evidence supporting the subclinical phenotype hypothesis, our findings support a role for rare variants in the etiology of OFCs.

Child Flourishing, School Engagement, Physical Activity, and Screen Time During the Coronavirus Disease 2019 Pandemic in 2020.

OBJECTIVE: To examine changes in flourishing, school engagement, physical activity, and recreational screen time among school-aged children in the United States during the Coronavirus Disease 2019 (COVID-19) pandemic in 2020. METHODS: In this cross-sectional study, data come from the 2018-2020 National Survey of Children's Health for 68,203 children aged 6 to 17 years. Flourishing is always/usually curious to learn, resilient and having self-regulation. School engagement is always/usually completing homework and having interest in doing well in school. Other outcomes are daily 60+ minutes physical activity or number of such days, and daily recreational screen time or 2+ hours/day. Weighted regression models compare 2020 to 2019 and 2019 to 2018 adjusting for child/household covariates and state indicators. RESULTS: Among children age 6 to 17 years in 2020, there was a decline in flourishing (OR = 0.69; 95% CI, 0.63, 0.75), school engagement (OR = 0.71; 95% CI, 0.64, 0.79), physically active days (0.26 days, 95% CI, 35, 0.17), and daily 60+ minutes activity (OR = 0.91; 95% CI, 0.83, 1.00), and increase in daily recreational screen time (0.29 hours; 95% CI, 0.25, 0.34) and 2+ hours/day (OR = 1.65; 95% CI, 1.49-1.83) compared to 2019. These differences were observed across all evaluated demographic and socioeconomics subgroups. There were no significant differences between 2019 and 2018, indicating that the 2020-2019 differences were related to the pandemic rather than a continuation of prepandemic trends. CONCLUSIONS: Children's flourishing, school engagement, and physical activity declined while recreational screen time increased during the COVID-19 pandemic in 2020. Monitoring these outcomes in the long-run is important to assessing needs and promoting children's learning and development.

The effects of Medicaid expansions on dental services at federally qualified health centers.

BACKGROUND: Federally qualified health centers (FQHCs) have become safety-net providers of dental services for low-income patients. The authors examined the effects of the Patient Protection and Affordable Care Act Medicaid expansions, according to level of dental benefits, on the number of visits for dental services at FQHCs. METHODS: The authors used publicly available facility-level data on 1,400 FQHCs across the United States from the 2011 through 2019 Uniform Data System. The authors used an event-study difference-in-difference design to examine the effects of expanding Medicaid in 2014, according to the level of dental benefits, compared with nonexpansion states. Outcomes included the number of dental visits for any dental service and separately for preventive and other services. Regression models adjusted for the demographic characteristics of the FQHC's patient population, county-level factors, and center and year fixed effects. RESULTS: Expanding Medicaid with extensive dental benefits has increased the number of dental visits provided at FQHCs in 2014 through 2019 from 2013 by 1,329 to 7,647 visits per FQHC on average compared with FQHCs in nonexpansion states. There was an increase in visits for both preventive and other dental services. In contrast, there was no evidence of such an increase from expanding Medicaid with limited or emergency-only dental benefits. CONCLUSIONS: Expanding Medicaid eligibility with extensive dental benefits has increased the number of dental visits at FQHCs, including for both preventive and other dental services. PRACTICAL IMPLICATIONS: As safety-net providers, FQHCs might be able to provide more oral health care for low-income patients after Medicaid expansions that offer extensive dental benefits.

Effects of Recent Medicaid Expansions on Infant Mortality by Race and Ethnicity.

INTRODUCTION: The purpose of this study is to examine year-by-year effects of the 2014 Affordable Care Act Medicaid expansion on infant mortality by race and ethnicity over the first 6 years. METHODS: Publicly available 2011-2019 Multiple Cause of Death data were extracted in October and analyzed by November 2021. A difference-in-differences event-study design compared infant mortality changes in states that expanded in 2014 to nonexpansion states. RESULTS: In the main model, the 2014 Medicaid expansions were associated with a statistically significant decline in Black infants' mortality in 2018 and 2019 by 1.19 (95% CI= -2.27, -0.12) and 1.35 (95% CI= -2.45, -0.26) deaths per 1,000 live births, respectively. There was also a decline in mortality for Hispanic infants in 2015-2019, including by 0.8 (95% CI= -1.25, -0.36) and 1.28 (95% CI= -1.88, -0.68) deaths per 1,000 live births in 2015 and 2019, respectively. Overall, infant mortality declined by 0.37 (95% CI= -0.70, -0.05) deaths per 1,000 live births in 2019. CONCLUSIONS: The study adds evidence on the association of the Affordable Care Act Medicaid expansions with a decline in mortality of Black and Hispanic infants. The findings shed light on the importance of examining year-by-year effects over multiple years.

The effect of nursing home closure on local employment in the United States.

OBJECTIVE: To estimate the effect of nursing home closure on local employment, overall, and by rurality. DATA SOURCES AND STUDY SETTING: We obtained 2008-2018 county-level data from the Quarterly Workforce Indicators, Medicare Provider of Services, Area Health Resource, and Urban Influence Codes files. From 2008 to 2018, 878 counties experienced at least one nursing home closure, and 2055 counties did not experience a closure. STUDY DESIGN: Using a difference-in-difference study design, we compare the changes of total employment, health sector employment and non-health sector employment over time between counties with and without a nursing home closure. We utilize the variation in the year and quarter of nursing home closures to estimate subsequent employment changes as well as employment trends before closure. We also account for contemporaneous events including nursing home entries and hospital entries and closures, and evaluate heterogeneity by rurality. DATA EXTRACTION: We include data on nursing home closure from the Medicare Provider of Service file. Quarterly county-level employee counts were obtained from the Quarterly Workforce Indicators provided by the Census Bureau. County-level demographic data were obtained from the Area Health Resource Files. We use Urban Influence Codes from the Economic Research Service, Department of Agriculture, to classify metropolitan, micropolitan, and rural (noncore) counties. PRINCIPAL FINDINGS: Health sector employment decreased by about 3.2%-4.1% (p < 0.01) in counties with a nursing home closure. The reduction was largest in rural counties (approximately 7.2%-9.4%, p < 0.01). The reduction in health sector employment persisted over time, particularly in rural counties. Overall, there was no discernable effect on non-health sector employment. CONCLUSIONS: Nursing home closure is associated with a persistent decline in health sector employment, particularly in rural counties, suggesting a reduction in the health care workforce and in the ability to sustain health care services supply, particularly in rural areas.

Genome-wide analysis of copy-number variation in humans with cleft lip and/or cleft palate identifies COBLL1, RIC1, and ARHGEF38 as clefting genes.

Cleft lip with or without cleft palate (CL/P) is a common birth defect with a complex, heterogeneous etiology. It is well established that common and rare sequence variants contribute to the formation of CL/P, but the contribution of copy-number variants (CNVs) to cleft formation remains relatively understudied. To fill this knowledge gap, we conducted a large-scale comparative analysis of genome-wide CNV profiles of 869 individuals from the Philippines and 233 individuals of European ancestry with CL/P with three primary goals: first, to evaluate whether differences in CNV number, amount of genomic content, or amount of coding genomic content existed within clefting subtypes; second, to assess whether CNVs in our cohort overlapped with known Mendelian clefting loci; and third, to identify unestablished Mendelian clefting genes. Significant differences in CNVs across cleft types or in individuals with non-syndromic versus syndromic clefts were not observed; however, several CNVs in our cohort overlapped with known syndromic and non-syndromic Mendelian clefting loci. Moreover, employing a filtering strategy relying on population genetics data that rare variants are on the whole more deleterious than common variants, we identify several CNV-associated gene losses likely driving non-syndromic clefting phenotypes. By prioritizing genes deleted at a rare frequency across multiple individuals with clefts yet enriched in our cohort of individuals with clefts compared to control subjects, we identify COBLL1, RIC1, and ARHGEF38 as clefting genes. CRISPR-Cas9 mutagenesis of these genes in Xenopus laevis and Danio rerio yielded craniofacial dysmorphologies, including clefts analogous to those seen in human clefting disorders.

State Eviction Moratoriums During The COVID-19 Pandemic Were Associated With Improved Mental Health Among People Who Rent.

In response to the COVID-19 pandemic, many US states implemented eviction moratoriums in 2020. Evidence from eviction filings from that year shows short-term declines in eviction filings. This study examined the short-term effects of these state eviction moratoriums in 2020 on the mental health status of renters. It employed nationally representative data from the Behavioral Risk Factor Surveillance System and a triple-difference design that compared renters with homeowners while leveraging state differences in moratoriums over time. During 2020 forty-three states and Washington, D.C., implemented eviction moratoriums of varying scope and enforcement. Some moratoriums targeted the whole eviction process, including early stages, whereas others focused on the later stages of eviction. We found that state moratoriums were associated with an improvement in mental health, including fewer days not in good mental health in the past thirty days and a lower likelihood of frequent mental distress (fourteen or more days not in good mental health in the past thirty days). Overall, there is some evidence from this study pointing to potential short-term benefits from state eviction moratoriums in 2020 to the mental health and well-being of renters, which would be important to consider when formulating policies that affect residential stability.