Durham County Research Articles

296. The Hepatitis C Cascade of Care across Four Safety Net Settings in the Southeast

BackgroundDespite advances in antivirals, disparities in hepatitis C (HCV) treatment remain. We evaluated persons diagnosed with HCV in 4 safety net sites in a large Southeastern county, using care cascades to conceptualize milestones in treatment.MethodsPersons diagnosed with HCV in 4 screening sites across Durham County, North Carolina, from December 2015 to May 2018 were included, allowing for 9 months of follow-up. Sites included the county health department (CHD), a federally qualified health center (FQHC) where providers trained in HCV care, jail and community outreach. Persons with HCV were eligible for a bridge counselor intervention to enhance linkage to care with an HCV-treating provider (either primary care or specialist). Outcomes were monitored by chart review. Persons linked to care in the prison (n = 36) were censored from subsequent cascade steps due to inability to obtain records. Cascades were compared by the site of diagnosis. Multivariable logistic regression was used to evaluate predictors of being prescribed antivirals.Results505 persons were diagnosed with HCV: 216 in the FQHC, 158 in the jail, 72 in the CHD, and 59 in community outreach. Overall, 89% were counseled on their diagnosis, 65% were linked to care, 41% prescribed antivirals, 38% started medications, 34% completed medications and 24% achieved sustained viral response at 12 weeks (SVR-12). Progression through the cascade was highest for those diagnosed at the FQHC (figure). In analyses adjusted for demographics and risk factors, diagnosis in a community outreach setting had lower odds of antiviral prescription, compared with diagnosis in the FQHC (OR 0.33, 95% CI 0.12–0.89). Linkage to care at a specialist clinic (vs. primary care) was associated with antiviral prescription (OR 3.82, CI 1.95–7.46). Sex, race/ethnicity, insurance status and HCV risk factors were not associated with antiviral prescription.ConclusionAmong persons diagnosed with HCV across four safety net sites, a quarter achieved SVR-12. Those diagnosed in community outreach had lower odds of antiviral prescription, and those who were linked to a specialist were more likely to receive antiviral prescription. Improving progression through cascade milestones across safety-net settings is integral to improving population-based HCV outcomes. Disclosures All authors: No reported disclosures.

162 Optimizing a Drone Network to Deliver Naloxone

Treatment of opioid overdoses depends on timely administration of naloxone. However, administration is delayed in some cases due to response time. Improvement in response time could be overcome with the use of drones. Drones have the potential to deliver naloxone efficiently to the scene of opioid overdose for bystander use. We hypothesize that using a mathematical model to optimize drone placement will reduce time to naloxone administration compared to ambulance response time. Using geocoded retrospective data from suspected opioid overdoses in Durham County, North Carolina from January 2016 to February 2019, we created a drone geospatial network model based on current technological specifications and potential base locations. All 29 fire, paramedic and EMS administrative buildings within Durham County were considered potential drone bases. The drone network modelled response time and county coverage. Then a genetic optimization model was built to maximize county coverage by drones and the number of overdoses covered per drone base. From this model, we quantified the optimum reduction in average response time balanced with the number drone bases required. From 2016 to early 2019, 2,327 distinct incidents of suspected opioid overdose data were found. The average time from 911 call to ambulance arrival at scene was 10 minutes 46 seconds. In the drone network model, as the response time decreased, the number of drone bases increased. In leveraging a balance between reductions in response time and number of drone bases required, we determined that the optimum number of drone bases would be four. Four drone bases would reduce response time by 4 minutes 38 seconds, covering 64.2% of the county (Fig. 1). Our analysis found that in a mathematical model for geospatial optimization, implementing four drone bases could reduce response time of 911 calls or opioid overdoses. Therefore, in theory, drones can improve time to naloxone delivery.

Randomized controlled trial of Family Connects: Effects on child emergency medical care from birth to 24 months.

One of Tom Dishion's most significant contributions to prevention science was the development of affordable, ecologically valid interventions, such as the Family Check-Up, that screen for child and family risk factors broadly, but concentrate family-specific interventions on those with greatest potential for population impact. In the spirit of this approach, investigators examined effects of a brief, universal postnatal home visiting program on child emergency medical care and billing costs from birth to age 24 months. Family Connects is a community-wide public health intervention that combines identification and alignment of community services and resources with brief, postpartum nurse home visits designed to assess risk, provide supportive guidance, and connect families with identified risk to community resources. Over 18 months, families of all 4,777 resident Durham County, North Carolina, births were randomly assigned based on even or odd birth date to receive a postnatal nurse home visiting intervention or services as usual (control). Independently, 549 of these families were randomly selected and participated in an impact evaluation study. Families, blind to study goals, provided written consent to access hospital administrative records. Results indicate that children randomly assigned to Family Connects had significantly less total emergency medical care (by 37%) through age 24 months, with results observed across almost all subgroups. Examination of billing records indicate a $3.17 decrease in total billing costs for each $1 in program costs. Overall, results suggest that community-wide postpartum support program can significantly reduce population rates of child emergency medical care through age 24 months while being cost-beneficial to communities.

Observations on the terrestrial leech Haemopis septagon Sawyer amp; Shelley, 1976 (Annelida: Hirudinea) from the Outer Banks, North Carolina, USA,with a revision of the species.

The terrestrial leech Haemopis septagon Sawyer Shelley, 1976, is indigenous to the Great Dismal Swamp and environs of northeastern North Carolina and southeastern Virginia, USA. Ever since its discovery in 1895 at Lake Drummond in the Dismal Swamp, this elusive species has been recognized as taxonomically aberrant. For example, it is the only jawed leech in the United States with seven annuli between gonopores, and the only one with sixteen complete (5-annulate) segments, both highly conserved characters in the Hirudinidae. The discovery of two populations of H. septagon in the Albemarle Peninsula in the Outer Banks region of North Carolina afforded an opportunity to investigate the taxonomy and biology of this inadequately characterized species. Its description in this study is the first comprehensive account of the external and internal anatomy of this species since its incomplete original description in 1976. This study is also an opportunity to correct errors in the incomplete original description, and to elucidate morphological and developmental variability of taxonomic significance. Evidence is presented for the first time of a possible aquatic or semi-aquatic form of H. septagon. These Albemarle individuals were compared to the holotype from Durham County, NC, specimens from southeastern Virginia and a terrestrial leech recently reported from southern New Jersey. All of these fall within the variability demonstrated in this study for the Albemarle populations, and are accordingly recognized as the same species, H. septagon. Consequentially, Haemopis ottorum Wirchansky Shain, 2010, is recognized as a junior synonym of Haemopis septagon.

Examining implementation and effects of a comprehensive community intervention addressing type 2 diabetes among high-risk minority patients in Durham County, NC

Type-2 diabetes affects millions of people. Racial minorities are at higher risk for developing diabetes and suffering complications. Duke University and its partners built a team to improve population-level health outcomes and reduce health disparities in Durham County, NC. An empirical case study design was used to examine the Durham Diabetes Program (DDP) and its effects on emergency department (ED) visits and hospital admissions (HAs). High-risk program participants (N = 200) were enrolled into the DDP using a risk algorithm. Culturally competent teams delivered various intervention components that were anchored in behavior change strategies (e.g. diabetes self-management education and support, enhancing clinical care, community mobilization, and health system/community transformation). More than a hundred community/system changes were implemented as part of the DDP. Further, the DDP was associated with decreased ED visits (by 34%) and HAs (by 40.5%). This research can inform the way diabetes is assessed and interventions are delivered.

A Council at War: Whickham Urban District Council 1939-45

This article will examine the responses to the dangers of the Second World War by a local authority in north-east England, Whickham Urban District Council. Councillors and officials received guidance from central Government, Durham County Council and from military authorities to prepare for the anticipated effects of total war, including invasion, bombing and chemical warfare against the civilian population. Detailed monthly reports to the Urban District Council reveal the extensive and expensive preparations made by the Council to counter these threats. Newspaper articles demonstrate the willingness of inhabitants to support the Council and participate in patriotic initiatives including voluntary work and fundraising.

Design and Implementation of a Comprehensive Surveillance System for Venous Thromboembolism in a Defined Region Using Electronic and Manual Approaches.

Systematic surveillance for venous thromboembolism (VTE) in the United States has been recommended by several organizations. Despite adoption of electronic medical records (EMRs) by most health care providers and facilities, however, systematic surveillance for VTE is not available. This article develops a comprehensive, population-based surveillance strategy for VTE in a defined geographical region. The primary surveillance strategy combined computerized searches of the EMR with a manual review of imaging data at the Duke University Health System in Durham County, North Carolina, United States. Different strategies of searching the EMR were explored. Consolidation of results with autopsy reports (nonsearchable in the EMR) and with results from the Durham Veterans' Administration Medical Center was performed to provide a comprehensive report of new VTE from the defined region over a 2-year timeframe. Monthly searches of the primary EMR missed a significant number of patients with new VTE who were identified by a separate manual search of radiology records, apparently related to delays in data entry and coding into the EMR. Comprehensive searches incorporating a location-restricted strategy were incomplete due to the assigned residence reflecting the current address and not the address at the time of event. The most comprehensive strategy omitted the geographic restriction step and identified all patients with VTE followed by manual review of individual records to remove incorrect entries (e.g., outside the surveillance time period or geographic location; no evidence for VTE). Consolidation of results from the EMR searches with results from autopsy reports and the separate facility identified additional patients not diagnosed within the Duke system. We identified several challenges with implementing a comprehensive VTE surveillance program that could limit accuracy of the results. Improved electronic strategies are needed to cross-reference patients across multiple health systems and to minimize the need for manual review and confirmation of results.

Abstract 017: Impact of Gentrification on Cardiovascular Disease Surveillance Using Data from the Electronic Health Record

Introduction: Current static approaches of CVD surveillance may not capture the true health of neighborhoods as the influx of younger, healthier, and wealthier individuals (i.e., gentrification) can impact long term residents (LTR) who can be older and of lower socioeconomic status (SES), potentially biasing prevalence estimates. Hypothesis: LTR in gentrifying vs. LTR in non-gentrifying neighborhoods will have a lower prevalence of CVD related conditions. Methods: We quantified the census tract prevalence of diabetes (DM), hypertension (HTN), obesity, and CVD (myocardial infarction or stroke hospitalization) using electronic health record (EHR) data from the Duke Health System and Lincoln Community Health Center from 2008-2010 and 2014-2016. The EHR population was 116,760 patients living in Durham County in 2008 followed until 12/31/16. LTR were patients with the same 2010 and 2015 address; patients moving in/out (i.e., movers) did not have a recorded address in 2010 or 2015. A census tract was defined as gentrifying if 3 of 4 SES indicators (positive z-score for median household income, median rental price, % with bachelor’s degree, or a negative z-score for % living below the poverty line) improved. In difference-in-difference (DiD) analysis, we compared changes in prevalence of CVD health indicators between LTR in gentrifying and non-gentrifying neighborhoods. Results: At baseline, patients had a median age of 43 years, 42% were black and 61% were female. The overall prevalence of DM, HTN, obesity, and CVD was 12%, 32%, 19%, and 5% in 2010 & 14%, 31%, 32%, and 7% in 2016. The prevalence increased in gentrifying and non-gentrifying neighborhoods over time and was higher in LTR than comparable movers. Estimates from DiD models were not statistically significant (Figure 1). Conclusions: LTR vs. movers and not gentrification impacted the surveillance of CVD health indicators. Novel public health informatics methods are needed to address dynamic changes in neighborhoods that may bias the enumeration of CVD health indicators.

Characterization of Perinatal Risk Factors and Complications Associated With Nonsyndromic Craniosynostosis.

Certain intrauterine risk factors are known to increase the risk of premature cranial suture fusion and may cause complications during birth. Some of these risk factors may be modifiable. Therefore, the authors sought to characterize the institutional patterns of prenatal risk factors and perinatal complications in nonsyndromic craniosynostosis patients compared to normal births from the surrounding area to identify areas for possible intervention or prevention. The medical records of all infants with nonsyndromic craniosynostosis and full birth records born at Duke University Health System from 2006 to 2017 were retrospectively reviewed. Maternal comorbidities, prenatal risk factors, and perinatal complications were collected. The North Carolina State Center for Health Statistics was queried for perinatal statistics from Durham county and the Northeastern Perinatal Care Region to represent a control cohort of normal births from the same time period and region. The primary outcome investigated was the incidence of prenatal risk factors and complications at birth associated with premature fusion of cranial sutures. Eighty births with nonsyndromic craniosynostosis were included in this study. The majority of these patients were males (61.7%) and born via cesarean section (55.0%). Intrauterine growth restriction occurred in 10.0% and head trauma during delivery occurred in 2.5%. Twinning (14.8% vs 3.6%, P < 0.0001), cesarean births (55.5% vs 30.0%, P < 0.0001), and breech presentation (17.3% vs 3.2%, P < 0.0001) were significantly more common in craniosynostosis patients. Prenatally, mothers of craniosynostosis infants had higher incidence of gestational diabetes (13.5% vs 5.0%, P < 0.0001) and oligohydramnios (6.1% vs 1.3%, P < 0.0001) compared to regional controls. This study demonstrates that premature suture fusion is associated with prenatal risk factors such as gestational diabetes and oligohydramnios. Continued research into potentially modifiable prenatal risk factors and more refined prenatal diagnostic tools has the potential to reduce both the incidence of premature suture fusion and the sequelae of birth complications in this population.

Improving Timeliness of Medical Evaluations for Children Entering Foster Care.

The American Academy of Pediatrics (AAP) recommends children in foster care (FC) have an initial medical evaluation within 3 days of custody initiation; however, this vulnerable population often suffers from disjointed care. Our aim was to improve the mean time to initial foster care evaluation (TIE) from 32 to <7 days within 12 months for children in FC in Durham County, North Carolina. This study was a time series, quality improvement project used to target interventions within an academic clinic and a community agency. Interventions were tested through multiple plan-do-study-act cycles. Control charts of the primary outcome, the TIE, were constructed. Charts were annotated with the dates of interventions, including workshops, performance feedback, integration of state forms, identification of appointments, development of an urgent appointment pathway, and empowerment of the scheduler. The mean TIE improved from 32 to 9 days within 12 months. Significant improvement in the following 2 process measures contributed to this: the time from custody initiation to the referral date improved from an average of 10 to 3 days, and the time from referral date to the initial evaluation improved from an average of 22 to 6 days. Improvement interventions and increased collaboration between medical and child welfare agencies can result in significant improvement of the TIE. However, despite improvement efforts, challenges remain in meeting the AAP 3-day TIE recommendation. We recommend further assessment of the AAP guideline as it relates to implementation feasibility and health outcomes of children in FC.

2211. Hepatitis C Testing and Linkage to Care in a Public Health Setting in North Carolina: Addressing Gaps Along the Care Continuum

BackgroundDespite national recommendations in the United States to conduct hepatitis C virus (HCV) screening among the birth cohort and high-risk populations, persons seeking public health services have limited access to care. We developed a HCV screening and linkage-to-care program at a public health facility in North Carolina (NC), and evaluated the HCV prevalence and care continuum.MethodsWe collaborated with the Durham County Department of Public Health in Durham, NC to integrate routine HCV testing at the human services facility. Targeted screening with HCV antibody and reflex RNA was conducted based on U.S. guidelines (e.g., birth cohort, intravenous drug use [IVDU]) in clinical areas and the department of social services. To support linkage to care, a “bridge counselor” or social worker assisted chronic HCV-infected persons with transportation, initial appointments with HCV specialists, and access to other services. We analyzed the HCV prevalence, risk factors, and the care continuum among this population.ResultsFrom March 2016 to February 2018, targeted HCV screening was conducted among 2,775 persons, of which 84 (3%) were HCV antibody positive and RNA positive. Among persons identified with chronic HCV infection, the median age was 48.5 (interquartile range (IQR): 23–76), 48 (57%) were male, and 53 (63%) were African-American. HCV-infected persons had multiple risk factors including past or current IVDU use (n = 38, 45%), history of unlicensed tattoo/ear piercings (n = 35, 42%), and prior incarceration (n = 31, 38%); no HIV co-infections were identified. An assessment of the care continuum demonstrated that the majority with chronic HCV infection received post-test counseling (96%), met with the bridge counselor (70%) and attended their first medical appointment (74%). However, only 49% were prescribed HCV treatment and 24% achieved sustained virologic response.ConclusionImplementation of targeted screening with HCV antibody and reflex RNA in a public health setting, coupled with bridge counseling, can identify persons with chronic HCV infections and link them to care. However, only half received HCV treatment and a fourth achieved HCV cure, highlighting the gaps in the care continuum where future interventions should be directed.Disclosures A. Sena, Gilead Sciences: Grant Investigator, Grant recipient. C. Givens, Gilead Sciences: Grant support for salary, Grant recipient. G. McKnight, Gilead Sciences: Grant Investigator, Grant recipient. J. Thayer, Gilead Sciences: Grant Investigator, Grant recipient. A. Hilton, Gilead Sciences: Grant Investigator, Grant recipient.

1295. Advancing the PrEP Continuum: A Novel Collaboration Between a Public Health Department and a Federally Qualified Healthcare Center in the Southern United States

BackgroundWhile pre-exposure prophylaxis (PrEP) is a promising strategy for HIV prevention, some high-risk persons have limited access to care, particularly Black and Latino men who have sex with men (MSM). Disparities also exist by region: the Southern United States accounts for over half of new HIV diagnoses but only a third of PrEP prescriptions. We evaluated a novel PrEP program based on a collaboration between a local department of public health (DPH) and a federally qualified health center (FQHC) providing care to underserved racial/ethnic minorities in Durham, North Carolina.MethodsIn May 2015, the Durham County DPH and Lincoln Community Health Center, an FQHC, developed a program to offer PrEP services using existing resources. The model included initial no-cost screening for sexually transmitted infections (STIs), hepatitis B/C, and HIV at the DPH STI clinic, followed by referral to the FQHC for PrEP services. We profiled the PrEP continuum for patients starting at program initiation until March 2018. For PrEP initiators and non-initiators, comparisons were made using Wilcoxon rank-sum test for continuous variables, and Chi-square or FisherÕs exact tests as indicated for categorical variables.ResultsOf 196 unique patients evaluated in the STI clinic and referred to the FQHC, 117 (60%) persons attended their initial PrEP appointments. Among these, 84 (43%) filled a PrEP prescription, 69 (35%) persisted in care for at least three months, and 58 (30%) reported >90% adherence at follow-up (see figure). Among those presenting for initial appointments (n = 117), more than half were Black (n = 62, 53%) and 21 (18%) were Latino. Most were MSM (n = 95, 81%) and 9 were transgender. Almost half (n = 55, 47%) were uninsured. We found statistically significant differences between PrEP initiators vs. noninitiators based on race/ethnicity (P = 0.02), insurance status (P = 0.05), and history of sex work (P = 0.05).ConclusionA collaborative model of PrEP care between a DPH and an FQHC in the Southern United States was able to reach predominantly Black and Latino MSM at high-risk for HIV. Although this program is sustainable, efforts to improve steps along the PrEP care continuum are still needed in this population. Disclosures A. Sena, Gilead: Grant Investigator, Research grant.

Association Between Driving Distance From Nearest Fire Station andSurvival of Out-of-Hospital Cardiac Arrest.

BackgroundFirefighter first responders dispatched in parallel with emergency medical services (EMS) personnel for out‐of‐hospital cardiac arrests (OHCA) can provide early defibrillation to improve survival. We examined whether survival following first responder defibrillation differed according to driving distance from nearest fire station to OHCA site.Methods and ResultsFrom the CARES (Cardiac Arrest Registry to Enhance Survival) registry, we identified non‐EMS witnessed OHCAs of presumed cardiac cause from 2010 to 2014 in Durham, Mecklenburg, and Wake counties, North Carolina. We used logistic regression to estimate the association between calculated driving distances (≤1, 1–1.5, 1.5–2, and >2 miles) and survival to hospital discharge following first responder defibrillation compared with defibrillation by EMS personnel. In total, 5020 OHCAs were included in the study. First responders more often applied the first automated external defibrillators at the shortest distances (≤1 mile) versus longest distances (>2 miles) (53.4% versus 46.6%, respectively, P<0.001). When compared with EMS defibrillation, first responder defibrillation within 1 mile and 1 to 1.5 miles of the nearest fire station was associated with increased survival to hospital discharge (odds ratio 2.01 [95% confidence interval 1.46–2.78] and odds ratio 1.61 [95% confidence interval 1.10–2.35], respectively). However, at the longest distances (1.5–2.0 and >2.0 miles), survival following first responder defibrillation did not differ from EMS defibrillation (odds ratio 0.77 [95% confidence interval 0.48–1.21] and odds ratio 0.97 [95% confidence interval 0.67–1.41], respectively).ConclusionsShorter driving distance from nearest fire station to OHCA location was associated with improved survival following defibrillation by first responders. These results suggest that the location of first responder units should be considered when organizing prehospital systems of OHCA care.

Senior PharmAssist: Less Hospital Use with Enrollment in an Innovative Community-Based Program.

To evaluate changes in acute health services use of Senior PharmAssist participants. Retrospective analysis. Community-based, nonprofit program in Durham County, North Carolina. Adults aged 60 and older with income of 200% of the federal poverty level or less who enrolled in the Senior PharmAssist program (N = 191) between August 1, 2011, and March 15, 2017. Medication therapy management (MTM), customized community referrals, Medicare insurance counseling, and medication copayment assistance provided by Senior PharmAssist. Primary outcomes were self-reported emergency department (ED) visits and hospital admissions in the previous year, assessed at baseline and every 6 months for up to 2 years. Mean number of ED visits declined over time (0.83 visits per year at baseline to 0.53 visits per year at 24 months, P = .002), as did the percentage of participants reporting an ED visit in the past year (49% at baseline to 31% at 24 months, P = .003). Mean hospital admissions also decreased (0.56 admissions per year at baseline to 0.4 admissions per year at 24 months, P = .02). There was no significant change in percentage of participants reporting a hospital admission in the past year (33% at baseline to 25% at 24 months, P = .23). Older adults who enrolled in a community-based program that helps them manage medications, connect with community resources, and overcome barriers to medication access experienced reductions in acute health services use. J Am Geriatr Soc 66:2394-2400, 2018.

Geographic and Racial Disparities in Infant Hearing Loss.

Approximately 1 to 2 of every 1000 American newborns has hearing loss identified by newborn screening. This study was designed to determine if infant hearing loss is more common in socioeconomically disadvantaged communities. In this retrospective study, we analyzed electronic medical record data using geostatistical models. Infants were residents of Durham County, North Carolina, born in 2 hospitals of the Duke University Health System. This county includes the city of Durham and surrounding suburban and rural communities. Subjects were hearing-screened newborns, born between 2005 and 2016, whose residential address was in Durham County, North Carolina. This was a retrospective study using medical record data. We used Bayesian regression models with smoothing of coordinate date to identify both spatial and nonspatial predictors of infant hearing loss. We identified 19,348 infants from Durham County, of whom 675 had failed initial hearing screening and 191 had hearing loss confirmed on follow-up. Hearing loss was significantly associated with minority race (odds ratio [OR], 2.45; 95% confidence interval, 1.97-3.06), as well as lower gestational age and maternal sexually transmitted infections. We identified significant geographic heterogeneity, with a higher probability of hearing loss in poorer urban neighborhoods (local OR range, 0.59-1.39). Neighborhood disadvantage was a significant predictor of hearing loss, as was high local seroprevalence of cytomegalovirus (CMV) among pregnant women. Urban, low-income neighborhoods have a high prevalence of infant hearing loss compared with more affluent surrounding communities, particularly among minorities. This distribution may be attributable to congenital CMV infection.

Dental Public Health In Action: Barriers to oral healthcare provision for older people in residential and nursing care homes: A mixed method evaluation and strategy development in County Durham, North East England.

This paper presents a case study on the use of mixed methods in research into practice to inform policy. The study was undertaken as part of a review of oral healthcare for older people in residential and nursing care homes in County Durham, North East England. The findings highlighted challenges in the provision of good quality oral healthcare to older people in residential and nursing care homes and informed the county's oral health strategy (Durham County Council DCC, 2016). Key recommendations include the need to develop and implement a minimum set of best practice oral health standards within care home contracts and train care home staff in oral healthcare. The paper relates to two key dental public health competencies: (i) designing and using mixed method studies to address gaps in evidence and triangulating the findings from quantitative and qualitative methods; (ii) the development of evidence based policies. The research is relevant to: care home staff; commissioners in local authority adult and social care; public health practitioners; oral health improvement teams; domiciliary and special care dentists, dental commissioners, researchers and academics.

Rapid organizational network analysis to assess coordination of services for HIV testing clients: An exploratory study

ABSTRACTRecognizing that HIV testing provides a gateway opportunity to connect with at-risk populations, we explored an approach to collect, analyze, and present data on the network of connections between HIV testing organizations and other health and social service agencies operating in Durham County, NC. We surveyed 26 health and social service organizations, including six providing HIV testing services, and presented the results including frequency tabulations, network visualizations and metrics, and geographic information system maps to the participating organizations. Mapping the landscape of organizational relationships was seen as a practical and expedient approach to facilitating cross-sector collaborative efforts to improve community health.

Exploring synergies between transit investment and dense redevelopment: A scenario analysis in a rapidly urbanizing landscape

Like many urban areas around the world, Durham and Orange counties in North Carolina, USA are experiencing population growth and sprawl that is putting stress on the transportation system. Light rail and denser transit-oriented development are being considered as possible solutions. However, local agencies and stakeholders are concerned the light rail may worsen housing affordability and have questioned whether investment in both light rail and dense redevelopment are necessary to achieve community goals. We developed an integrated system dynamics model to quantitatively explore the outcomes of these land use and transportation options across multiple societal dimensions. The model incorporates feedbacks among the land, transportation, economic, equity, and energy sectors. This paper uses the results of four model scenarios, run between 2000 and 2040, to address two main questions: (1) what role does redevelopment play in capturing the socioeconomic benefits of transit infrastructure investment? And (2) how do redevelopment and light-rail transit interact to affect housing and transportation affordability? We find that transit investment and dense redevelopment combine synergistically to better achieve the goals of the light-rail line, including economic development, mobility, and compact growth. However, housing affordability does worsen in the combined scenario, as transportation-cost savings are not sufficient to offset the rise in housing costs. We emphasize that model users may input their own assumptions to explore the dynamics of alternative scenarios. We demonstrate how spatially-aggregated systems models can complement traditional land use and transportation models in the regional planning process.

Risk Profiles for Falls among Older Adults: New Directions for Prevention.

To address whether neighborhood factors, together with older adults' levels of health and functioning, suggest new combinations of risk factors for falls and new directions for prevention. To explore the utility of Grade-of-Membership (GoM) analysis to conduct this descriptive analysis. This is a cross-sectional, descriptive study of 884 people aged ≥65 years from Alameda County, CA, Cook County, IL, Allegheny County, PA, and Wake and Durham counties, NC. Interviews focused on neighborhood characteristics, physical and cognitive function, walking, and falls and injuries. Four risk profiles (higher order interactions of individual and neighborhood factors) were derived from GoM analysis. Profiles 1 and 2 reflect previous results showing that frail older adults are likely to fall indoors (Profile 1); healthy older adults are likely to fall outdoors (Profile 2). Profile 3 identifies the falls risk for older with mild cognitive impairment living in moderately walkable neighborhoods. Profile 4 identifies the risk found for healthy older adults living in neighborhoods with low walkability. Neighborhood walkability, in combination with levels of health and functioning, is associated with both indoor and outdoor falls. Descriptive results suggest possible research hypotheses and new directions for prevention, based on individual and neighborhood factors.

The association of single-nucleotide polymorphisms in the oxytocin receptor and G protein–coupled receptor kinase 6 (GRK6) genes with oxytocin dosing requirements and labor outcomes

Oxytocin is a potent uterotonic agent that is widely used for induction and augmentation of labor. Oxytocin has a narrow therapeutic index and the optimal dosing for any individual woman varies widely. The objective of this study was to determine whether genetic variation in the oxytocin receptor (OXTR) or in the gene encoding G protein-coupled receptor kinase 6 (GRK6), which regulates desensitization of the oxytocin receptor, could explain variation in oxytocin dosing and labor outcomes among women being induced near term. Pregnant women with a singleton gestation residing in Durham County, NC, were prospectively enrolled as part of the Healthy Pregnancy, Healthy Baby cohort study. Those women undergoing an induction of labor at 36 weeks or greater were genotyped for 18 haplotype-tagging single-nucleotide polymorphisms in OXTR and 7 haplotype-tagging single-nucleotide polymorphisms in GRK6 using TaqMan assays. Linear regression was used to examine the relationship between maternal genotype and maximal oxytocin infusion rate, total oxytocin dose received, and duration of labor. Logistic regression was used to test for the association of maternal genotype with mode of delivery. For each outcome, backward selection techniques were utilized to control for important confounding variables and additive genetic models were used. Race/ethnicity was included in all models because of differences in allele frequencies across populations, and Bonferroni correction for multiple testing was used. DNA was available from 482 women undergoing induction of labor at 36 weeks or greater. Eighteen haplotype-tagging single-nucleotide polymorphisms within OXTR and 7 haplotype-tagging single-nucleotide polymorphisms within GRK6 were examined. Five single-nucleotide polymorphisms in OXTR showed nominal significance with maximal infusion rate of oxytocin, and two single-nucleotide polymorphisms in OXTR were associated with total oxytocin dose received. One single-nucleotide polymorphism in OXTR and two single-nucleotide polymorphisms in GRK6 were associated with duration of labor, one of which met the multiple testing threshold (P= .0014, rs2731664 [GRK6], mean duration of labor, 17.7 hours vs 20.2 hours vs 23.5 hours for AA, AC, and CC genotypes, respectively). Three single-nucleotide polymorphisms, two in OXTR and one in GRK6, showed nominal significance with mode of delivery. Genetic variation in OXTR and GRK6 is associated with the amount of oxytocin required as well as the duration of labor and risk for cesarean delivery among women undergoing induction of labor near term. With further research, pharmacogenomic approaches may potentially be utilized to develop personalized treatment to improve safety and efficacy outcomes among women undergoing induction of labor.