State Health Services Research Articles

New Practices of Cultural Truth Making: Evidence Work in Negotiations with State Authorities

AbstractThis article looks at negotiations with state authorities and the evidentiary criteria they create in culturally contrasting contexts when phenomena deal with elements that for the dominant society are conceptualized as “supernatural.” We draw from the level of experiences of other‐than‐human beings, especially spirits and “ungraspable” presences, as social practices in and of themselves as well as acts of mobilizing those which are meaningful for knowledge production in Indigenous Amazonia and North European contexts. Our two cases show how in state territorial protection debates and health services, visibility, quantification, measurability, Euro‐American dominant, mainly binary, and bounded concepts are employed to create the grounds of validity. Yet, for actual individual or collective experiences, new types of evidence work can emerge in collaborations. Thus, this article sheds light on the needs for contextual and communicative actions to overcome contrasting onto‐epistemologies in the context of the state.

Abstract P4-17-10: Obesity increases the risk of male breast cancer and protects against triple negative male breast cancer

Abstract Introduction: Male breast cancer (MaBC) is an uncommon disease that represents less than 1% of all breast cancers. Obesity has been associated with increased breast cancer incidence in post-menopausal women. Overweight and obese rates have almost tripled since the 1990’s in the U.S. In 2016, 68% of Texas adults were classified as overweight or obese. The Rio Grande Valley (Cameron, Hidalgo, Starr and Willacy counties) is one of the areas with the highest levels of obesity in the country (37% of the population). The aim of this exploratory retrospective population-based study is to analyze the incidence of MaBC in Texas and the Rio Grande Valley (RGV), as well as to compare the association of obesity with triple negative MaBC. Methods: Retrospectively, we reviewed available data from the Texas Cancer Registry, Cancer Epidemiology and Surveillance Branch, and Texas Department of State Health Services from the years 2011-2016 of patients with a diagnosis of invasive MaBC. The incidence of MaBC was examined according to sex, stage, tumor subtypes (HR+, HER2-Neu, Triple Negative) and BMI in Texas and the RGV. Some cases were excluded due to issues with data quality regarding BMI. Results: Between 2011-2016, there were 869 patients diagnosed with MaBC in Texas. The incidence of MaBC almost doubled during this time period. MaBC with distant metastasis had a downward trend (< 10% of cases). Evaluating MaBC tumor markers, there was no increase in the number of triple negative MaBC cases in Texas or the RGV despite a dramatic increase in MaBC cases. Furthermore, the number of triple negative MaBC cases in the RGV was significantly less than Texas’s, despite the RGV having higher levels of obesity (see table 1).A total of 495 cases of MaBC in Texas and 18 cases in the RGV had good quality data regarding BMI for analysis. There was a significant increase in the incidence of MaBC associated with obesity (BMI >30), which almost tripled in Texas and the RGV during the years studied. In the RGV, there was a trend to zero cases of MaBC in patients who were underweight and normal weight, see table 2. Conclusion: (1)There is a significant increase in MaBC, as well as in MaBC associated with obesity between the years 2011-2016 in Texas and the RGV. (2)There is no increase in the incidence of triple negative MaBC in Texas or the RGV despite a significant increase in obesity associated MaBC. (3)There is no increase in the incidence of MaBC in patients who are underweight or normal weight in the RGV. (4)Obesity appears to be a protective factor for the development of triple negative MaBC. Table 1. Male Breast Cancer Cases between 2011-2016 in Texas and the RGV201120122013201420152016Incidences of MaBC (Texas)104117121133202192MaBC Triple Negative (Texas)511556Incidences of MaBC (RGV)434366MaBC Triple Negative (RGV)001000 Table 2. Male Breast Cancer Cases by BMI between 2011-2016 in Texas and the RGVTexas Statewide2011-2016201120122013201420152016Underweight (<18.5)7111211Normal Weight (18.5–24.9)98768202928Overweight (25–29.9)167101617225547Obese (≥30)223151921416562Total49533424785150138Rio GrandeValley2011-2016201120122013201420152016Underweight (<18.5)0000000Normal Weight (18.5–24.9)3111000Overweight (25–29.9)4020011Obese (≥30)11002234Total18133245 Citation Format: Nicolas Restrepo, Kristina Vatcheva, Katia Moreno, Aimee Trejo, Alvaro Restrepo. Obesity increases the risk of male breast cancer and protects against triple negative male breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-17-10.

Disparities in Access to Bariatric Surgery in Texas 2013-2017.

Background:Access to bariatric care varies across regions, ethnic, and racial groups. Some of these variations may be due to insurance status or socioeconomic status. There are also regional and state variations in access to metabolic and bariatric surgery (MBS). The Texas Inpatient Public Use Data File (IPUDF) and Texas Outpatient Public Use Data File is a state-mandated database that collects information on demographics, procedures, diagnoses, and cost on almost all admissions in Texas. We used them to examine racial disparities in MBS over a 5-y period.Methods:The IPUDF and Texas Outpatient Public Use Data File were examined from the years 2013 through, 2017. We included all patients undergoing a laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy and examined the demographics of these patients. Race and ethnicity are reported separately. We used U.S. Census Bureau statistics and the Texas Department of State Health Services statistics to determine the crude (unadjusted) and adjusted procedure rates of patients undergoing MBS.Results:In the IUPUDF, the crude unadjusted procedure rate for blacks undergoing MBS was 7.29 per 10,000 population followed by 6.85 per 10,000 for non-Hispanic whites. Hispanics had the lowest rate at 3.20 per 10,000. When adjusted for sex, obesity, age, and race, blacks still had a higher rate of access followed by whites and then Hispanics.Conclusions:There are disparities to access for bariatric surgery in Texas. Blacks have the greatest access followed by whites. Hispanics have the lowest procedure rate per population.

Knowledge of SCD and psychosocial burden experienced by caregivers of children with SCD at a secondary level hospital in Lagos, Nigeria - A cross sectional study

Background: Sickle cell anemia (SCA) is the most prevalent genetic disease in the world and the most severe of the sickle cell disorders. Individuals with SCA undergo numerous psychosocial problems. The severity of the clinical status of SCA imposes differing degrees of suffering to patients and their relatives, and the overall health of these patients depends on the quality of life and psychological preparedness of the caregivers. This study assessed the knowledge of sickle cell disease (SCD) and the psychosocial burdens of the disease on caregivers. Methods: This was a cross-sectional study conducted at Massey Street Children Hospital. Following consent, an interviewer-administered structured pro forma was utilized for the survey. The study was approved by the Health, Research, and Ethics Committee with permission from the Lagos State Health Service Commission. Data were analyzed using Epi Info™ 7.140. Results: Two hundred and sixteen respondents were interviewed with a mean age of 37.7 ± 7.8 years. Most of the respondents were female (90.7%) and presently married (90.7%). The mean knowledge score was 7.5 ± 2.1, with most (74.1%) of the respondents having good knowledge. The vast majority of respondents had lost income or financial benefits due to time spent caring for the child (91.2%) and reported that a child's illness disturbs activities at home (77.3%). Almost all (96.8%) reported an atmosphere of tension in the homes due to a child's illness, 80.6% reported episodes of depression and feeling sorrowful, 34% felt angry with self or child, and 14.3% felt stigmatized because of child's illness. There was a statistically significant association between respondents' level of education, gender, age, relationship to a child, and knowledge of SCD, and a higher proportion of those with good knowledge had no disruption of family interactions. Conclusion: Majority of the caregivers accessing care for children with SCD had good knowledge of the disease and experienced varied degrees of disruption in their finances, family routine, and family interaction. Improving knowledge of SCD is recommended among caregivers to alleviate psychosocial burdens, especially those associated with family interactions.

Wide distribution of Trypanosoma cruzi-infected triatomines in the State of Bahia, Brazil

BackgroundThe identification of Trypanosoma cruzi and blood-meal sources in synanthropic triatomines is important to assess the potential risk of Chagas disease transmission. We identified T. cruzi infection and blood-meal sources of triatomines caught in and around houses in the state of Bahia, northeastern Brazil, and mapped the occurrence of infected triatomines that fed on humans and domestic animals.MethodsTriatominae bugs were manually captured by trained agents from the Epidemiologic Surveillance team of Bahia State Health Service between 2013 and 2014. We applied conventional PCR to detect T. cruzi and blood-meal sources (dog, cat, human and bird) in a randomized sample of triatomines. We mapped triatomine distribution and analyzed vector hotspots with kernel density spatial analysis.ResultsIn total, 5906 triatomines comprising 15 species were collected from 127 out of 417 municipalities in Bahia. The molecular analyses of 695 triatomines revealed a ~10% T. cruzi infection rate, which was highest in the T. brasiliensis species complex. Most bugs were found to have fed on birds (74.2%), and other blood-meal sources included dogs (6%), cats (0.6%) and humans (1%). Trypanosoma cruzi-infected triatomines that fed on humans were detected inside houses. Spatial analysis showed a wide distribution of T. cruzi-infected triatomines throughout Bahia; triatomines that fed on dogs, humans, and cats were observed mainly in the northeast region.ConclusionsSynanthropic triatomines have a wide distribution and maintain the potential risk of T. cruzi transmission to humans and domestic animals in Bahia. Ten species were recorded inside houses, mainly Triatoma sordida, T. pseudomaculata, and the T. brasiliensis species complex. Molecular and spatial analysis are useful to reveal T. cruzi infection and blood-meal sources in synanthropic triatomines, identifying areas with ongoing threat for parasite transmission and improving entomological surveillance strategies.

Utilizing Maps to Identify Possible Missed Cases of Chagas Disease

Chagas disease is one of the world9s most neglected health conditions. It is a leading cause of heart disease in the Americas, creating a greater burden than any other parasitic infection. In 2013, Chagas became a reportable condition in Texas. Between 2013-17, the Texas Department of State Health Services confirmed 124 human and 436 canine cases. In the United States, less than 1% of people with the disease receive a clinical diagnosis, mainly due to low provider awareness and poor diagnostics. The study9s objective was to identify possible missed diagnosis of Chagas in Texas utilizing mapping software and public health data. It was hypothesized that higher rates non-ischemic cardiac disease and cardiomyopathy would be concentrated in areas of higher populations of Hispanic populations. ArcView 10.6 software was used to generate maps showing confirmed cases of Chagas along with cardiac diagnostic specific codes of Inpatient Public Use Data. Confirmed cases were not homogenously dispersed due to more testing being done near urban areas and research centers. However, heart-related diagnosis and age/ethnicity demographics showed the possibility of missed diagnosis throughout the state, especially along the border region. Maps indicated that areas to focus screenings are in rural counties with a higher percentage of Hispanics and with younger heart-related disease. Diagnostics for Chagas disease cases occurring in North America are considered to be very inaccurate. The majority of diagnostics are developed in South America based on large prevalence studies using genotypes not commonly found in North America (types I and IV). Future research in the United States should focus on screenings in higher-risk populations locally, which allows developing better diagnostic tools to identify cases accurately. By having reliable and affordable diagnostics, health care providers may actually screen patients therefore providing us with a better understanding of the prevalence of the disease.

A case-crossover analysis of indoor heat exposure on mortality and hospitalizations among the elderly in Houston, Texas

TPS 664: Climate change: temperature effects 2, Exhibition Hall, Ground floor, August 27, 2019, 3:00 PM - 4:30 PM Background. Despite the substantial role indoor heat exposure has played in temperature-related mortality, few epidemiological studies have examined the health effects of exposure to indoor heat. As a result, knowledge gaps regarding indoor heat-health thresholds, vulnerability, and adaptive capacity persist. Methods. We evaluate the role of indoor heat exposure on heat-related mortality and morbidity among the elderly (≥ 65 years) in Houston, Texas. Mortality and emergency hospital admission data from 2004-2013 were obtained through the Texas Department of State Health Services. Indoor heat exposure was estimated at the census block group level using building energy models, outdoor weather data, and parcel data from Houston’s tax assessor database. To assess indoor heat-health associations, we used time-stratified case-crossover models, controlling for temporal trends and meteorology, and matching on census block group of residence, year, month, and day of the adverse health event. Separate models were fitted for three indoor exposure metrics, for lag days 0–6 and for 3-day moving averages. Results. Positive, significant odds ratios (OR) were observed between circulatory and heat-related mortality and maximum indoor Discomfort Index (combined measure of temperature and humidity), suggesting an increase in the odds of death due to exposure to high indoor heat. [e.g., OR per 5°C =1.31 (95% CI: 1.10, 1.57)]. For circulatory deaths, associations were strongest when indoor heat exposure was defined using minimum indoor temperature [e.g., OR per 5°C =1.37 (95% CI: 1.03, 1.82)], suggesting that high nighttime temperatures may play a prominent role in disease processes that lead specifically to circulatory related deaths. At both the individual and neighborhood level, effect modification analyses suggest stronger associations between indoor heat exposure and health outcomes among African Americans compared to Caucasians. Conclusion. These findings underscore the importance of characterizing harmful indoor conditions and including estimates of indoor exposure in population-based health studies.

Spatial analysis of birth defects and proximity to unconventional natural gas developments in Texas, USA

PDS 74: Pregnancy outcomes, Exhibition Hall (PDS), Ground floor, August 26, 2019, 1:30 PM - 3:00 PM Background/Aim: The link between environmental risk factors and common birth defects is still unclear. There are concerns that unconventional natural gas developments (UNGD) may emit air pollution and contaminate drinking water, potentially leading to adverse health effects. Our objective was to investigate the spatial relationship between birth defects and UNGDs. Methods: We analyzed geocoded data for 10,957 birth defect cases and 649,132 controls born from 1999 to 2011 from the Texas Department of State Health Services (DSHS). UNGD locations were obtained from the Texas Railroad Commission (RRC) and were used to create a density raster of UNGD per km2 to estimate exposure. We used separate generalized additive models to produce maps of smoothed odds ratios (ORs) across Texas while simultaneously estimating the association of UNGD density with neural tube defects (NTDs), gastroschisis, and oral cleft birth defects adjusted for maternal age and parity. Results: UNGD density and risk of NTDs were positively associated [OR (95%CI): 1.27 (1.20, 1.34)] per increased interquartile range of UNGD density. UNGDs were inversely associated with oral cleft defects [OR (95%CI): 0.88 (0.85, 0.92)]. There was no association with gastroschisis [OR (95%CI): 1.00 (0.95, 1.06)]. Risk patterns for birth defects varied spatially across Texas. Statistically significant areas of increased ORs for NTDs and gastroschisis were identified in central or south Texas. ORs for cleft defects were elevated in north Texas. Conclusion: Study results suggest that proximity to UNGDs are associated with increased risk of NTDs in Texas. Two prior studies found possible associations between proximity to natural gas wells and prevalence of some NTDs and heart defects, but spatial distributions were not examined in those studies. Further exploration of spatial-temporal patterns associated with UNGDs may add to our understanding of birth defect risks.

From Surveillance To Control: Evaluation of A Larvicide Intervention Against Aedes aegypti In Brownsville, Texas.

South Texas is recognized as a potential area for the emergence and re-emergence of mosquito-borne diseases due to recent circulation of Zika, chikungunya, and dengue viruses. During 2017, high Aedes aegypti abundance found in the city of Brownsville, TX, in combination with the previous year's local transmission of Zika virus, triggered the activation of the Texas Department of State Health Services Emergency Mosquito Control Contingency Contract. A contract with the Clarke Environmental and Mosquito Control was a response to control Ae. aegypti, using a ground-based wide-area larvicide spray (WALS™) containing Bacillus thuringiensis israelensis. The WALS application was evaluated through a field-based bioassay and by comparing surveillance data pre- and post-WALS application. The WALS application bioassay demonstrated that the larvicide was effective up to 60 m into the target properties. Additionally, the number of Ae. aegypti captured in traps decreased in the WALS intervention areas compared with the untreated control areas, with an estimated 29% control.

Enhancing TX SyS by integrating EMS and Poison Data for Opioid Overdose Surveillance

ObjectiveTo improve Texas Syndromic Surveillance by integrating data from the Texas Poison Center and Emergency Medical Services for opioid overdose surveillance.IntroductionIn recent years, the number of deaths from illicit and prescription opioids has increased significantly resulting in a national and local public health crisis. According to the Texas Center for Health Statistics, there were 1340 opioid related deaths in 2015.1 In 2005, by comparison, there were 913 opioid related deaths. Syndromic surveillance can be used to monitor overdose trends in near real-time and provide much needed information to public health officials. Texas Syndromic Surveillance (TxS2) is the statewide syndromic surveillance system hosted by the Texas Department of State Health Services (DSHS). To enhance the capabilities of TxS2 and to better understand the opioid epidemic, DSHS is integrating both Texas Poison Center (TPC) data and Emergency Medical Services (EMS) data into the system.Much of the data collected at public health organizations can be several years old by the time it is released for public use. As a result, there have been major efforts to integrate more real-time data sources for a variety of surveillance needs and during emergency response activities.MethodsGuided by the Oregon Public Health Division’s successful integration of poison data into Oregon ESSENCE, DSHS has followed a similar path.2 DSHS already receives TPC data from the Commission on State Emergency Communication (CSEC), hence copying and routing that data into TxS2 requires a Memorandum of Understanding (MOU) with CSEC, which is charged with administering the implementation of the Texas Poison Control Network.EMS records are currently received by the DSHS Office of Injury Prevention (OIP) via file upload and extracted from web services as an XML file. Regional and Local Health Operations, the division where the syndromic surveillance program is located, and OIP, are both sections within DSHS. Therefore, it is not necessary to have a formal MOU in place. Both parties would operate under the rules and regulations that are established for data under the Community Health Improvement Division.CSEC and EMS will push data extracts to a DSHS SFTP folder location for polling by Rhapsody in Amazon Web Services. The message data will be extracted and transformed into the ESSENCE database format. Data are received at least once every 24 hours.ResultsTxS2 will now include TPC and EMS data, giving system users the ability to analyze and overlay real-time data for opioid overdose surveillance in one application. The integration of these data sources in TxS2 can be used for both routine surveillance and for unexpected public health events. This effort has led to discussions on how different sections within DSHS can collaborate by using syndromic surveillance data, and has generated interest in incorporating additional data streams into TxS2 in the future.ConclusionsWhile this venture is still a work in progress, it is anticipated that adding TPC and EMS data to TxS2 will be beneficial in surveilling not just opioid overdoses but other conditions and illnesses, as well as capturing disaster related injuries.

Comparison of melanoma incidence in metropolitan areas versus nonmetropolitan areas in the state of Texas stratified by poverty classification

Numerous risk factors for the development of melanoma have been identified; however, there is conflicting research on whether residence in nonmetropolitan areas, with a population <49,999 people, is associated with an increased cancer risk. This retrospective study aimed to identify the correlation of nonmetropolitan residence in Texas and the incidence of melanoma, while also stratifying the results by poverty level. Data were obtained from the Texas Department of State Health Services’ Texas Cancer Registry. The incidence of melanoma in Texas from 1996 to 2015 in nonmetropolitan and metropolitan counties was calculated and stratified by poverty classification. Overall, the incidence of melanoma was 51,431 out of 22,140,398 (0.23%) in metropolitan areas and 9685 out of 3,005,163 (0.32%) in nonmetropolitan areas. Thus, the proportion of residents with melanoma in nonmetropolitan areas was 1.39 times that in metropolitan areas, which translates to an ∼39% increase in likelihood to develop melanoma. When these data were stratified by poverty, 57% of the cases of melanoma among those living in nonmetropolitan counties were in areas with a poverty rate of 10% to <20%; conversely, only 2% of the cases were among those living in nonmetropolitan counties with a poverty rate of 0% to 5%.

A statewide quality improvement (QI) initiative for better health outcomes and family stability among pregnant women with opioid use disorder (OUD) and their infants

A collaborative led by state health and human service agencies, academic leaders, and stakeholders tested interventions to expand use of medication assisted treatment (MAT) through a maternal medical home (MMH) model that coordinated behavioral health and prenatal care with social supports for pregnant women with opioid use disorder (OUD) enrolled in Medicaid. The program was anchored in four clinical organizations with distinct models of care: community behavioral health, residential behavioral health, hospital-based obstetrical practice, and co-located obstetrical and behavioral health. A modified version of the Institute for Healthcare Improvement Breakthrough Series Model for Improvement was implemented using monthly performance data feedback to conduct small tests of change and improve care. Administrative data from the state's Medicaid, vital statistics, and child welfare systems were linked to evaluate the impact of MOMS on 252 mother-infant dyads compared to a sample of 846 Medicaid beneficiaries with OUD in the third trimester of pregnancy. MOMS participation was associated with increased likelihood of MAT in trimesters one, two and three (AOR = 2.30, 4.40, 2.75, respectively), behavioral health counseling during trimesters two and three (AOR = 3.75 and 2.07, respectively), retention in MAT during postpartum months one through three and four through six (AOR = 2.86, 2.40, respectively), and marginally lower out-of-home placement of infants born to mothers with OUD (AOR = 0.66). Within the MOMS program, greater participation in behavioral health treatment and MAT (χ2(3) ≥ 12.09) was observed in the co-located behavioral health/obstetrical care practice site compared to behavioral health-led and obstetrical provider-led sites.

Identification of Health Technology Management departments in Mexico’s State health services

To advance in the verification for the development of Health Technology Management (HTM) tasks that the State Health Services in Mexico have obligation to perform, the National Center for Health Technology Excellence (CENETEC) carried out a survey of information to identify the organizational areas in charge for such activities within each of the 32 States, since to date there is no reliable and up-to-date official information about them. It could be identified that not all States have a department with specific designation for HTM, that the vast majority of existing areas are lead by a biomedical engineering professional, and also, in most cases, they respond to infrastructure planning area directives. These findings seek to promote a discussion on the need to standardize across the country, regarding State Health Services, this type of services to improve the processes necessary for the integral management processes of medical equipment.

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

Abstract P104: Impact of Cold Weather on Cardiovascular Diseases in Texas

Background: Cardiovascular disease (CVD) has been estimated to account for nearly 50% of total deaths during cold seasons, and cold weather has been shown to have a significant impact on CVD. More importantly, detrimental health effects of cold were particularly pronounced in regions with mild winter climate. Texas is the second largest state in the U.S. and is associated with varying climates. This study aims to improve the understanding of how cold weather affects CVD-related mortality and morbidity in Texas. Methods: We obtained mortality data (1990-2013) and emergency hospital admissions (EHA) data (2003-2014) from the Texas Department of State Health Services and weather data from the National Climate Data Center. Our analysis included cases diagnosed as cardiovascular disease (CVD, ICD-9 390-429; ICD-10 I01-I52), ischemic heart disease (IHD, ICD-9 410-414; ICD-10 I20-I52), myocardial infarction disease (MI, ICD-9 410; ICD-10 I21, I22) and stroke (ICD-9 430-438; ICD-10 I60-I69). We first applied Poisson regression models to 12 Texas major Metropolitan Areas (MSAs) to estimate cold effects on deaths and hospital admissions related to CVDs. A random effects meta-regression analysis was then used to estimate pooled effects for the entire state. Results: With a 1°C decrease in temperature below a MSA-specific threshold, increased death risks were observed in CVDs (1.8% [95%CI: 1.1%, 2.6%]), stroke (1.2% [95%CI: -0.2%, 2.6%]), IHD 2.5% [95%CI: 1.1%, 4.0%], and MI 4.3% [95%CI: 1.2%, 7.5%]). Estimates of cold effects were lower for EHA risks, and they were 1.1% (95%CI: 0.4%, 1.8%) for CVDs, 2.3% (95%CI: -0.3%, 4.9%) for stroke, 1.7% (95%CI: -0.1%, 3.6%) for IHD, and 0.3% (95%CI: -3.5%, 4.2%) for MI. Conclusion: This is the first multi-city study in the U.S. that examined the effect of cold weather on CVD using both mortality and hospital admission data. Cold weather increases mortality risk significantly but less in EHA risk in Texas, and effects vary geographically. Our findings can provide insights to design better intervention strategies for targeted vulnerable populations towards reducing adverse health effects of cold weather.

Age‐specific distributed lag models for heat ‐ related mortality

AbstractDistributed lag (DL) models have been consistently used throughout the years to assess the cumulative impact of multiple days of high heat on public health. DL models, however, are often used on an aggregate level (e.g., city or census tracts) in spite of the fact that the effect of heat on health is individual specific, leading to possible ecological fallacies. To capture more individualized effects of heat on health, we propose a negative binomial regression model where the effect of lagged temperatures is age specific. Utilizing principles of predictive process models, we place appropriate smoothness and decay constraints on the associated DL surfaces. Furthermore, we borrow strength across ages to facilitate the estimation of the age‐specific DL function. Using death certificate data from the Texas Department of State Health Services, we show how different ages are impacted by consecutive days of high heat.

The risk of birth defects is not associated with semen parameters or mode of conception in offspring of men visiting a reproductive health clinic.

What is the relationship between semen parameters and birth defect (BD) rates in offspring of men evaluated for infertility? Among men undergoing infertility evaluation, there is no significant relationship between semen parameters and defect rates in live or still births, even when considering mode of conception. Approximately 15% of couples have fertility difficulties, with up to a 50% male factor contribution. An increased risk of BDs exists in couples using ART, particularly IVF and ICSI, but it is unknown if this related to the ART procedures or an underlying male factor. To determine if the severity of male factor infertilty, as assessed via sperm quality and mode of conception, is associated with BD rates, we performed a retrospective cohort study. Fathers with semen analysis data in the Baylor College of Medicine Semen Database (BCMSD) were linked with their offspring using Texas Birth Defects Registry (TBDFR) data between 1999 and 2009. In this 10-year period, a total of 1382 men were identified in linkage between the BCMSD and TBDFR. A total of 109 infants with and 2115 infants without BDs were identified. To determine the association between BDs and semen parameters, we used hierarchical linear modeling to determine odds ratios between BD rates, semen parameters, and mode of conception before and after adjustment for paternal, maternal and birth covariates. Semen parameters were stratified based on thresholds defined by the WHO fifth edition laboratory manual for the examination and processing of human semen. In total 4.9% of 2224 infants were identified with a BD. No statistically significant association was observed between BD rates and semen parameters, before or after adjustment for covariates. The association between sperm concentration and BDs demonstrated an odds ratio (OR) of 1.07 (95% confidence interval: 0.63-1.83); motility: OR 0.91 (0.52-2.22); and total motile count: OR 1.21 (0.70-2.08). Likewise, mode of conception, including infertility treatment and ART, did not affect BD rates (P > 0.05). BDs recorded in the TBDFR only include live born infants or still births after 20 weeks, our study did not evaluate the effect of impaired semen parameters on developmental defects prior to 20 weeks of gestation. With 109 BDs, our statistical analysis was powered to detect moderate differences associated with particular semen parameters. Additionally, data about mode of conception was not available for 1053 of 2224 births. BD rates are not associated with semen quality or mode of conception. The current study suggests that the severity of male factor infertility does not impact the rate of congenital anomalies. This information is important when counseling couples concerned about the relationship between impaired semen quality and BDs. Supported in part by the NIH Men's Reproductive Health Research (MRHR) K12 HD073917 (D.J.L.), the Multidisciplinary K12 Urologic Research (KURe) Career Development Program (D.J.L.), P01HD36289 from the Eunice Kennedy Shriver National Institute for Child Health and Human Development, NIH (D.J.L.), and by U01DD000494 from the Centers for Disease Control and Prevention and the Title V Block Grant to the Texas Department of State Health Services. A.W.P. is a National Institutes of Health K08 Scholar supported by a Mentored Career Development Award (K08DK115835-01) from the from the National Institute of Diabetes and Digestive and Kidney Diseases. This work is also supported in part through a Urology Care Foundation Rising Stars in Urology Award (to A.W.P.) None of the authors has a conflict of interest. Not applicable.

Brazilian Breast Cancer Care Network: the perspective of health managers.

To analyze the organization of the Brazilian Breast Cancer Care Network, according to the perspective of managers of the Coordenadoria Regional de Saúde Sudeste (Southeast Regional Coordination of Health) of the city of São Paulo. A descriptive study, with a qualitative approach, carried out with seven managers of this Coordination. The interview data were analyzed based on the components of the operational structure of the Brazilian Health Care Network: Communication Center; Secondary and Tertiary Care Points; Support Systems; Logistic Systems; and Network Governance System. There is heterogeneity in the operationalization of the Care Network and the obstacles to its integration and comprehensiveness were: fragility of the bond with the users; high turnover of professionals in Primary Health Care; lack of standardization of the reference system and counter-referral, and low cooperation between municipal and state health services. The organization of the Brazilian Breast Cancer Care Network is fragmented, thus compromising the comprehensiveness of care.

Abortion Disclosure Laws and the First Amendment: The Broader Public Health Implications of the Supreme Court's Becerra Decision.

In 2018, the US Supreme Court analyzed a California state requirement that clinics serving pregnant women must provide government notices-1 for licensed clinics about the availability of state health services including abortion and 1 for unlicensed clinics, notifying potential clients that the clinics are not licensed medical facilities and have no licensed medical professionals on-site. The Supreme Court found that both notices violated the First Amendment rights of the clinics. The Supreme Court's opinion elicits new uncertainties about the government's ability to require the disclosure of factual information in the context of reproductive health services and more broadly in the commercial context. However, the Supreme Court's silence on 1 of the state's purposes for the unlicensed clinic notice, which was to address deceptive speech by the clinics, highlights a potential avenue for future regulation. Policymakers can require the disclosure of factual information in the commercial context specifically to prevent consumer deception consistent with the First Amendment. Public health researchers can generate evidence to support such disclosure requirements intended to protect health and safety.

224: Trends in mode of delivery of infants with congenital heart disease

Prenatal diagnosis of critical congenital heart disease (CCHD) has been increasing over the last two decades. While this allows care teams to plan deliveries of infants with CCHD, efforts may result in increasing rates of Cesarean-section delivery. We sought to identify trends in mode of delivery in infants with CCHD over an 18-year period in Texas and compare this to the general population in the state of Texas over the same time period. We identified live born infants with a diagnosis of CCHD from January 1999 through December 2016 using the Texas Public Use Data File, a population-based administrative database that captures nearly 100% of hospitalizations in the state of Texas. CCHD was defined as congenital heart disease likely to require intervention within the first year of life. Infants with a discharge diagnosis of a multiple gestation birth, significant birth defect or a known genetic abnormality were excluded. We evaluated the proportion of births annually that were delivered via Cesarean over the course of the time period studied. We compared this to the proportion of live births that were delivered via Cesarean in the state of Texas, using data from the Texas Department of State Health Services Vital Statistics Data over the same time period. Cesarean delivery over time in CCHD was evaluated using generalized estimating equations accounting for hospital clustering. The rates of Cesarean delivery were compared between CCHD and Texas data overall using Chi square test and Chi square test for trend. There was a total of 5,961 births fulfilling inclusion criteria. The mean percentage of cesareans performed for infants with CCHD during the study period was 46.1% compared to 32.6% in the overall infant population in Texas (p<0.001). For both groups, there appeared to be a significant yearly increase in the number of cesareans performed for both groups until 2008 (CCHD group mean annual change +1.45%, p=0.024, and Texas +1.13%, p=0.003); after this time the number of cesarean sections plateaued in CCHD and has had a mild decline overall (CCHD group mean annual change -0.06%; p=0.854, and Texas -0.13%, p=0.031). Cesarean delivery occurred more frequently in infants with CCHD than the general population in the state of Texas from 1999-2016. For both groups, the rates of Cesarean delivery increased and then appear to have plateaued. Further study to identify the reason for the higher percentage of cesarean delivery in CCHD is warranted.