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The racial gap in infant mortality is a pressing public-health concern, and [B. N. Greenwood et al., Proc. Natl. Acad. Sci. U.S.A. 117, 21194-21200 (2020), 10.1073/pnas.1913405117] suggest that Black newborns are more likely to survive if cared for by Black physicians after birth, even in models that control for numerous variables, including hospital and physician fixed effects, and the 65 most common comorbidities affecting newborns (as described by International Classification of Disease codes). We acquired the data used in the study, covering Florida hospital discharges from 1992 through the third quarter of 2015, to replicate and extend the analysis. We find that the magnitude of the concordance effect is substantially reduced after controlling for diagnoses indicating very low birth weight (<1,500 g), which are a strong predictor of neonatal mortality but not among the 65 most common comorbidities. In fact, the estimated effect is near zero and statistically insignificant in the expanded specifications that control for very low birth weight and include hospital and physician fixed effects.

Asunto(s)

Mortalidad Infantil , Humanos , Recién Nacido , Mortalidad Infantil/etnología , Florida/epidemiología , Femenino , Lactante , Masculino , Negro o Afroamericano , Relaciones Médico-Paciente , Médicos

RESUMEN

BACKGROUND: When the vast majority (e.g., ≈90%) of a specialty's elective (scheduled) care is ambulatory (i.e., length of stay 0 or 1 night), the administrative, clinical, and economic policy implications are profound. We examined the progressive shift of elective anesthetics in Florida from inpatient to ambulatory, from the first quarter of 2010 through the fourth quarter of 2022. We were particularly interested in the most recent data following the lifting of COVID-19 restrictions on elective surgery in the state. METHODS: This retrospective cohort study included major therapeutic and major diagnostic procedures with >0 American Society of Anesthesiologists base units in the state of Florida inpatient and ambulatory surgery databases. The last 8 quarters of these operating room anesthetic data corresponded to the end of restrictions on elective surgery in Florida due to the COVID-19 pandemic. Our goal was to determine whether the overall mean percentage of cases with 0- or 1-day lengths of stay has reached 90% since the lifting of pandemic restrictions. Numbers of cases over periods of at least four weeks tend to follow normal distributions. Therefore, we analyzed the N = 8 quarters of cases from 2021 to 2022 using Student's t-test. The study was performed when there were N = 8 quarters available from the Florida healthcare databases. RESULTS: There were overall 22,584,752 surgical cases studied. The percentages of elective anesthetics with length of stay ≤1-day increased progressively from 2010 through 2020. Among the eight successive quarters since the end of pandemic-related elective surgery restrictions, the percentage of elective cases with length of stay 0- or 1 day was stable, averaging 90% (95% two-sided confidence interval 89.4% to 90.3%). CONCLUSION: Since the COVID-19 pandemic, the mean quarterly percentage of elective surgery cases with anesthesia in Florida that were ambulatory has been reliably ≈90%. Implications include value in expecting overnight post-anesthesia care unit stay in ambulatory surgery centers and scheduling and sequencing cases based on post-anesthesia care unit capacity. Furthermore, because the vast majority (i.e., ≈90%) of cases would be excluded (i.e., not involve hospital admission for at least 2 midnights), there is a minimal role that risk-adjusted hospital length of stay and mortality can have in evaluating anesthesia department overall quality and economic effectiveness.

Asunto(s)

Procedimientos Quirúrgicos Ambulatorios , COVID-19 , Procedimientos Quirúrgicos Electivos , Tiempo de Internación , Humanos , Florida/epidemiología , COVID-19/epidemiología , COVID-19/prevención & control , Estudios Retrospectivos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Anestésicos/administración & dosificación , Persona de Mediana Edad , Adulto , Femenino , Masculino , Anciano , Anestesia/estadística & datos numéricos , Anestesia/métodos

RESUMEN

INTRODUCTION: Diabetes disparities exist based on socioeconomic status, race, and ethnicity. The aim of this study is to compare two cohorts with diabetes from California and Florida to better elucidate how health outcomes are stratified within underserved communities according to state location, race, and ethnicity. RESEARCH DESIGN AND METHODS: Two cohorts were recruited for comparison from 20 Federally Qualified Health Centers as part of a larger ECHO Diabetes program. Participant-level data included surveys and HbA1c collection. Center-level data included Healthcare Effectiveness Data and Information Set metrics. Demographic characteristics were summarized overall and stratified by state (frequencies, percentages, means (95% CIs)). Generalized linear mixed models were used to compute and compare model-estimated rates and means. RESULTS: Participant-level cohort: 582 adults with diabetes were recruited (33.0% type 1 diabetes (T1D), 67.0% type 2 diabetes (T2D)). Mean age was 51.1 years (95% CI 49.5, 52.6); 80.7% publicly insured or uninsured; 43.7% non-Hispanic white (NHW), 31.6% Hispanic, 7.9% non-Hispanic black (NHB) and 16.8% other. Center-level cohort: 32 796 adults with diabetes were represented (3.4% with T1D, 96.6% with T2D; 72.7% publicly insured or uninsured). Florida had higher rates of uninsured (p<0.0001), lower continuous glucose monitor (CGM) use (18.3% Florida; 35.9% California, p<0.0001), and pump use (10.2% Florida; 26.5% California, p<0.0001), and higher proportions of people with T1D/T2D>9% HbA1c (p<0.001). Risk was stratified within states with NHB participants having higher HbA1c (mean 9.5 (95% CI 8.9, 10.0) compared with NHW with a mean of 8.4 (95% CI 7.8, 9.0), p=0.0058), lower pump use (p=0.0426) and CGM use (p=0.0192). People who prefer to speak English were more likely to use a CGM (p=0.0386). CONCLUSIONS: Characteristics of medically underserved communities with diabetes vary by state and by race and ethnicity. Florida's lack of Medicaid expansion could be a factor in worsened risks for vulnerable communities with diabetes.

Asunto(s)

Diabetes Mellitus Tipo 2 , Disparidades en Atención de Salud , Humanos , Femenino , Masculino , Persona de Mediana Edad , Disparidades en Atención de Salud/estadística & datos numéricos , California/epidemiología , Adulto , Diabetes Mellitus Tipo 2/epidemiología , Florida/epidemiología , Estudios de Cohortes , Área sin Atención Médica , Diabetes Mellitus Tipo 1/epidemiología , Hemoglobina Glucada/análisis , Factores Socioeconómicos , Diabetes Mellitus/epidemiología , Estudios de Seguimiento

RESUMEN

Positive blood cultures have been identified in debilitated, stranded, and deceased green turtles (Chelonia mydas), suggestive of septicemia. Interpretation of these results is often difficult because multiple studies have previously identified bacteremia in clinically healthy reptiles. In this study, paired blood cultures and skin cultures obtained after aseptic preparation of the venipuncture site were collected from 50 immature free-ranging green turtles from Port Canaveral, Florida. Blood culture results were compared with health status (apparently healthy versus unhealthy, based on physical examination findings and appropriate body condition), date of collection, presence of external fibropapillomatosis, healed or unhealed injuries, and presence of barnacles. Weight, body condition score, body condition index, morphometric measures, volume of blood collected, and body temperature were compared between blood culture-positive and blood culture-negative turtles. Positive blood cultures were identified in 14% (7 of 50) of all turtles, including 15.6% (5 of 32) of apparently healthy turtles. Vibrio spp., Bacillus megaterium, Cellulomonas sp., and Staphylococcus pasteuri were isolated in blood culture from apparently healthy individuals. There was a significant association (P = 0.048) between positive skin cultures and positive blood cultures, but isolates obtained were consistently different between paired results. There was no significant association (P > 0.05) between blood culture results and health status, evidence of healed or unhealed injuries, external fibropapillomatosis, or presence of barnacles. Based on the results of this study, positive blood cultures suggestive of nonclinical bacteremia may be present in apparently healthy green turtles. The results of this study will aid the attending clinician in interpretation of blood culture results of apparently healthy or presumed septicemic captive and rehabilitating green turtles as part of the conservation and population recovery of this threatened species.

Asunto(s)

Cultivo de Sangre , Tortugas , Animales , Tortugas/sangre , Tortugas/microbiología , Florida/epidemiología , Cultivo de Sangre/veterinaria , Animales Salvajes , Femenino , Masculino , Bacteriemia/veterinaria , Bacteriemia/microbiología

RESUMEN

INTRODUCTION: Pancreatic ductal adenocarcinoma (PDAC) is currently the third-leading cause of cancer-related death in the United States. African Americans (AAs) with PDAC have worse survival in comparison to other racial groups. The COVID-19 pandemic caused significant stress to the healthcare system. We aim to evaluate the pandemic's impact on already known disparities in newly diagnosed patients with PDAC in Florida. METHODS: This is a retrospective analysis of newly diagnosed patients with PDAC in the OneFlorida+ Data Trust based upon date of diagnosis: Pre-pandemic (01/01/2017- 09/30/2019), Transition (10/01/2019-02/28/2020), and Pandemic (03/1/2020-10/31/2020). Primary endpoints are time to treatment initiation and rate of surgery and secondary endpoint is survival time. Disparities due to age, sex, race, and income were also evaluated. Chi-squared or Fisher's exact test when necessary, Kruskal-Wallis test, and Kaplan-Meier analysis with log-rank test were performed to compare the differences between the comparative groups for categorical, quantitative, and survival outcomes, respectively. Multivariable regression analyses were conducted to estimate the effects of cofactors. RESULTS: 934 patients with a median age of 67 years were included. There were 47.8% females and 52.2% males; 19.4% AA, 70.2% Caucasian, 10.4% Other race; median income was $53,551. While we observed a significant reduction in the diagnosis rate of new PDAC cases during the pandemic, there were no significant differences in demographic distributions among the three cohorts. Time to treatment did not significantly change from the pre-pandemic to the pandemic, and no difference was observed across all demographics. Rate of surgery increased significantly from the pre-pandemic (35.8%) to the pandemic (55.6%). AAs in the pre-pandemic cohort had a significantly lower rate of surgery of 25.0% compared to 41.7% in Caucasians. AAs, patients ≥ 67 years, and income < $53,000 had significantly higher hazards to death and shorter median survival time (mST). CONCLUSIONS: While no differences in time to initial treatment are observed among the newly diagnosed PDAC patients, there remain significant disparities in the rate of surgery and overall survival. Observing a significant reduction in diagnosis rate and analyzing disparities can provide insight into the effect of a resource-restricting pandemic for patients with newly diagnosed PDAC.

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Carcinoma Ductal Pancreático , Disparidades en Atención de Salud , Neoplasias Pancreáticas , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Negro o Afroamericano/estadística & datos numéricos , Carcinoma Ductal Pancreático/terapia , Carcinoma Ductal Pancreático/mortalidad , Carcinoma Ductal Pancreático/etnología , COVID-19/epidemiología , Florida/epidemiología , Disparidades en Atención de Salud/etnología , Neoplasias Pancreáticas/mortalidad , Neoplasias Pancreáticas/terapia , Neoplasias Pancreáticas/etnología , Pandemias , Estudios Retrospectivos , Blanco/estadística & datos numéricos

RESUMEN

BACKGROUND: Although substance use may have adverse impacts on cancer outcomes, little is known regarding patterns of concurrent substance use with cannabis among cancer patients. Our objective was to examine predictors of concurrent substance use with cannabis among cancer patients since their cancer diagnosis and explore perceptions of cannabis among these patients. METHODS: Patients treated at a National Cancer Institute-designated comprehensive cancer center were invited to participate in an electronic survey regarding medical cannabis from August to November 2021. Survey data were linked to internal data resources including electronic health records and patient intake forms to obtain history of substance use (defined as within at least 3 months of cancer diagnosis) of cigarettes, injection drugs, high levels of alcohol, or clinically unsupervised prescription drugs (total n = 1094). Concurrent substance users were defined as those with any reported substance use and cannabis use at the time of cancer diagnosis. We used descriptive statistics (χ2 or exact tests) to compare groups and estimated adjusted odds ratios (AORs) with 95% confidence intervals (CIs) to identify predictors of substance use among users and nonusers of cannabis. RESULTS: Approximately 45% (n = 489) of the sample reported cannabis use since their cancer diagnosis. Of patients who reported using cannabis, 20% self-reported concurrent polysubstance use, while 8% of cannabis nonusers reported substance use (P < .001). Among patients who use cannabis, those who reported 2 or more self-reported treatment-related symptoms (eg, pain, fatigue) were more likely to have self-reported concurrent substance use (AOR = 3.15, 95% CI = 1.07 to 9.27) compared with those without any symptoms. Among nonusers, those with lower educational background were more likely to have a history of concurrent substance use (AOR = 3.74, 95% CI = 1.57 to 8.92). Patients who use cannabis with concurrent substance use were more likely to report improved sleep (P = .04), increased appetite (P = .03), and treatment of additional medical conditions (P = .04) as perceived benefits of cannabis use. CONCLUSIONS: High symptom burden may be associated with concurrent substance use with cannabis among cancer patients.

Asunto(s)

Neoplasias , Trastornos Relacionados con Sustancias , Humanos , Masculino , Femenino , Neoplasias/epidemiología , Neoplasias/diagnóstico , Neoplasias/complicaciones , Neoplasias/etiología , Persona de Mediana Edad , Florida/epidemiología , Anciano , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/complicaciones , Trastornos Relacionados con Sustancias/diagnóstico , Adulto , Estados Unidos/epidemiología , National Cancer Institute (U.S.) , Marihuana Medicinal/uso terapéutico , Marihuana Medicinal/efectos adversos , Encuestas y Cuestionarios

Asunto(s)

Servicio de Urgencia en Hospital , Infecciones por VIH , Tamizaje Masivo , Humanos , Infecciones por VIH/diagnóstico , Infecciones por VIH/transmisión , Infecciones por VIH/prevención & control , Infecciones por VIH/epidemiología , Florida/epidemiología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Adulto , Tamizaje Masivo/métodos , Masculino , Femenino , Prueba de VIH/estadística & datos numéricos , Persona de Mediana Edad , Aceptación de la Atención de Salud/estadística & datos numéricos

RESUMEN

Background: Chronic obstructive pulmonary disease (COPD) is a chronic, inflammatory respiratory disease that obstructs airflow and decreases lung function and is a leading cause death globally. In the United States (US), the prevalence among adults is 6.2%, but increases with age to 12.8% among those 65 years or older. Florida has one of the largest populations of older adults in the US, accounting for 4.5 million adults 65 years or older. This makes Florida an ideal geographic location for investigating COPD as disease prevalence increases with age. Understanding the geographic disparities in COPD and potential associations between its disparities and environmental factors as well as population characteristics is useful in guiding intervention strategies. Thus, the objectives of this study are to investigate county-level geographic disparities of COPD prevalence in Florida and identify county-level socio-demographic predictors of COPD prevalence. Methods: This ecological study was performed in Florida using data obtained from the US Census Bureau, Florida Health CHARTS, and County Health Rankings and Roadmaps. County-level COPD prevalence for 2019 was age-standardized using the direct method and 2020 US population as the standard population. High-prevalence spatial clusters of COPD were identified using Tango's flexible spatial scan statistics. Predictors of county-level COPD prevalence were investigated using multivariable ordinary least squares model built using backwards elimination approach. Multicollinearity of regression coefficients was assessed using variance inflation factor. Shapiro-Wilks, Breusch Pagan, and robust Lagrange Multiplier tests were used to assess for normality, homoskedasticity, and spatial autocorrelation of model residuals, respectively. Results: County-level age-adjusted COPD prevalence ranged from 4.7% (Miami-Dade) to 16.9% (Baker and Bradford) with a median prevalence of 9.6%. A total of 6 high-prevalence clusters with prevalence ratios >1.2 were identified. The primary cluster, which was also the largest geographic cluster that included 13 counties, stretched from Nassau County in north-central Florida to Charlotte County in south-central Florida. However, cluster 2 had the highest prevalence ratio (1.68) and included 10 counties in north-central Florida. Together, the primary cluster and cluster 2 covered most of the counties in north-central Florida. Significant predictors of county-level COPD prevalence were county-level percentage of residents with asthma and the percentage of current smokers. Conclusions: There is evidence of spatial clusters of COPD prevalence in Florida. These patterns are explained, in part, by differences in distribution of some health behaviors (smoking) and co-morbidities (asthma). This information is important for guiding intervention efforts to address the condition, reduce health disparities, and improve population health.

Asunto(s)

Enfermedad Pulmonar Obstructiva Crónica , Humanos , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Florida/epidemiología , Anciano , Masculino , Femenino , Prevalencia , Análisis Espacial , Anciano de 80 o más Años , Persona de Mediana Edad , Factores de Riesgo , Factores Sociodemográficos , Disparidades en el Estado de Salud

RESUMEN

Aedes aegypti is an important vector of dengue virus and other arboviruses that affect human health. After being ingested in an infectious bloodmeal, but before being transmitted from mosquito to human, dengue virus must disseminate from the vector midgut into the hemocoel and then the salivary glands. This process, the extrinsic incubation period, typically takes 6-14 days. Since older mosquitoes are responsible for transmission, understanding the age structure of vector populations is important. Transcriptional profiling can facilitate predictions of the age structures of mosquito populations, critical for estimating their potential for pathogen transmission. In this study, we utilized a two-gene transcript model to assess the age structure and daily survival rates of three populations (Key West, Marathon, and Key Largo) of Ae. aegypti from the Florida Keys, United States, where repeated outbreaks of autochthonous dengue transmission have recently occurred. We found that Key Largo had the youngest Ae. aegypti population with the lowest daily survival rate, while Key West had the oldest population and highest survival rate. Across sites, 22.67% of Ae. aegypti females were likely old enough to transmit dengue virus (at least 15 days post emergence). Computed estimates of the daily survival rate (0.8364 using loglinear and 0.8660 using non-linear regression), indicate that dengue vectors in the region experienced relatively low daily mortality. Collectively, our data suggest that Ae. aegypti populations across the Florida Keys harbor large numbers of older individuals, which likely contributes to the high risk of dengue transmission in the area.

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Aedes , Virus del Dengue , Dengue , Mosquitos Vectores , Aedes/virología , Aedes/genética , Animales , Florida/epidemiología , Virus del Dengue/genética , Mosquitos Vectores/virología , Mosquitos Vectores/genética , Femenino , Dengue/transmisión , Dengue/virología , Perfilación de la Expresión Génica , Humanos , Masculino

RESUMEN

OBJECTIVE: In order to predict at hospital admission the prognosis of patients with serious and life-threatening COVID-19 pneumonia, we sought to understand the clinical characteristics of hospitalised patients at admission as the SARS-CoV-2 pandemic progressed, document their changing response to the virus and its variants over time, and identify factors most importantly associated with mortality after hospital admission. DESIGN: Observational study using a prospective hospital systemwide COVID-19 database. SETTING: 15-hospital US health system. PARTICIPANTS: 26 872 patients admitted with COVID-19 to our Northeast Ohio and Florida hospitals from 1 March 2020 to 1 June 2022. MAIN OUTCOME MEASURES: 60-day mortality (highest risk period) after hospital admission analysed by random survival forests machine learning using demographics, medical history, and COVID-19 vaccination status, and viral variant, symptoms, and routine laboratory test results obtained at hospital admission. RESULTS: Hospital mortality fell from 11% in March 2020 to 3.7% in March 2022, a 66% decrease (p<0.0001); 60-day mortality fell from 17% in May 2020 to 4.7% in May 2022, a 72% decrease (p<0.0001). Advanced age was the strongest predictor of 60-day mortality, followed by admission laboratory test results. Risk-adjusted 60-day mortality had all patients been admitted in March 2020 was 15% (CI 3.0% to 28%), and had they all been admitted in May 2022, 12% (CI 2.2% to 23%), a 20% decrease (p<0.0001). Dissociation between observed and predicted decrease in mortality was related to temporal change in admission patient profile, particularly in laboratory test results, but not vaccination status or viral variant. CONCLUSIONS: Hospital mortality from COVID-19 decreased substantially as the pandemic evolved but persisted after hospital discharge, eclipsing hospital mortality by 50% or more. However, after accounting for the many, even subtle, changes across the pandemic in patients' demographics, medical history and particularly admission laboratory results, a patient admitted early in the pandemic and predicted to be at high risk would remain at high risk of mortality if admitted tomorrow.

Asunto(s)

COVID-19 , Mortalidad Hospitalaria , Hospitalización , SARS-CoV-2 , Humanos , COVID-19/mortalidad , COVID-19/epidemiología , Masculino , Femenino , Persona de Mediana Edad , Anciano , Mortalidad Hospitalaria/tendencias , Hospitalización/estadística & datos numéricos , Estudios Prospectivos , Pandemias , Estados Unidos/epidemiología , Adulto , Anciano de 80 o más Años , Pronóstico , Florida/epidemiología

RESUMEN

BACKGROUND: The Beijing genotype of Mycobacterium tuberculosis (Mtb) has sparked debate regarding its virulence and transmissibility. This study contributes to this discussion by assessing its effect on the risk of latent tuberculosis infection (LTBI), active tuberculosis (TB) disease among contacts, and clustering of known TB cases. METHODS: We conducted a retrospective cohort study using the records of 4457 culture-confirmed TB patients and their contacts (20,448) reported to the Florida Department of Health between 2009 and 2023. Univariate and multivariate analyses were used to evaluate the effect of the Beijing strain on LTBI, active TB risk among contacts, and case clustering. RESULTS: Our study revealed no significant difference in transmissibility between the Beijing and non-Beijing genotypes among contacts. LTBI prevalence was 19.9%, slightly higher in non-Beijing than Beijing genotypes (20.2% vs. 15.5%, p < 0.001). The prevalence of active TB was 1.8%, with no significant difference between the Beijing and non-Beijing genotypes (1.4% vs. 1.8%, p = 0.296). Increased LTBI risk was associated with older age, male sex, Hispanic ethnicity, multidrug-resistant TB exposure, household exposure, and a longer exposure duration. Active TB risk was higher for males, HIV-positive individuals, and contacts with more prolonged exposure to index cases. The Beijing genotype was associated with increased TB case clustering (aOR = 1.98, 95%CI: 1.53, 2.55, p < 0.001) as compared to the non-Beijing genotypes. US birthplace (aOR = 2.75, 95%CI: 2.37, 3.19, p < 0.001), pulmonary disease (aOR = 1.27, 95%CI: 1.04, 1.56, p < 0.020), cavitary TB (aOR = 1.25, 95% CI: 1.08, 1.44, p < 0.003), previous year alcohol use (aOR = 1.68, 95%CI: 1.38, 2.04, p < 0.001), and recreational drug use (aOR = 1.32, 95%CI: 1.04, 1.67, p < 0.024) were also associated with an increased risk of TB case clustering. CONCLUSION: While the Beijing genotype did not increase the risk of LTBI or active TB among contacts, it showed a higher tendency for case clustering. Hence, interventions should prioritize populations where this genotype is prevalent.

Asunto(s)

Genotipo , Tuberculosis Latente , Mycobacterium tuberculosis , Humanos , Masculino , Mycobacterium tuberculosis/genética , Femenino , Tuberculosis Latente/epidemiología , Tuberculosis Latente/microbiología , Adulto , Persona de Mediana Edad , Estudios Retrospectivos , Adulto Joven , Factores de Riesgo , Adolescente , Análisis por Conglomerados , Anciano , Prevalencia , Tuberculosis/epidemiología , Tuberculosis/microbiología , Niño , Preescolar , Lactante , Florida/epidemiología

RESUMEN

BACKGROUND: Elevated levels of lipoprotein(a) (Lp(a)) are independently associated with an increased risk of atherosclerotic cardiovascular disease events. However, the mechanisms driving this association are poorly understood. We aimed to evaluate the association between Lp(a) and coronary plaque characteristics in a contemporary US cohort without clinical atherosclerotic cardiovascular disease, undergoing coronary computed tomography angiography, the noninvasive gold standard for the assessment of coronary atherosclerosis. METHODS: We used baseline data from the Miami Heart Study-a community-based, prospective cohort study-which included asymptomatic adults aged 40 to 65 years evaluated using coronary computed tomography angiography. Those taking any lipid-lowering therapies were excluded. Elevated Lp(a) was defined as ≥125 nmol/L. Outcomes included any plaque, coronary artery calcium score >0, maximal stenosis ≥50%, presence of any high-risk plaque feature (positive remodeling, spotty calcification, low-attenuation plaque, napkin ring), and the presence of ≥2 high-risk plaque features. RESULTS: Among 1795 participants (median age, 52 years; 54.3% women; 49.6% Hispanic), 291 (16.2%) had Lp(a) ≥125 nmol/L. In unadjusted analyses, individuals with Lp(a) ≥125 nmol/L had a higher prevalence of all outcomes compared with Lp(a) <125 nmol/L, although differences were only statistically significant for the presence of any coronary plaque and ≥2 high-risk features. In multivariable models, elevated Lp(a) was independently associated with the presence of any coronary plaque (odds ratio, 1.40, [95% CI, 1.05-1.86]) and with ≥2 high-risk features (odds ratio, 3.94, [95% CI, 1.82-8.52]), although only 35 participants had this finding. Among participants with a coronary artery calcium score of 0 (n=1200), those with Lp(a) ≥125 nmol/L had a significantly higher percentage of any plaque compared with those with Lp(a) <125 nmol/L (24.2% versus 14.2%; P<0.001). CONCLUSIONS: In this contemporary analysis, elevated Lp(a) was independently associated with the presence of coronary plaque. Larger studies are needed to confirm the strong association observed with the presence of multiple high-risk coronary plaque features.

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Enfermedades Asintomáticas , Biomarcadores , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Enfermedad de la Arteria Coronaria , Lipoproteína(a) , Placa Aterosclerótica , Humanos , Persona de Mediana Edad , Femenino , Masculino , Lipoproteína(a)/sangre , Florida/epidemiología , Estudios Prospectivos , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/diagnóstico , Adulto , Biomarcadores/sangre , Anciano , Factores de Riesgo , Vasos Coronarios/diagnóstico por imagen , Regulación hacia Arriba , Valor Predictivo de las Pruebas , Medición de Riesgo , Prevalencia , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/epidemiología , Calcificación Vascular/sangre

RESUMEN

Background: Over the last few decades, diabetes-related mortality risks (DRMR) have increased in Florida. Although there is evidence of geographic disparities in pre-diabetes and diabetes prevalence, little is known about disparities of DRMR in Florida. Understanding these disparities is important for guiding control programs and allocating health resources to communities most at need. Therefore, the objective of this study was to investigate geographic disparities and temporal changes of DRMR in Florida. Methods: Retrospective mortality data for deaths that occurred from 2010 to 2019 were obtained from the Florida Department of Health. Tenth International Classification of Disease codes E10-E14 were used to identify diabetes-related deaths. County-level mortality risks were computed and presented as number of deaths per 100,000 persons. Spatial Empirical Bayesian (SEB) smoothing was performed to adjust for spatial autocorrelation and the small number problem. High-risk spatial clusters of DRMR were identified using Tango's flexible spatial scan statistics. Geographic distribution and high-risk mortality clusters were displayed using ArcGIS, whereas seasonal patterns were visually represented in Excel. Results: A total of 54,684 deaths were reported during the study period. There was an increasing temporal trend as well as seasonal patterns in diabetes mortality risks with high risks occurring during the winter. The highest mortality risk (8.1 per 100,000 persons) was recorded during the winter of 2018, while the lowest (6.1 per 100,000 persons) was in the fall of 2010. County-level SEB smoothed mortality risks varied by geographic location, ranging from 12.6 to 81.1 deaths per 100,000 persons. Counties in the northern and central parts of the state tended to have high mortality risks, whereas southern counties consistently showed low mortality risks. Similar to the geographic distribution of DRMR, significant high-risk spatial clusters were also identified in the central and northern parts of Florida. Conclusion: Geographic disparities of DRMR exist in Florida, with high-risk spatial clusters being observed in rural central and northern areas of the state. There is also evidence of both increasing temporal trends and Winter peaks of DRMR. These findings are helpful for guiding allocation of resources to control the disease, reduce disparities, and improve population health.

Asunto(s)

Diabetes Mellitus , Humanos , Florida/epidemiología , Estudios Retrospectivos , Diabetes Mellitus/mortalidad , Diabetes Mellitus/epidemiología , Femenino , Masculino , Teorema de Bayes , Disparidades en el Estado de Salud , Persona de Mediana Edad , Factores de Riesgo , Estaciones del Año , Anciano , Adulto

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INTRODUCTION: Improving the delivery of existing evidence-based interventions to prevent and diagnose HIV is key to Ending the HIV Epidemic in the United States. Structural barriers in the access and delivery of related health services require municipal or state-level policy changes; however, suboptimal implementation can be addressed directly through interventions designed to improve the reach, effectiveness, adoption or maintenance of available interventions. Our objective was to estimate the cost-effectiveness and potential epidemiological impact of six real-world implementation interventions designed to address these barriers and increase the scale of delivery of interventions for HIV testing and pre-exposure prophylaxis (PrEP) in three US metropolitan areas. METHODS: We used a dynamic HIV transmission model calibrated to replicate HIV microepidemics in Atlanta, Los Angeles (LA) and Miami. We identified six implementation interventions designed to improve HIV testing uptake ("Academic detailing for HIV testing," "CyBER/testing," "All About Me") and PrEP uptake/persistence ("Project SLIP," "PrEPmate," "PrEP patient navigation"). Our comparator scenario reflected a scale-up of interventions with no additional efforts to mitigate implementation and structural barriers. We accounted for potential heterogeneity in population-level effectiveness across jurisdictions. We sustained implementation interventions over a 10-year period and evaluated HIV acquisitions averted, costs, quality-adjusted life years and incremental cost-effectiveness ratios over a 20-year time horizon (2023-2042). RESULTS: Across jurisdictions, implementation interventions to improve the scale of HIV testing were most cost-effective in Atlanta and LA (CyBER/testing cost-saving and All About Me cost-effective), while interventions for PrEP were most cost-effective in Miami (two of three were cost-saving). We estimated that the most impactful HIV testing intervention, CyBER/testing, was projected to avert 111 (95% credible interval: 110-111), 230 (228-233) and 101 (101-103) acquisitions over 20 years in Atlanta, LA and Miami, respectively. The most impactful implementation intervention to improve PrEP engagement, PrEPmate, averted an estimated 936 (929-943), 860 (853-867) and 2152 (2127-2178) acquisitions over 20 years, in Atlanta, LA and Miami, respectively. CONCLUSIONS: Our results highlight the potential impact of interventions to enhance the implementation of existing evidence-based interventions for the prevention and diagnosis of HIV.

Asunto(s)

Análisis Costo-Beneficio , Infecciones por VIH , Homosexualidad Masculina , Profilaxis Pre-Exposición , Humanos , Infecciones por VIH/prevención & control , Infecciones por VIH/epidemiología , Infecciones por VIH/diagnóstico , Masculino , Profilaxis Pre-Exposición/métodos , Profilaxis Pre-Exposición/economía , Epidemias/prevención & control , Estados Unidos/epidemiología , Adulto , Georgia/epidemiología , Los Angeles/epidemiología , Florida/epidemiología , Adulto Joven , Prueba de VIH/métodos

RESUMEN

Men who have sex with men (MSM) with history of childhood sexual abuse (CSA) are at high risk for HIV acquisition. One reason is posttraumatic responses compromise ability to accurately appraise risk for danger/vulnerability. Health behavior change models and related interventions assume risk perception can be changed in an enduring manner. Given paucity of studies examining how risk perception changes or sustains over time post-intervention, this underlying assumption is not confirmed. Among this particularly high-risk group who struggle with perceiving risk due to trauma-related cognitions, it may be accuracy of risk perception is fluid. The study primarily aimed to examine accuracy of HIV risk perception over time post-HIV prevention behavioral intervention. Leveraging data from a larger RCT, N = 190 MSM in Boston, MA and Miami, FL USA completed a psychosocial baseline assessment, an intervention aimed to increase awareness of personal HIV risk level, then four follow-up assessments three months apart for a year. Linear mixed effect models were used to examine the degree to which accuracy of HIV risk perception (vs. traditional construct of risk perception with no information about accuracy) predicts sex risk behavior over time delineated by between-person (trait level) and within-person (state level) effects. Majority (92%) of participants fluctuated in HIV risk accuracy over time post-intervention. Within-person risk accuracy (one's accuracy at any given timepoint) predicted sex risk behavior (condomless sex not protected by adherent PrEP) over time, but not between-person (one's average of accuracy). Findings have implications for intervention and counseling related to specific HIV prevention strategies.

Asunto(s)

Abuso Sexual Infantil , Infecciones por VIH , Conocimientos, Actitudes y Práctica en Salud , Homosexualidad Masculina , Asunción de Riesgos , Minorías Sexuales y de Género , Humanos , Masculino , Infecciones por VIH/psicología , Infecciones por VIH/prevención & control , Infecciones por VIH/epidemiología , Adulto , Estudios Longitudinales , Minorías Sexuales y de Género/psicología , Minorías Sexuales y de Género/estadística & datos numéricos , Abuso Sexual Infantil/psicología , Abuso Sexual Infantil/estadística & datos numéricos , Homosexualidad Masculina/psicología , Homosexualidad Masculina/estadística & datos numéricos , Boston/epidemiología , Persona de Mediana Edad , Florida/epidemiología , Niño , Conducta Sexual/psicología , Percepción , Adulto Joven , Adultos Sobrevivientes del Maltrato a los Niños/psicología , Adultos Sobrevivientes del Maltrato a los Niños/estadística & datos numéricos

RESUMEN

Introduction: Globally, overdose deaths increased near the beginning of the COVID-19 pandemic, which created availability and access barriers to addiction and social services. Especially in times of a crisis like a pandemic, local exposures, service availability and access, and system responses have major influence on people who use drugs. For policy makers to be effective, an understanding at the local level is needed. Methods: This retrospective epidemiologic study from 2019 through 2021 compares immediate and 20-months changes in overdose deaths from the pandemic start to 16 months before its arrival in Pinellas County, FL We examine toxicologic death records of 1,701 overdoses to identify relations with interdiction, and service delivery. Results: There was an immediate 49% increase (95% CI 23-82%, p < 0.0001) in overdose deaths in the first month following the first COVID deaths. Immediate increases were found for deaths involving alcohol (171%), heroin (108%), fentanyl (78%), amphetamines (55%), and cocaine (45%). Overdose deaths remained 27% higher (CI 4-55%, p = 0.015) than before the pandemic through 2021.Abrupt service reductions occurred when the pandemic began: in-clinic methadone treatment dropped by two-thirds, counseling by 38%, opioid seizures by 29%, and drug arrests by 56%. Emergency transport for overdose and naloxone distributions increased at the pandemic onset (12%, 93%, respectively) and remained higher through 2021 (15%, 377%,). Regression results indicate that lower drug seizures predicted higher overdoses, and increased 911 transports predicted higher overdoses. The proportion of excess overdose deaths to excess non-COVID deaths after the pandemic relative to the year before was 0.28 in Pinellas County, larger than 75% of other US counties. Conclusions: Service and interdiction interruptions likely contributed to overdose death increases during the pandemic. Relaxing restrictions on medical treatment for opioid addiction and public health interventions could have immediate and long-lasting effects when a major disruption, such as a pandemic, occurs. County level data dashboards comprised of overdose toxicology, and interdiction and service data, can help explain changes in overdose deaths. As a next step in predicting which policies and practices will best reduce local overdoses, we propose using simulation modeling with agent-based models to examine complex interacting systems.

Asunto(s)

COVID-19 , Sobredosis de Droga , Humanos , COVID-19/mortalidad , COVID-19/epidemiología , Sobredosis de Droga/mortalidad , Sobredosis de Droga/epidemiología , Estudios Retrospectivos , Adulto , Masculino , Florida/epidemiología , Femenino , Persona de Mediana Edad , Pandemias , SARS-CoV-2

RESUMEN

Background: Hospital electronic medical record (EMR) systems are becoming increasingly integrated for management of patient data, especially given recent policy changes issued by the Centers for Medicaid and Medicare Services. In addition to data management, these data provide evidence for patient-centered outcomes research for a range of diseases, including cancer. Integrating EMR patient data with existing disease registries strengthens all essential components for assuring optimal health outcomes. Objectives: To identify the mechanisms for extracting, linking, and processing hospital EMR data with the Florida Cancer Data System (FCDS); and to assess the completeness of existing registry treatment data as well as the potential for data enhancement. Methods: A partnership among the Florida Department of Health, FCDS, and a large Florida hospital system was established to develop methods for hospital EMR extraction and transmission. Records for admission years between 2007 and 2010 were extracted using ICD-9-CM codes as the trigger and were linked with the cancer registry for patients with invasive cancers of the breast. Results: A total of 11,506 unique patients were linked with a total of 12,804 unique breast tumors. Evaluation of existing registry treatment data against the hospital EMR produced a total of 5% of registry records with updated surgery information, 1% of records with updated radiation information, and 7% of records updated with chemotherapy information. Enhancement of registry treatment information was particularly affected by the availability of chemotherapy medications data. Conclusion: Hospital EMR linkages to cancer disease registries is feasible but challenged by lack of standards for data collection, coding and transmission, comprehensive description of available data, and the exclusion of certain hospital datasets. The FCDS standard treatment data variables are highly robust and complete but can be enhanced by the addition of detailed chemotherapy regimens that are commonly used in patient centered outcomes research.

Asunto(s)

Registros Electrónicos de Salud , Registro Médico Coordinado , Sistema de Registros , Humanos , Proyectos Piloto , Florida/epidemiología , Femenino , Neoplasias de la Mama/epidemiología , Neoplasias de la Mama/terapia , Neoplasias/epidemiología , Neoplasias/terapia

RESUMEN

The onset of the COVID-19 pandemic drove a widespread, often uncoordinated effort by research groups to develop mathematical models of SARS-CoV-2 to study its spread and inform control efforts. The urgent demand for insight at the outset of the pandemic meant early models were typically either simple or repurposed from existing research agendas. Our group predominantly uses agent-based models (ABMs) to study fine-scale intervention scenarios. These high-resolution models are large, complex, require extensive empirical data, and are often more detailed than strictly necessary for answering qualitative questions like "Should we lockdown?" During the early stages of an extraordinary infectious disease crisis, particularly before clear empirical evidence is available, simpler models are more appropriate. As more detailed empirical evidence becomes available, however, and policy decisions become more nuanced and complex, fine-scale approaches like ours become more useful. In this manuscript, we discuss how our group navigated this transition as we modeled the pandemic. The role of modelers often included nearly real-time analysis, and the massive undertaking of adapting our tools quickly. We were often playing catch up with a firehose of evidence, while simultaneously struggling to do both academic research and real-time decision support, under conditions conducive to neither. By reflecting on our experiences of responding to the pandemic and what we learned from these challenges, we can better prepare for future demands.

Asunto(s)

COVID-19 , SARS-CoV-2 , COVID-19/epidemiología , COVID-19/prevención & control , COVID-19/transmisión , Humanos , Florida/epidemiología , Pandemias/prevención & control , Análisis de Sistemas , Modelos Teóricos

RESUMEN

BACKGROUND: Hospitalizations due to diabetes complications are potentially preventable with effective management of the condition in the outpatient setting. Diabetes-related hospitalization (DRH) rates can provide valuable information about access, utilization, and efficacy of healthcare services. However, little is known about the local geographic distribution of DRH rates in Florida. Therefore, the objectives of this study were to investigate the geographic distribution of DRH rates at the ZIP code tabulation area (ZCTA) level in Florida, identify significant local clusters of high hospitalization rates, and describe characteristics of ZCTAs within the observed spatial clusters. METHODS: Hospital discharge data from 2016 to 2019 were obtained from the Florida Agency for Health Care Administration through a Data Use Agreement with the Florida Department of Health. Raw and spatial empirical Bayes smoothed DRH rates were computed at the ZCTA level. High-rate DRH clusters were identified using Tango's flexible spatial scan statistic. Choropleth maps were used to display smoothed DRH rates and significant high-rate spatial clusters. Demographic, socioeconomic, and healthcare-related characteristics of cluster and non-cluster ZCTAs were compared using the Wilcoxon rank sum test for continuous variables and Chi-square test for categorical variables. RESULTS: There was a total of 554,133 diabetes-related hospitalizations during the study period. The statewide DRH rate was 8.5 per 1,000 person-years, but smoothed rates at the ZCTA level ranged from 0 to 101.9. A total of 24 significant high-rate spatial clusters were identified. High-rate clusters had a higher percentage of rural ZCTAs (60.9%) than non-cluster ZCTAs (41.8%). The median percent of non-Hispanic Black residents was significantly (p < 0.0001) higher in cluster ZCTAs than in non-cluster ZCTAs. Populations of cluster ZCTAs also had significantly (p < 0.0001) lower median income and educational attainment, and higher levels of unemployment and poverty compared to the rest of the state. In addition, median percent of the population with health insurance coverage and number of primary care physicians per capita were significantly (p < 0.0001) lower in cluster ZCTAs than in non-cluster ZCTAs. CONCLUSIONS: This study identified geographic disparities of DRH rates at the ZCTA level in Florida. The identification of high-rate DRH clusters provides useful information to guide resource allocation such that communities with the highest burdens are prioritized to reduce the observed disparities. Future research will investigate determinants of hospitalization rates to inform public health planning, resource allocation and interventions.

Asunto(s)

Diabetes Mellitus , Hospitalización , Humanos , Florida/epidemiología , Hospitalización/estadística & datos numéricos , Masculino , Femenino , Persona de Mediana Edad , Adulto , Diabetes Mellitus/epidemiología , Diabetes Mellitus/terapia , Anciano , Adolescente , Disparidades en Atención de Salud/estadística & datos numéricos , Adulto Joven , Teorema de Bayes , Análisis Espacial , Complicaciones de la Diabetes/epidemiología , Preescolar , Niño , Factores Socioeconómicos , Lactante

RESUMEN

INTRODUCTION: People who use drugs (PWUD) are at increased risk for HIV infection. HIV self-testing (HIVST) is a promising method for identifying new infections, but optimal distribution strategies remain understudied. METHODS: To characterize PWUD by HIVST distribution strategy (peers vs. mail), we examined data from July 2022 to June 2023 collected from a real-world HIVST program led by the non-profit, Florida Harm Reduction Collective. We used descriptive statistics and Poisson regressions with robust error variance to compare those who received HIVST through peers or via mail by socio-demographics, Ending the HIV Epidemic (EHE) county designation, and HIV testing experience. RESULTS: Among 728 participants, 78% received HIVST from peers, 47% identified as cisgender female, 48% as heterosexual, and 45% as non-White; 66% resided in an EHE county, and 55% had no HIV testing experience. Compared to those who received an HIV self-test from peers, those who received tests via mail were less likely to be cisgender male (vs. cisgender female; prevalence ratio [PR] = 0.59, 95% confidence interval [CI]: 0.43, 0.81), non-Hispanic Black (vs. non-Hispanic White; PR = 0.57, 95% CI: 0.36, 0.89) or from EHE counties (vs. non-EHE counties; PR = 0.33, 95% CI: 0.25, 0.44). Those who received tests via mail were also more likely to identify their sexual orientation as "Other/Undisclosed" (vs. straight/heterosexual; PR = 2.00, 95% CI: 1.51, 2.66). CONCLUSION: Our findings support the role of community-based HIVST distribution strategies in increasing HIV testing coverage among PWUD. Additional research could help inform the equitable reach of HIVST.

Asunto(s)

Infecciones por VIH , Prueba de VIH , Grupo Paritario , Servicios Postales , Autoevaluación , Humanos , Femenino , Florida/epidemiología , Masculino , Infecciones por VIH/epidemiología , Infecciones por VIH/diagnóstico , Adulto , Prueba de VIH/estadística & datos numéricos , Persona de Mediana Edad , Adulto Joven , Consumidores de Drogas/estadística & datos numéricos , Reducción del Daño