Trends in breast, colon, pancreatic, and uterine cancers in women during the COVID-19 pandemic in North Carolina.

IMPORTANCE: The COVID-19 pandemic led to reductions in primary care and cancer screening visits, which may delay detection of some cancers. The impact on incidence has not been fully quantified. We examined change in cancer incidence to determine how the COVID-19 pandemic may have altered the characteristics of cancers diagnosed among women. METHODS: This study included female patients aged ≥18 years and diagnosed with breast (n = 9489), colon (n = 958), pancreatic (n = 669), or uterine (n = 1991) cancer at three hospitals in North Carolina. Using interrupted time series, we compared incidence of cancers diagnosed between March 2020 and November 2020 (during pandemic) with cancers diagnosed between January 2016 and February 2020 (pre-pandemic). RESULTS: During the pandemic, incidence of breast and uterine cancers was significantly lower than expected compared to pre-pandemic (breast-18%, p = 0.03; uterine -20%, p = 0.05). Proportions of advanced pathologic stage and hormone receptor-negative breast cancers, and advanced clinical stage and large size uterine cancers were more prevalent during the pandemic. No significant changes in incidence were detected for pancreatic (-20%, p = 0.08) or colon (+14%, p = 0.30) cancers. CONCLUSION AND RELEVANCE: In women, the COVID-19 pandemic resulted in a significant reduction in the incidence of breast and uterine cancers, but not colon or pancreatic cancers. A change in the proportion of poor prognosis breast and uterine cancers suggests that some cancers that otherwise would have been diagnosed at an earlier stage will be detected in later years. Continued analysis of long-term trends is needed to understand the full impact of the pandemic on cancer incidence and outcomes.

Community health worker outreach to farmworkers in rural North Carolina: Learning from adaptations to the SARS-CoV-2 pandemic.

BACKGROUND: Community health workers represent a critical part of the health outreach and services for migrant and seasonal farmworkers ('farmworkers') in rural areas of the United States. PURPOSE: We sought to identify adaptations to farmworker patient engagement and health outreach made by community health workers during the first 18 months of the COVID-19 pandemic. METHODS: In this qualitative study, we used semi-structured interviews with community health workers from August 2020 to February 2022 (n = 21). Two coders used thematic analysis to identify three themes related to the experiences of community health workers in conducting health education and outreach to farmworkers prior to and following the onset of the pandemic. FINDINGS: We found themes related to pre-pandemic outreach efforts to provide health education resource sharing with farmworkers and pandemic-related outreach efforts that included adoption of porch drops and distanced delivery of health education, adaptation of modes of health education and communication through technology and the internet, and taking on new roles related to COVID-19. Finally, we identified changes that reverted after the pandemic or will continue as adaptations. CONCLUSIONS: Community health workers created practice-based innovations in outreach in response to the COVID-19 pandemic. These innovations included new COVID-19 related roles and new modes of health education and outreach, including the use of digital resources. The changes developed for emergency use in COVID-19, particularly related to internet and technology, have likely altered how community health workers conduct outreach in North Carolina going forward. Funders, community health worker training programs, and researchers should take note of these innovations. PATIENT OR PUBLIC CONTRIBUTION: Community health workers who typically come from patient populations and provide critical navigation and connection with the health care system advised on the design and creation of this research project, including serving on an advisory board. Two authors have experience working as community health workers.

Associations between long-term exposure to air pollution and kidney function utilizing electronic healthcare records: a cross-sectional study.

BACKGROUND: Chronic kidney disease (CKD) affects more than 38 million people in the United States, predominantly those over 65 years of age. While CKD etiology is complex, recent research suggests associations with environmental exposures. METHODS: Our primary objective is to examine creatinine-based estimated glomerular filtration rate (eGFRcr) and diagnosis of CKD and potential associations with fine particulate matter (PM2.5), ozone (O3), and nitrogen dioxide (NO2) using a random sample of North Carolina electronic healthcare records (EHRs) from 2004 to 2016. We estimated eGFRcr using the serum creatinine-based 2021 CKD-EPI equation. PM2.5 and NO2 data come from a hybrid model using 1 km2 grids and O3 data from 12 km2 CMAQ grids. Exposure concentrations were 1-year averages. We used linear mixed models to estimate eGFRcr per IQR increase of pollutants. We used multiple logistic regression to estimate associations between pollutants and first appearance of CKD. We adjusted for patient sex, race, age, comorbidities, temporality, and 2010 census block group variables. RESULTS: We found 44,872 serum creatinine measurements among 7,722 patients. An IQR increase in PM2.5 was associated with a 1.63 mL/min/1.73m2 (95% CI: -1.96, -1.31) reduction in eGFRcr, with O3 and NO2 showing positive associations. There were 1,015 patients identified with CKD through e-phenotyping and ICD codes. None of the environmental exposures were positively associated with a first-time measure of eGFRcr < 60 mL/min/1.73m2. NO2 was inversely associated with a first-time diagnosis of CKD with aOR of 0.77 (95% CI: 0.66, 0.90). CONCLUSIONS: One-year average PM2.5 was associated with reduced eGFRcr, while O3 and NO2 were inversely associated. Neither PM2.5 or O3 were associated with a first-time identification of CKD, NO2 was inversely associated. We recommend future research examining the relationship between air pollution and impaired renal function.

Opioid Use Among Children and Adults With Sickle Cell Disease in North Carolina Medicaid Enrollees in the Era of Opioid Harm Reduction.

Adults and children with sickle cell disease (SCD) are predominantly African American, with pain-related health disparities. We examined opioid prescription fill patterns in adults and children with SCD and compared factors associated with fills in North Carolina Medicaid enrollees. Our retrospective cohort study included 955 enrollees diagnosed with SCD having at least one opioid fill. Associations were measured between two cohorts (12 and 24 mo of continuous enrollment) for the following characteristics: sex, age, enrollee residence, hydroxyurea adherence, comanagement, enrollment in Community Care North Carolina, prescription for short versus short and long-acting opioids, and emergency department reliance. The majority of individuals did not have an opioid claim over a 12 or 24-month period. Claims increased at ages 10 to 17, peaking at ages 18 to 30. The increased number of claims was associated with the following factors: increasing age, male, short versus long-acting opioids, and Medicaid enrollment for 24 versus 12 months. Community Care North Carolina enrollees in the 12-month cohort had higher opioid days of supply per month; the inverse was true of the 24-month cohort.

Does Paging Clinicians about Tick-Borne Disease Serological Results Impact Clinical Care? A Retrospective Analysis of 70 Cases in North Carolina.

Delayed treatment of Rocky Mountain spotted fever is associated with increased morbidity and mortality. Because the diagnosis cannot be established from a single serological test, guidelines recommend empirical antibiotic initiation in suspect patients. We evaluated a policy used by UNC Health of paging clinicians when acute testing for Rickettsia returned with a titer ≥1:256. Our objective was to assess the potential effect of paging on routine treatment practices. Notably, we found that a high proportion of cases (N = 28, 40%) were not prescribed antibiotics until the results were available. The vast majority of these cases did not have evidence of compatible symptoms or disease progression. These findings suggest that paging may have prompted unnecessary treatment. Overall, the policy, which has now been discontinued, appears to have had limited benefit. Efforts are urgently needed to improve adherence to testing and treatment guidelines.

Delayed Diagnosis of Locally Acquired Lyme Disease, Central North Carolina, USA.

Healthcare providers in North Carolina, USA, have limited experience diagnosing and managing Lyme disease because few cases occur annually statewide. We outline the prolonged diagnostic course for a patient with locally acquired Lyme disease in North Carolina. This case highlights the need for greater awareness and professional education.

COVSIM: A stochastic agent-based COVID-19 SIMulation model for North Carolina.

We document the evolution and use of the stochastic agent-based COVID-19 simulation model (COVSIM) to study the impact of population behaviors and public health policy on disease spread within age, race/ethnicity, and urbanicity subpopulations in North Carolina. We detail the methodologies used to model the complexities of COVID-19, including multiple agent attributes (i.e., age, race/ethnicity, high-risk medical status), census tract-level interaction network, disease state network, agent behavior (i.e., masking, pharmaceutical intervention (PI) uptake, quarantine, mobility), and variants. We describe its uses outside of the COVID-19 Scenario Modeling Hub (CSMH), which has focused on the interplay of nonpharmaceutical and pharmaceutical interventions, equitability of vaccine distribution, and supporting local county decision-makers in North Carolina. This work has led to multiple publications and meetings with a variety of local stakeholders. When COVSIM joined the CSMH in January 2022, we found it was a sustainable way to support new COVID-19 challenges and allowed the group to focus on broader scientific questions. The CSMH has informed adaptions to our modeling approach, including redesigning our high-performance computing implementation.

25-Year fatal workplace suicide trends in North Carolina: 1992-2017.

BACKGROUND: Suicide is a serious public health problem in the United States, but limited evidence is available investigating fatal suicides at work. There is a substantial need to characterize workplace suicides to inform suicide prevention interventions and target high-risk settings. This study aims to examine workplace suicide rates in North Carolina (NC) by worker characteristics, means of suicide used, and industry between 1992 and 2017. METHODS: Fatal workplace suicides were identified from records of the NC Office of the Chief Medical Examiner system and the NC death certificate. Sex, age, race, ethnicity, class of worker, manner of death, and industry were abstracted. Crude and age-standardized homicide rates were calculated as the number of suicides that occurred at work divided by an estimate of worker-years (w-y). Rate ratios and 95% confidence intervals (CIs) were calculated, and trends over calendar time for fatal workplace suicides were examined overall and by industry. RESULTS: 81 suicides over 109,464,430 w-y were observed. Increased rates were observed in workers who were male, self-employed, and 65+ years old. Firearms were the most common means of death (63%) followed by hanging (16%). Gas service station workers experienced the highest fatal occupational suicide rate, 11.5 times (95% CI: 3.62-36.33) the overall fatal workplace suicide rate, followed by Justice, Public Order, and Safety workers at 3.23 times the overall rate (95% CI: 1.31-7.97). CONCLUSION: Our findings identify industries and worker demographics that were vulnerable to workplace suicides. Targeted and tailored mitigation strategies for vulnerable industries and workers are recommended.

Understanding mechanisms of racial disparities in breast cancer: an assessment of screening and regular care in the Carolina Breast Cancer Study.

PURPOSE: Screening history influences stage at detection, but regular preventive care may also influence breast tumor diagnostic characteristics. Few studies have evaluated healthcare utilization (both screening and primary care) in racially diverse screening-eligible populations. METHODS: This analysis included 2,058 women age 45-74 (49% Black) from the Carolina Breast Cancer Study, a population-based cohort of women diagnosed with invasive breast cancer between 2008 and 2013. Screening history (threshold 0.5 mammograms per year) and pre-diagnostic healthcare utilization (i.e. regular care, based on responses to "During the past ten years, who did you usually see when you were sick or needed advice about your health?") were assessed as binary exposures. The relationship between healthcare utilization and tumor characteristics were evaluated overall and race-stratified. RESULTS: Among those lacking screening, Black participants had larger tumors (5 + cm) (frequency 19.6% vs 11.5%, relative frequency difference (RFD) = 8.1%, 95% CI 2.8-13.5), but race differences were attenuated among screening-adherent participants (10.2% vs 7.0%, RFD = 3.2%, 0.2-6.2). Similar trends were observed for tumor stage and mode of detection (mammogram vs lump). Among all participants, those lacking both screening and regular care had larger tumors (21% vs 8%, RR = 2.51, 1.76-3.56) and advanced (3B +) stage (19% vs 6%, RR = 3.15, 2.15-4.63) compared to the referent category (screening-adherent and regular care). Under-use of regular care and screening was more prevalent in socioeconomically disadvantaged areas of North Carolina. CONCLUSIONS: Access to regular care is an important safeguard for earlier detection. Our data suggest that health equity interventions should prioritize both primary care and screening.

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).

Legionnaires' Disease Outbreak Associated With a Hot Tub Display at the North Carolina Mountain State Fair, September 2019.

OBJECTIVES: On September 23, 2019, the North Carolina Division of Public Health identified a legionellosis increase in western North Carolina; most patients had recently attended the North Carolina Mountain State Fair. We conducted a source investigation. METHODS: Cases were fair attendees with laboratory-confirmed legionellosis and symptom onset within 2 to 14 days (Legionnaires' disease) or ≤3 days (Pontiac fever). We conducted a case-control study matching cases to non-ill fair attendees as control participants and an environmental investigation, and we performed laboratory testing (Legionella bacteria culture and polymerase chain reaction) of 27 environmental samples from fairgrounds and hot tubs and 14 specimens from case patients. We used multivariable unconditional logistic regression models to calculate adjusted odds ratios for potential Legionella exposure sources and risk factors. RESULTS: Of 136 people identified with fair-associated legionellosis, 98 (72%) were hospitalized and 4 (3%) died. Case patients were more likely than control participants to report walking by hot tub displays (adjusted odds ratio = 10.0; 95% CI, 4.2-24.1). Complete hot tub water treatment records were not kept, precluding evaluation of water maintenance conducted on display hot tubs. Legionella pneumophila sequence types (STs) were consistent among 10 typed clinical specimens (ST224) but distinct from the only positive environmental sample from the fair (ST7 and ST8). CONCLUSIONS: Hot tub displays were identified as the most likely outbreak source, making this the largest hot tub-associated Legionnaires' disease outbreak worldwide. Following the investigation, the North Carolina Division of Public Health and the Centers for Disease Control and Prevention released guidance on mitigating risk of Legionella exposure from hot tub displays. Results highlight the importance of properly maintaining equipment that aerosolizes water, including hot tubs intended for display purposes only.

Industrial Hog Operation Workers' Perspectives on Occupational Exposure to Zoonotic Pathogens: A Qualitative Pilot Study in North Carolina, USA.

Industrial hog operation (IHO) workers face a range of occupational hazards, including exposure to zoonotic pathogens such as livestock-associated antimicrobial-resistant Staphylococcus aureus and swine-origin influenza viruses with epidemic or pandemic potential. To better understand this population's occupational exposure to zoonotic pathogens, we conducted a community-driven qualitative research study in eastern North Carolina. We completed in-depth interviews with ten IHO workers and used thematic analysis to identify and analyze patterns of responses. Workers described direct and indirect occupational contact with hogs, with accompanying potential for dermal, ingestion, and inhalation exposures to zoonotic pathogens. Workers also described potential take-home pathways, wherein they could transfer livestock-associated pathogens and other contaminants from IHOs to their families and communities. Findings warrant future research, and suggest that more restrictive policies on antimicrobials, stronger health and safety regulations, and better policies and practices across all IHOs could afford greater protection against worker and take-home zoonotic pathogen exposures.

Forty-year trends in fatal occupational injuries in North Carolina.

BACKGROUND: We describe progress in the control of deaths on-the-job due to fatal occupational injury in North Carolina over the period 1978-2017. METHODS: Forty years of information on fatal occupational injuries in North Carolina has been assembled from medical examiners' reports and death certificates, supplemented by newspaper and police reports. Cases were defined as unintentional fatal occupational injuries among adults. Annual estimates of the population at risk were derived from US Census data, and rates were quantified using Poisson regression methods. RESULTS: There were 4434 eligible deaths. The unintentional fatal occupational injury rate at the beginning of the study period was more than threefold the rate at the end of the study. The fatal occupational injury rate among men declined from 9.6 per 100,000 worker-years in the period 1978-1982 to 3.1 per 100,000 worker-years in the period 2013-2017. The fatal occupational injury rate among women declined from 0.3 per 100,000 worker-years in the period 1978-1981 to 0.1 per 100,000 worker-years in the period 2013-2017. Declines in rates were observed for young adults as well as older workers and were observed across all major industry categories. Average annual declines in rates were greatest in those industries and occupations that had the highest fatal injury rates at the start of the study period. CONCLUSIONS: The substantial decline in fatal injury rates underscores the importance of injury prevention and demonstrates the ability to make meaningful reductions in unintentional fatal injury.

Multiple joint osteoarthritis (MJOA): What's in a name?

OBJECTIVE: To summarize the current state of the literature regarding multi-joint osteoarthritis (MJOA) and discuss important future directions. DESIGN: A narrative review of the author's work and other key references on this topic with a focus on the Johnston County studies, definitions of MJOA and their impact, multi-site pain in osteoarthritis (OA), genetics and biomarkers in MJOA, and perspectives on future work. RESULTS: MJOA is variably defined and lacks a clear consensus definition, making comprehensive study challenging. Involvement of both symptoms and structural changes of OA in multiple joints in an individual is common, but patterns vary by sex, race/ethnicity, and other factors. Outcomes (e.g., general health, function, falls, mortality) are negatively impacted by a greater whole-body OA burden. Recent genetic and biomarker studies including whole-body OA assessments have begun to shed some light on potentially unique factors in the MJOA population. CONCLUSIONS: Consideration of MJOA is essential for ongoing study of OA phenotypes, epidemiology, risk factors, genetics, biomarkers, and outcomes, to fully understand and eventually limit the negative impact of OA burden on health.

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.

Suicide Mortality Among Formerly Incarcerated People Compared With the General Population in North Carolina, 2000-2020.

We aimed to compare rates and characteristics of suicide mortality in formerly incarcerated people with those of the general population in North Carolina. We conducted a retrospective cohort study of 266,400 people released from North Carolina state prisons between January 1, 2000, and March 1, 2020. Using direct and indirect standardization by age, sex, and calendar year, we calculated standardized suicide mortality rates and standardized mortality ratios comparing formerly incarcerated people with the North Carolina general population. We evaluated effect modification by race/ethnicity, sex, age, and firearm involvement. Formerly incarcerated people had approximately twice the overall suicide mortality of the general population for 3 years after release, with the highest rate of suicide mortality being observed in the 2-week period after release. In contrast to patterns in the general population, formerly incarcerated people had higher rates of non-firearm-involved suicide mortality than firearm-involved suicide mortality. Formerly incarcerated female, White and Hispanic/Latino, and emerging adult people had a greater elevation of suicide mortality than their general-population peers compared with other groups. These findings suggest a need for long-term support for formerly incarcerated people as they return to community living and a need to identify opportunities for interventions that reduce the harms of incarceration for especially vulnerable groups. This article is part of a Special Collection on Mental Health.

Two years of newborn screening for Duchenne muscular dystrophy as a part of the statewide Early Check research program in North Carolina.

PURPOSE: Current and emerging treatments for Duchenne muscular dystrophy (DMD) position DMD as a candidate condition for newborn screening (NBS). In anticipation of the nomination of DMD for universal NBS, we conducted a prospective study under the Early Check voluntary NBS research program in North Carolina, United States. METHODS: We performed screening for creatine kinase-MM (CK-MM), a biomarker of muscle damage, on residual routine newborn dried blood spots (DBS) from participating newborns. Total creatine kinase testing and next generation sequencing of an 86-neuromuscular gene panel that included DMD were offered to parents of newborns who screened positive. Bivariate and multivariable analyses were performed to assess effects of biological and demographic predictors on CK-MM levels in DBS. RESULTS: We screened 13,354 newborns and identified 2 males with DMD. The provisional 1626 ng/mL cutoff was raised to 2032 ng/mL to improve specificity, and additional cutoffs (900 and 360 ng/mL) were implemented to improve sensitivity for older and low-birthweight newborns. CONCLUSION: Population-scale screening for elevated CK-MM in DBS is a feasible approach to identify newborns with DMD. Inclusion of birthweight- and age-specific cutoffs, repeat creatine kinase testing after 72 hours of age, and DMD sequencing improve sensitivity and specificity of screening.

The most common types of nontraumatic dental conditions among emergency department visits in North Carolina before and during the COVID-19 pandemic.

BACKGROUND: This study aimed to identify the most common types of nontraumatic dental conditions (NTDCs) before and during the COVID-19 pandemic and assess the variations in the most common NTDCs by patient age groups and rural or urban locations and the impact of COVID-19 on emergency department (ED) visits for NTDCs in North Carolina. METHODS: The authors conducted a retrospective data analysis of ED data from the North Carolina Disease Event Tracking and Epidemiology Collection Tool. The authors estimated the proportions of NTDCs of all ED visits in 2019 and 2021 and ranked the proportions of the major categories of NTDCs by age groups and rural or urban locations. They used a multiple logistic regression model to assess the impact of COVID-19 on NTDCs. RESULTS: By the first diagnosis, the proportion of NTDCs dropped from 1.1% in 2019 to 0.99% in 2021 (P < .001). Caries was specified as the third most common NTDC. Oral infection was the top NTDC among young (≤ 17 years) and older patients (≥ 65 years). No significant differences were found in NTDCs between rural and urban areas (P = .68). Children younger than 2 years (adjusted odds ratio, 4.36) and adults aged 18 through 44 years (adjusted odds ratio, 4.54) were more likely to visit the ED for NTDCs than those 75 years and older. CONCLUSIONS: The proportion of NTDCs seen at the ED was lower during the COVID-19 pandemic in 2021 than in 2019. The common NTDCs varied by age group but were similar in rural and urban areas. The most common NTDCs were related to toothache, oral infection, and caries. PRACTICAL IMPLICATIONS: More efforts are needed to reduce ED visits for NTDCs.

Accessing perinatal substance use disorder care in your local community: A case study of an innovative hub and spoke network in western North Carolina.

INTRODUCTION: The incidence of substance use disorders (SUD) in the general population and in the pregnant person population has risen over the last 20 years. Concurrently, both perinatal and SUD care in rural areas is laden with access barriers including but not limited to geographical distance from potential treatment and stigma. An integrated outpatient perinatal substance use disorder (PSUD) clinic in an urban area in western North Carolina (WNC) found that patients who traveled further for prenatal care were less likely to continue seeking care in the postpartum period. Acknowledging that the risk of overdose increases in the postpartum period, the PSUD clinic utilized a hub and spoke model to promote healthcare accessibility. METHODS: The clinic adapted the Vermont hub and spoke model and the CHARM (Children and Recovering Mothers) collaborative. The urban hub in WNC has now developed eight spokes in rural communities. The hub provides education and technical assistance to the rural spokes, and the two engage in bidirectional referral pathways. This manuscript details the model and analyzes the existing strengths and barriers at two spokes, a family medicine Federally Qualified Health Center and a hospital affiliated obstetrics and gynecology practice and analyzes their process of implementation of integrated outpatient perinatal substance use care. RESULTS: Both spokes found coaching relationships and the sharing of resources such as clinical guidelines useful to begin prescribing buprenorphine for PSUD. Their context led one spoke to begin prescribing within one year while the other took two years. CONCLUSION: Comparing and contrasting these spokes serves to demonstrate that across many contexts, a hub and spoke model is a replicable intervention for rural perinatal substance use access to care barriers. Comparing the two spokes emphasizes the need for adaptation as well as standardization of the model to improve evidence-based PSUD care most effectively.

The effect modification of greenspace and impervious surface on the heat-mortality association: Differences by the dissimilarity index.

Recent studies have shown that heat-mortality risk differs by level of greenspace and impervious surface. However, these studies do not consider both green spaces and impervious surfaces simultaneously, and further did not fully consider community- and individual-level characteristics. In this study we explored the effect modification of greenspace and impervious surface on the association between heat and mortality and how it differs by race/ethnicity dissimilarity index levels in North Carolina, USA. We aggregated datasets for greenspace, impervious surface estimates, temperature, and mortality for 1275 census tracts for North Carolina, USA, for 2000 to 2016 for 5 warm months (May to September). We used distributed lag non-linear models to estimate the heat-mortality relationship in each census tract. Heat-mortality relative risk (RR) was higher for census tracts with low greenspace than high greenspace (RR comparing risk at 99th temperature and minimum mortality temperature: 1.08 (1.02, 1.15) for low greenspace and 0.97 (0.87, 1.08) for high greenspace). Heat-mortality RR was higher for tracts with high impervious surface than low impervious surface (1.04 (1.00, 1.09) for high impervious surface and 0.94 (0.84, 1.05) for low impervious surface). Census tracts with high dissimilarity value and low greenspace had the highest heat-mortality risk compared to the tracts with high dissimilarity value with and high greenspace (1.13 (1.02, 1.24) for high dissimilarity index and 0.97 (0.86, 1.09) for low dissimilarity index). Communities with low greenspace or high impervious surfaces had higher heat-mortality associations, and this effect modification was higher for high race/ethnicity dissimilarity regions.