Perceptions of preparedness, timing of cancer diagnosis, and objective emergency preparedness among gynecological cancer patients in Puerto Rico before and after Hurricane Maria.

OBJECTIVES: This study investigated the impact of cancer diagnosis status, individual feelings of preparedness, and other covariates on objective emergency preparedness among women diagnosed with gynecological cancers before or after the 2017 Hurricanes Irma and Maria in Puerto Rico. METHODS: This study included 240 women who were interviewed by telephone from 9/2019-11/2020. Objective emergency preparedness was assessed using a list of six items. Subjective emergency preparedness was assessed by asking the women how prepared they felt (well, somewhat, or not at all) to face an emergency. Crude and multivariable logistic regression analyses were conducted to assess the associations (odds ratios [ORs] and 95% confidence intervals [CIs]) between variables of interest and objective preparedness. RESULTS: Before and after the hurricanes, 60% and 66% of women, respectively, were objectively prepared. Before the hurricanes, women reporting feeling well-prepared (vs. not prepared) (OR=9.31, 95%CI:3.96-21.91) and those who were diagnosed before (vs. after) the hurricanes (OR=1.71, 95%CI:0.95-3.09) were more likely to be objectively prepared. After the hurricanes, self-perceived well-preparedness (OR=2.46, 95% CI: 1.10-5.51) was positively associated with emergency preparedness when compared to feeling unprepared. CONCLUSIONS: Perceptions of emergency preparedness and having a cancer diagnosis increased the likelihood of being objectively prepared for an emergency. POLICY SUMMARY: This study demonstrates the need for state, territorial, and federal governments to include emergency preparedness plans for cancer patients in the Comprehensive Cancer Control plans. The study also indicates a need for cancer specific emergency preparedness information to be readily available for patients.

Associations Between Preconception Glycemia and Preterm Birth: The Potential Role of Health Care Access and Utilization.

Background: Preconception diabetes is strongly associated with adverse birth outcomes. Less is known about the effects of elevated glycemia at levels below clinical cutoffs for diabetes. In this study, we estimated associations between preconception diabetes, prediabetes, and hemoglobin A1c (HbA1c) on the risk of preterm birth, and evaluated whether associations were modified by access to or utilization of health care services. Materials and Methods: We used data from Add Health, a US prospective cohort study with five study waves to date. At Wave IV (ages 24-32), glucose and HbA1c were measured. At Wave V (ages 32-42), women with a live birth reported whether the baby was born preterm. The analytic sample size was 1989. Results: The prevalence of preterm birth was 13%. Before pregnancy, 6.9% of women had diabetes, 23.7% had prediabetes, and 69.4% were normoglycemic. Compared to the normoglycemic group, women with diabetes had 2.1 (confidence interval [95% CI]: 1.5-2.9) times the risk of preterm birth, while women with prediabetes had 1.3 (95% CI: 1.0, 1.7) times the risk of preterm birth. There was a nonlinear relationship between HbA1c and preterm birth such that risk of preterm birth emerged after HbA1c = 5.7%, a standard cutoff for prediabetes. The excess risks of preterm birth associated with elevated HbA1c were four to five times larger among women who reported unstable health care coverage and among women who used the emergency room as usual source of care. Conclusion: Our findings replicate prior research showing strong associations between preconception diabetes and preterm birth, adding that prediabetes is also associated with higher risk. Policies and interventions to enhance access and utilization of health care among women before pregnancy should be examined.

ICU Admission Risk Factors for Latinx COVID-19 Patients at a U.S.-Mexico Border Hospital.

OBJECTIVE: Few studies have examined the impact of coronavirus disease 2019 (COVID-19) on the primarily Latinx community along the U.S.-Mexico border. This study explores the socioeconomic impacts which contribute to strong predictors of severe COVID-19 complications such as intensive care unit (ICU) hospitalization in a primarily Latinx/Hispanic U.S.-Mexico border hospital. METHODS: A retrospective, observational study of 156 patients (≥ 18 years) Latinx/Hispanic patients who were admitted for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at a U.S.-Mexico border hospital from April 10, 2020, to May 30, 2020. Descriptive statistics of sex, age, body mass index (BMI), and comorbidities (coronary artery disease, hypertension, diabetes, cancer/lymphoma, current use of immunosuppressive drug therapy, chronic kidney disease/dialysis, or chronic respiratory disease). Multivariate regression models were produced from the most significant variables and factors for ICU admission. RESULTS: Of the 156 hospitalized Latinx patients, 63.5% were male, 84.6% had respiratory failure, and 45% were admitted to the ICU. The average age was 67.2 (± 12.2). Those with body mass index (BMI) ≥ 25 had a higher frequency of ICU admission. Males had a 4.4 (95% CI 1.58, 12.308) odds of ICU admission (p = 0.0047). Those who developed acute kidney injury (AKI) and BMI 25-29.9 were strong predictors of ICU admission (p < 0.001 and p = 0.0020, respectively). Those with at least one reported comorbidity had 1.98 increased odds (95% CI 1.313, 2.99) of an ICU admission. CONCLUSION: Findings show that age, AKI, and male sex were the strongest predictors of COVID-19 ICU admissions in the primarily Latinx population at the U.S.-Mexico border. These predictors are also likely driven by socioeconomic inequalities which are most apparent in border hospitals.

Chronic hypertension and risk of preterm delivery: National Longitudinal Study of Adolescents to Adult Health.

BACKGROUND: Chronic hypertension during pregnancy is associated with increased risk of adverse birth outcomes. In 2017, the American College of Cardiology and American Heart Association (ACC/AHA) lowered thresholds to classify hypertension in non-pregnant adults to SBP ≥ 130 mmHg and DBP ≥ 80 mmHg (ie stage I hypertension), resulting in an additional 4.5-million reproductive-aged women meeting criteria for hypertension. Little is known about effects of pre-pregnancy blood pressure (BP) in this range. OBJECTIVES: To examine the effect of pre-pregnancy maternal BP on preterm delivery. METHODS: We analysed the data from two waves of the National Longitudinal Study of Adolescent to Adult Health, including participants that had measured BP at Wave IV (2008-09) and a pregnancy that resulted in a singleton live birth between Waves IV and V (2016-18; n = 2038). We categorised BP using ACC/AHA cut-offs: normal (SBP < 120 mmHg and DBP < 80 mmHg), elevated (SBP 120-129 mmHg and DBP < 80 mmHg), hypertension stage I (SBP 130-139 mmHg or DBP 80-89 mmHg) and hypertension stage II (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg). We estimated risk ratios (RR) with log-binomial regression adjusting for maternal demographics, anthropometrics and medication use. RESULTS: The prevalence of preterm delivery was 12.6%. A standard deviation (SD) increment in SBP (SD = 12.2 mmHg) and DBP (SD = 9.3 mmHg) was associated with a 14% (95% confidence interval [CI] 2, 27) and 20% (95% CI 4, 37) higher risk of preterm delivery. Compared to normotensive controls, stage I (RR 1.33, 95% CI 1.01, 1.74) and stage II (RR 1.34, 95% CI 0.89, 2.00) hypertension were associated with increased risk. CONCLUSIONS: We observed greater risk of preterm delivery among women with higher pre-pregnancy BP. Women with stage I hypertension during pregnancy may benefit from increased BP monitoring. Additional studies on the utility of foetal surveillance in this group are warranted.

Hold the Phone! Cell Phone-Related Injuries in Children, Teens, and Young Adults Are On the Rise.

We describe trends in cell phone-related injuries in patients 21 years of age and under presenting to United States Emergency Departments. We calculated age-adjusted rates of cell phone-related injury per 100 000 individuals using data from the National Electronic Injury Surveillance System (NEISS) database and United States Census Bureau. From 2002 to 2015, an estimated 38 063 patients 21 years old and younger sustained a cell phone-related injury. The overall rate of injuries for all ages increased from 17.1 injuries per 100 000 in 2002 to 138 injuries per 100 000 in 2015, an increase of over 700%. The incidence of cell phone-related injuries increased across all age groups, with children 2 years of age and under experiencing the highest single incidence rate of 159 injuries per 100 000 in 2014. These findings highlight an important and relatively under-reported pediatric safety issue. Anticipatory guidance and injury prevention plans should be updated accordingly.

The Impact of Behavioral Health Patients on a Pediatric Emergency Department's Length of Stay and Left Without Being Seen.

OBJECTIVE: Emergency department (ED) boarding of admitted patients negatively impacts ED length of stay (LOS). Behavioral health (BH) patients are often challenging to safely discharge. We examined the association between daily BH census and non-BH LOS and left without being seen (LWBS) rates. METHODS: Retrospective analysis of BH and non-BH patients at a high-volume tertiary care pediatric ED from December 2014 to June 2016 examined the association between BH patients and non-BH LOS and LWBS rates. Behavioral health patients were identified by presence of social work assessment and BH chief complaint and/or final diagnosis. Data were analyzed using 1-sample test of proportions, Student t test, Spearman and Pearson correlations, logistic regression, and odds ratios with 95% confidence intervals. RESULTS: A total of 143,141 patients were seen, 3% (n = 4351) for BH presentations. Median LOS for discharged non-BH patients was 128 minutes compared with 446 minutes for BH patients. Daily LOS and bed hold hours were significantly longer for BH than for non-BH patients (P < 0.0001 for each analysis). After adjusting for ED census, daily BH census was significantly associated with increasing LWBS rates and non-BH LOS. CONCLUSIONS: Behavioral health census and bed hold hours were significantly associated with increased LOS and LWBS rates and with our inability to meet desired LOS and LWBS rates. These associations support the existence of a threshold where the ED has reached capacity and is no longer able to absorb BH patients. Improving BH facility access may help improve overall pediatric ED patient care.

Application of the MASCC and CISNE Risk-Stratification Scores to Identify Low-Risk Febrile Neutropenic Patients in the Emergency Department.

STUDY OBJECTIVE: Although validated risk-stratification tools have been used to send low-risk febrile neutropenic patients home from clinic and inpatient settings, there is a dearth of research evaluating these scores in the emergency department (ED). We compare the predictive accuracy of the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores for patients with chemotherapy-induced febrile neutropenia and presenting to the ED. METHODS: We conducted a retrospective cohort study to evaluate all patients with febrile neutropenia (temperature ≥38°C [100.4°F], absolute neutrophil count <1,000 cells/µL) who presented to 2 academic EDs from June 2012 through January 2015. MASCC and CISNE scores were calculated for all subjects, and each visit was evaluated for several outcome variables, including inpatient length of stay, upgrade in level of care, clinical deterioration, positive blood culture results, and death. Descriptive statistics are reported and continuous variables were analyzed with Wilcoxon rank sum. RESULTS: During our study period, 230 patients presented with chemotherapy-induced febrile neutropenia. The CISNE score identified 53 (23%) of these patients as low risk and was highly specific in the identification of a low-risk cohort for all outcome variables (98.3% specific, 95% confidence interval [CI] 89.7% to 99.9%; positive predictive value 98.1%, 95% CI 88.6% to 99.9%). Median length of stay was shorter for low-risk versus high-risk CISNE patients (3-day difference; P<.001). The MASCC score was much less specific (54.2%; 95% CI 40.8% to 67.1%) in the identification of a low-risk cohort. CONCLUSION: Our results suggest that the CISNE score may be the most appropriate febrile neutropenia risk-stratification tool for use in the ED.

Defining Population Health Vulnerability Following an Extreme Weather Event in an Urban Pacific Island Environment: Honiara, Solomon Islands.

Extreme weather events are common and increasing in intensity in the southwestern Pacific region. Health impacts from cyclones and tropical storms cause acute injuries and infectious disease outbreaks. Defining population vulnerability to extreme weather events by examining a recent flood in Honiara, Solomon Islands, can help stakeholders and policymakers adapt development to reduce future threats. The acute and subacute health impacts following the April 2014 floods were defined using data obtained from hospitals and clinics, the Ministry of Health and in-country World Health Organization office in Honiara. Geographical information system (GIS) was used to assess morbidity and mortality, and vulnerability of the health system infrastructure and households in Honiara. The April flash floods were responsible for 21 acute deaths, 33 injuries, and a diarrhea outbreak that affected 8,584 people with 10 pediatric deaths. A GIS vulnerability assessment of the location of the health system infrastructure and households relative to rivers and the coastline identified 75% of the health infrastructure and over 29% of Honiara's population as vulnerable to future hydrological events. Honiara, Solomon Islands, is a rapidly growing, highly vulnerable urban Pacific Island environment. Evaluation of the mortality and morbidity from the April 2014 floods as well as the infectious disease outbreaks that followed allows public health specialists and policy makers to understand the health system and populations vulnerability to future shocks. Understanding the negative impacts natural disaster have on people living in urban Pacific environments will help the government as well as development partners in crafting resilient adaptation development.

One Bioregion/One Health: An Integrative Narrative for Transboundary Planning along the US-Mexico Border.

Global megatrends-including climate change, food and water insecurity, economic crisis, large-scale disasters and widespread increases in preventable diseases-are motivating a bioregionalisation of planning in city-regions around the world. Bioregionalisation is an emergent process. It is visible where societies have begun grappling with complex socio-ecological problems by establishing place-based (territorial) approaches to securing health and well-being. This article examines a bioregional effort to merge place-based health planning and ecological restoration along the US-Mexico border. The theoretical construct underpinning this effort is called One Bioregion/One Health (OBROH). OBROH frames health as a transborder phenomenon that involves human-animal-environment interactions. The OBROH approach aims to improve transborder knowledge networking, ecosystem resilience, community participation in science-society relations, leadership development and cross-disciplinary training. It is a theoretically informed narrative to guide action. OBROH is part of a paradigm shift evident worldwide; it is redefining human-ecological relationships in the quest for healthy place making. The article concludes on a forward-looking note about the promise of environmental epidemiology, telecoupling, ecological restoration, the engaged university and bioregional justice as concepts pertinent to reinventing place-based planning.