Factors associated with delaying medical care: cross-sectional study of Nebraska adults.

BACKGROUND: Delayed medical care may result in adverse health outcomes and increased cost. Our purpose was to identify factors associated with delayed medical care in a primarily rural state. METHODS: Using a stratified random sample of 5,300 Nebraska households, we conducted a cross-sectional mailed survey with online response option (27 October 2020 to 8 March 2021) in English and Spanish. Multiple logistic regression models calculated adjusted odds ratios (aOR) and 95% confidence intervals. RESULTS: The overall response rate was 20.8% (n = 1,101). Approximately 37.8% of Nebraskans ever delayed healthcare (cost-related 29.7%, transportation-related 3.7%), with 22.7% delaying care in the past year (10.1% cost-related). Cost-related ever delay was associated with younger age [< 45 years aOR 6.17 (3.24-11.76); 45-64 years aOR 2.36 (1.29-4.32)], low- and middle-income [< $50,000 aOR 2.85 (1.32-6.11); $50,000-$74,999 aOR 3.06 (1.50-6.23)], and no health insurance [aOR 3.56 (1.21-10.49)]. Transportation delays were associated with being non-White [aOR 8.07 (1.54-42.20)], no bachelor's degree [≤ high school aOR 3.06 (1.02-9.18); some college aOR 4.16 (1.32-13.12)], and income < $50,000 [aOR 8.44 (2.18-32.63)]. Those who did not have a primary care provider were 80% less likely to have transportation delays [aOR 0.20 (0.05-0.80)]. CONCLUSIONS: Delayed care affects more than one-third of Nebraskans, primarily due to financial concerns, and impacting low- and middle-income families. Transportation-related delays are associated with more indicators of low socio-economic status. Policies targeting minorities and those with low- and middle-income, such as Medicaid expansion, would contribute to addressing disparities resulting from delayed care.

Outbreak of SARS-CoV-2 B.1.617.2 (Delta Variant) in a Youth Camp Associated With Community Spread, Nebraska, June-July 2021.

OBJECTIVES: During June-July 2021, an outbreak of SARS-CoV-2 occurred among attendees of a summer youth camp in Nebraska. We assessed the factors that contributed to onward transmission of disease. METHODS: The Four Corners Health Department conducted an outbreak investigation and recorded both laboratory-confirmed and self-reported cases of SARS-CoV-2 and mitigation measures employed. We generated sequences on positive specimens, created an epidemic curve to assist with outbreak visualization, and examined epidemiologic, genomic, and laboratory outcomes. RESULTS: Evaluation of 3 index cases led to the identification of 25 people with COVID-19 who interacted directly with the camp. Contact tracing revealed an additional 18 cases consistent with onward community transmission. Most (24 of 35, 68.5%) vaccine-eligible community cases were not vaccinated. We sequenced 8 positive specimens; all were identified as the Delta variant. Precamp planning incorporated local health officials who recommended wearing face masks, practicing social distancing, and using attendee cohorts to limit mixing of people involved in various activities. CONCLUSION: Low vaccination levels and poor face mask-wearing habits among attendees resulted in secondary and tertiary spread of SARS-CoV-2 and severe outcomes among young adults. This outbreak of COVID-19 at a youth camp highlights the importance of vaccination and use of other measures to interrupt opportunities for SARS-CoV-2 spread in the community and shows that vaccinated people remain vulnerable to infection when in an environment of high exposure to SARS-CoV-2. Proactive case identification and interruption of chains of transmission can help decrease the number of cases and avoid further severe outcomes.

Reduced susceptibility of western corn rootworm (Diabrotica virgifera virgifera LeConte) populations to Cry34/35Ab1-expressing maize in northeast Nebraska.

The western corn rootworm (WCR; Diabrotica virgifera virgifera LeConte) is a significant pest of maize (Zea mays L.) across the United States Corn Belt. Transgenic maize hybrids expressing insecticidal proteins derived from Bacillus thuringiensis (Bt) have been used to manage WCR since 2003. Widespread resistance to Cry3Bb1 (and associated cross-resistance to mCry3A and eCry3.1Ab) has placed increased selection pressure on Cry34/35Ab1 in single-protein and pyramided transgenic maize hybrids. Data on the susceptibility of Nebraska WCR populations to Cry34/35Ab1 has not been published since 2015 and plant-based bioassays conducted in 2017-2018 confirmed resistance to Cry3Bb1 + Cry34/35Ab1 maize, suggesting resistance to Cry34/35Ab1 has evolved in the Nebraska landscape. Therefore, plant-based bioassays were conducted on F1 progeny of WCR populations collected from northeast Nebraska in 2018 and 2019. Larval survival and development were used to classify resistance to Cry34/35Ab1 in each WCR population. Bioassays confirmed incomplete resistance to Cry34/35Ab1 maize in 21 of 30 WCR populations; 9 of 30 WCR populations remained susceptible to Cry34/35Ab1. Collectively, results indicate that northeast Nebraska WCR populations were in the initial stages of resistance evolution to Cry34/35Ab1 during 2018-2019. Appropriate resistance management strategies are needed to mitigate resistance and preserve efficacy of rootworm-active products containing Cry34/35Ab1.

Access, socioeconomic environment, and death from COVID-19 in Nebraska.

Our study assesses whether factors related to healthcare access in the first year of the pandemic affect mortality and length of stay (LOS). Our cohort study examined hospitalized patients at Nebraska Medicine between April and October 2020 who were tested for SARS-CoV-2 and had a charted sepsis related diagnostic code. Multivariate logistic was used to analyze the odds of mortality and linear regression was used to calculate the parameter estimates of LOS associated with COVID-19 status, age, gender, race/ethnicity, median household income, admission month, and residential distance from definitive care. Among 475 admissions, the odds of mortality is greater among those with older age (OR: 1.04, 95% CI: 1.02-1.07) and residence in an area with low median household income (OR: 2.11, 95% CI: 0.52-8.57), however, the relationship between mortality and wealth was not statistically significant. Those with non-COVID-19 sepsis had longer LOS (Parameter Estimate: -5.11, adjusted 95% CI: -7.92 to -2.30). Distance from definitive care had trends toward worse outcomes (Parameter Estimate: 0.164, adjusted 95% CI: -1.39 to 1.97). Physical and social aspects of access to care are linked to poorer COVID-19 outcomes. Non-COVID-19 healthcare outcomes may be negatively impacted in the pandemic. Strategies to advance patient-centered outcomes in vulnerable populations should account for varied aspects (socioeconomic, residential setting, rural populations, racial, and ethnic factors). Indirect impacts of the pandemic on non-COVID-19 health outcomes require further study.

The Quest to Identify a New Virus Disease of Sunflower from Nebraska.

Between 2010 and 2018, sunflower plants exhibiting virus-like symptoms, including stunting, mottling, and chlorotic ringspots on leaves, were observed from commercial fields and research plots from four sites within three distinct counties of western Nebraska (Box Butte, Kimball, and Scotts Bluff). Near identical symptoms from field samples were reproduced on seedlings mechanically in the greenhouse on multiple occasions, confirming the presence of a sap-transmissible virus from each site. Symptomatic greenhouse-inoculated plants from the 2010 and 2011 Box Butte samples tested negative for sunflower mosaic virus (SuMV), sunflower chlorotic mottle virus (SuCMoV), and all potyviruses in general by ELISA and RT-PCR. Similar viral-like symptoms were later observed on plants in a commercial sunflower field in Kimball County in 2014, and again from volunteers in research plots in Scotts Bluff County in 2018. Samples from both of these years were again successfully reproduced on seedlings in the greenhouse as before following mechanical transmissions. Symptom expression for all years began 12 to 14 days after inoculation as mild yellow spots followed by the formation of chlorotic ringspots from the mottled pattern. The culture from 2014 tested negatively for three groups of nepoviruses via RT-PCR, ruling this group out. However, transmission electron microscopy assays of greenhouse-infected plants from both 2014 and 2018 revealed the presence of distinct, polyhedral virus particles. With the use of high throughput sequencing and RT-PCR, it was confirmed that the infections from both years were caused by a new virus in the tombusvirus genus and was proposed to be called Sunflower ring spot mottle virus (SuRSMV). Although the major objective of this project was to identify the causal agent of the disease, it became evident that the diagnostic journey itself, with all the barriers encountered on the 10-year trek, was actually more important and impactful than identification.

Lessons Learned from the 2019 Nebraska Floods: Implications for Emergency Management, Mass Care, and Food Security.

This qualitative study aimed to understand the actions, challenges, and lessons learned for addressing the food and water needs of flood survivors, with a special focus on vulnerable populations and the implications for food security, to inform future disaster response efforts in the U.S. Semi-structured in-depth interviews were conducted from January to August 2020 with the local, state, and national stakeholders (n = 27) involved in the disaster response to the 2019 Nebraska floods, particularly those involved in providing mass care, such as food, water, and shelter, for the flood survivors. The challenge themes were related to limited risk awareness and apathy, the large scope of the impact, the difficulty with coordination and communication, the challenges in risk communication, the limited local-level capacity, and the perceived stigma and fear limiting the utilization of governmental assistance. The mitigation recommendations included the need to consider zoning and infrastructure updates, the implementation of efficient systems that leverage technology for coordination and communication, and guidance on how to address certain human factors. This study reinforces previous findings related to flood disasters and adds to our understanding of disaster response and food insecurity. The practical takeaways from this study can inform future flood-related disaster mitigation approaches in Nebraska and other rural areas.

Examining missingness among children in out-of-home care placement in Nebraska.

BACKGROUND: Little is known regarding the prevalence and context of missingness (i.e., being reported as a missing person) among children in out-of-home (OOH) care. OBJECTIVE: The present research examines the relationship between missingness and OOH care placements as well as predictors and case contexts of children missing from OOH care. METHODS: Point-in-time count data of reported missing persons in Nebraska and administrative records on children's OOH placements are used. Bivariate significance tests examine group differences; case contexts are explored through content analysis of OOH case reviews. RESULTS: About 30 % of Nebraska's missing children are in OOH care. Bivariate tests show that children missing from OOH care are older and are more likely to be Black and less likely to have their race listed as "unknown" than children missing from their families of origin. Children in OOH who are missing are also more likely to be in group care, on probation, and have greater placement instability compared to children in OOH care who are not missing. Case contexts of missingness include unmet substance use and mental health challenges, experiences with violence and victimization, and few bonds to school. CONCLUSIONS: Screening and interventions for high-need children in OOH care and their caregivers are necessary to prevent children from going missing from placements.

Origins of high latitude introductions of Aedes aegypti to Nebraska and Utah during 2019.

Aedes aegypti (L.), the yellow fever mosquito, is also an important vector of dengue and Zika viruses, and an invasive species in North America. Aedes aegypti inhabits tropical and sub-tropical areas of the world and in North America is primarily distributed throughout the southern US states and Mexico. The northern range of Ae. aegypti is limited by cold winter months and establishment in these areas has been mostly unsuccessful. However, frequent introductions of Ae. aegypti to temperate, non-endemic areas during the warmer months can lead to seasonal activity and disease outbreaks. Two Ae. aegypti incursions were reported in the late summer of 2019 into York, Nebraska and Moab, Utah. These states had no history of established populations of this mosquito and no evidence of previous seasonal activity. We genotyped a subset of individuals from each location at 12 microsatellite loci and ~ 14,000 single nucleotide polymorphic markers to determine their genetic affinities to other populations worldwide and investigate their potential source of introduction. Our results support a single origin for each of the introductions from different sources. Aedes aegypti from Utah likely derived from Tucson, Arizona, or a nearby location. Nebraska specimen results were not as conclusive, but point to an origin from southcentral or southeastern US. In addition to an effective, efficient, and sustainable control of invasive mosquitoes, such as Ae. aegypti, identifying the potential routes of introduction will be key to prevent future incursions and assess their potential health threat based on the ability of the source population to transmit a particular virus and its insecticide resistance profile, which may complicate vector control.

How a Medical Orchestra Cultivates Creativity, Joy, Empathy, and Connection.

Background: Inspired by research indicating that exposure to humanities correlates with reduced burnout, the Nebraska Medical Orchestra was founded in 2018 as a collaboration between the University of Nebraska Medical Center and the University of Nebraska at Omaha School of Music. Methods: Semistructured interviews about orchestra participants' experiences were conducted with 9 musicians and recorded and transcribed. Transcripts were analyzed using the constant comparative method. Results: The interviews suggested that participants are drawn to the orchestra to pursue a love of music, to be part of an ensemble, and to connect with others in an environment that provides a lighthearted, nonjudgmental, noncompetitive forum in which to create and enjoy music for its own sake. Conclusions: This study has implications for designing arts-based wellness activities for clinicians and scaling them nationwide.

Wellness Through the Lens of a Medical Orchestra.

Stress and burnout afflict medical students and professionals at alarming rates, which has led institutions to invest in counseling services and other traditional wellness programming. However, the stigma of utilizing these services permeates the medical community. This narrative explores the founding of the Nebraska Medical Orchestra-an orchestra created as a nontraditional antidote to reduce stress and burnout among health care students and professionals-and also examines the concept of wellness through interactions between the orchestra's director and health care-related musicians.

Analyzing Unnecessary Imaging for Low Back Pain in Nebraska from a Statewide Health Information Exchange.

Excessive amounts of resources in healthcare are wasted due to duplicated or unnecessary health screenings, especially in the diagnosis of low back pain (LBP). Research shows that two-thirds of people will present with LBP at some point throughout their lifetime, but 20-50% of high-tech imaging procedures fail to provide information that improves the patient's condition, representing unnecessary services. The purpose of this study was to evaluate the existence of unnecessary imaging for low back pain throughout healthcare systems in Nebraska based on what was documented in the electronic health record. This study was a retrospective electronic health record analysis of a limited data set focused on procedures related to imaging for LBP extracted from Nebraska Health Information Exchange (HIE) managed by CyncHealth. The sample included 937 patient records with a diagnosis of LBP who received imaging in the state of Nebraska and whose health record was recorded in the Nebraska HIE. To determine necessity, records were categorized in three areas including necessary imaging, likely wasteful imaging, or wasteful imaging based on the criteria from the "First, Do No Harm" study conducted by the Washington Health Alliance. Results revealed a total of 51% of low back pain imaging considered wasteful, 35% likely wasteful, and 14% necessary. Based on these results, further research is warranted to determine specific demographics related to necessary, likely wasteful, and wasteful imaging and the purpose for performing these expensive imaging procedures.

The Behavioral Health Education Center of Nebraska: A Creative Solution to a Persistent Behavioral Health Workforce Shortage.

States all across the United States are experiencing a shortage in their behavioral health workforces. Although many studies have suggested factors that contribute to or mitigate the shortage-particularly in rural and underserved areas-no nationwide guidance exists on best practices to develop a behavioral health workforce that can meet community need. The Behavioral Health Education of Nebraska (BHECN) can serve as an exemplar for others looking to take a multifaceted approach to develop the behavioral health workforce in their community. Evidence from published studies is reviewed, and BHECN's approach and practices are explained.

Drought and all-cause mortality in Nebraska from 1980 to 2014: Time-series analyses by age, sex, race, urbanicity and drought severity.

BACKGROUND: Climate change will increase drought duration and severity in many regions around the world, including the Central Plains of North America. However, studies on drought-related health impacts are still sparse. This study aims to explore the potential associations between drought and all-cause mortality in Nebraska from 1980 to 2014. METHODS: The Evaporative Demand Drought Index (EDDI) were used to define short-, medium- and long-term drought exposures, respectively. We used a Bayesian zero-inflated censored negative binomial (ZICNB) regression model to estimate the overall association between drought and annual mortality first in the total population and second in stratified sub-populations based on age, race, sex, and the urbanicity class of the counties. RESULTS: The main findings indicate that there is a slightly negative association between all-cause mortality and all types of droughts in the total population, though the effect is statistically null. The joint-stratified analysis renders significant results for a few sub-groups. White population aged 25-34 and 45-64 in metro counties and 45-54 in non-metro counties were the population more at risk in Nebraska. No positive associations were observed in any race besides white. Black males aged 20-24 and white females older than 85 showed protective effect against drought mainly in metro counties. We also found that more sub-populations had higher rates of mortality with longer-term droughts compared to shorter-term droughts (12-month vs 1- or 6-month timescales), in both metro and non-metro counties, collectively. CONCLUSION: Our results suggest that mortality in middle aged white population in Nebraska shows a greater association with drought. Moreover, women aged 45-54 were more affected than men in non-metro counties. With a projected increase in the frequency and severity of drought due to climate change, understanding these relationships between drought and human health will better inform drought mitigation planning to reduce potential impacts.

Ecological Approach to Family-Style, Multilevel Child Care Intervention: Formative Evaluation Using RE-AIM Framework.

OBJECTIVE: Conduct formative evaluation of Ecological Approach to Family-Style Dining (EAT) Intervention. DESIGN: Qualitative semistructured interviews and demographic surveys. SETTING: Early care and education (ECE) centers in Nebraska. PARTICIPANTS: Cooperative Extension coaches (n = 9), ECE administrators (n = 8), and teachers (n = 17) caring for children aged 3-5 years. INTERVENTION: The EAT intervention (a 16-week, 7-lesson, evidence-based online responsive feeding ECE model) uses a multilevel improvement system of 5 implementation strategies. Early care and education administrators and teachers completed 1 lesson/wk followed by a coaching session. MAIN OUTCOME MEASURES: The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework includes 5 evaluative dimensions. ANALYSIS: Thematic analysis. RESULTS: Overall, 77% of children aged 3-5 years (n = 216) participated from targeted Child and Adult Care Food Program ECEs (Reach). All perceived EAT improved children's nutritional and developmental outcomes and encouraged a positive mealtime environment (Effectiveness). Coaches found professional development incentives important, whereas administrators/teachers valued inservice hours (Adoption). Teachers reported successful implementation of responsive feeding, and administrators supported the teachers (Implementation). All reported they intended to continue using EAT, and administrators and teachers discussed incorporating EAT practices into the handbook/school policy (Maintenance). CONCLUSION AND IMPLICATIONS: The EAT was valued by all stakeholders for its perceived effectiveness to positively impact children's nutritional outcomes. Furthermore, stakeholders valued the provided incentives and multilevel design with coaching, ECE administrators, and teachers. Future research is needed on how to use Extension coaches in ECE interventions.

Aedes japonicus japonicus in Nebraska and Texas.

Aedes japonicus japonicus continues to spread westward and in this study, its presence is documented in 8 counties in Nebraska and in Bowie County, TX. In 1998, Ae. japonicus was collected in Connecticut, New Jersey, and New York for the 1st records of this species in North America. Except for Louisiana, it has been reported from all states that border or are east of the Mississippi River. In Canada, it has been reported in Ontario and all eastern provinces. In the Pacific Northwest, it has been reported in Washington, Oregon, and British Columbia, and in the midwestern states that do not border the Mississippi River, Kansas, Oklahoma, and South Dakota are the only states to have reported its presence in peer-reviewed journals.

Context-dependent role of abiotic and biotic factors structuring nematode communities along two environmental gradients.

Although abiotic environmental factors have been historically regarded as the dominant deterministic process in microbial community assembly, recent studies indicate that biotic interactions may be equally significant. However, the extent to which both processes are important in assembly of belowground communities is unknown. Along two environmental gradients: alkalinity (ranging from pH ~7 to ~11) and habitat type (lakes, shorelines, and prairies around lakes) present in the Western Nebraska Sandhills, we used 18S rRNA gene marker metabarcoding and statistical analyses, including generalized dissimilarity modelling (GDM), to evaluate the dynamics between abiotic and biotic factors that might play a role in nematode community assembly. Lakes supported the least diverse and prairies the most diverse communities with completely distinct compositions. We also observed a potential role of alkalinity in shaping these communities but only in lakes. Generally, GDMs indicated the influence of both abiotic and biotic factors. However, their relative importance in explaining community variability was dependent on the habitat. Biotic factors influenced the lake communities most, followed by shorelines and prairies, explaining ~47%, 27% and 8% of the variation, respectively. In contrast, the role of abiotic factors was relatively similar in lakes, shorelines and prairies (~15%, 18% and 14% of the variation, respectively). Most variation in the shorelines (62%) and prairies (82%) remained unexplained, suggesting the potential importance of factors associated with specific traits or a stronger role of stochastic processes. Nevertheless, our findings suggest both deterministic processes are important in nematode community assembly, but their specific contributions are context-dependent.

Correlates of Betel Nut Chewing among Burmese Refugees in Nebraska.

BACKGROUND: Betel nut chewing is an important risk factor for oral cancer, yet there has been little research identifying correlates of betel nut chewing among Burmese refugees in the U.S. METHODS: Based on survey data from 188 Burmese refugees from Nebraska between 2015 and 2016, logistic regression was estimated to identify correlates of betel nut chewing. RESULTS: The prevalence rate of betel nut chewing among participating Burmese refugees in Nebraska was 29%. Relative to Burmese refugees who had an education of less than high school, refugees with higher education were less likely to report betel nut chewing (AOR=0.1, 95% CI (0.02, 0.61)). Refugees who worked full time had higher odds of chewing betel nuts compared to those otherwise (AOR=6.17, 95% CI (1.80, 21.10)). Delaying medication purchase due to cost during the past 12 months was associated with higher odds of betel nut chewing (AOR=5.20, 95% CI (1.02, 26.39)). CONCLUSIONS: Betel nut chewing was common among Burmese refugees in the U.S., yet the odds of betel nut chewing varied across different socioeconomic groups. Health education programs that aim to reduce betel nut chewing might become more cost-effective by disproportionately targeting and serving high-risk groups among Burmese refugees.