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Paper constitutes about 38% of municipal solid waste, much of which is disposed of in landfills. Sorption to such lignocellulosic materials may limit the bioavailability of organic contaminants in landfills. The objective of this study was to identify the effect of individual biopolymers in paper on toluene sorption and bioavailability by subjecting fresh and anaerobically degraded office paper and newsprint to enzymatic hydrolysis and acid hydrolysis. Enzymatic degradation of cellulose and hemicellulose had no effect on toluene bioavailability. In contrast, acid-insoluble lignin controlled toluene sorption and bioavailability for both fresh and degraded newsprint. Acid-insoluble lignin could explain only 54% of the toluene sorption capacity of degraded office paper however, suggesting that crude protein and/or lipophilic organic matter were also important sorbent phases. Toluene sorbed to degraded office paper was also less bioavailable than toluene sorbed to an equivalent mass of lignin extracted from this sorbent. The latter result suggests that a fraction of toluene sorbed to degraded office paper may have been sequestered by lipophilic organic matter. The sorption and bioavailability data indicate that the preferential decomposition of cellulose and hemicellulose relative to lignin in landfills should not decrease the overall toluene sorption capacity of paperwaste or increase the bioavailability of sorbed toluene.

This paper describes the design considerations for the implementation of a bedside computer system in an intensive care environment. Specific issues discussed include application design, implementation problems, design revisions, and design solutions. Specific examples of the above issues include passive data acquisition from bedside devices and computer systems, automated nursing assessments, respiratory therapy assessments and integrated reports.

Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are widespread groundwater contaminants and are present in over 7000 drinking water wells near a North Carolina (NC) PFAS plant (Chemours). To understand options available to affected residents, we used new and previously existing water quality data to investigate deeper aquifers as alternate drinking water supplies and compared the regulatory responses near Chemours and three other PFAS production facilities with nearby contaminated wells. Data from >100 wells show that GenX concentrations decrease with increasing depth through the four aquifers in the study area: surficial, Black Creek, Upper Cape Fear, and bedrock. This illustrates the extent of vertical PFAS penetration through the aquifer sequence following roughly 40 years of atmospheric emissions. Detailed data on 143 water quality parameters in nine deep wells (two Upper Cape Fear, seven bedrock) revealed only eight exceedances of drinking water standards (one each for arsenic, perfluorooctanoic acid [PFOA], iron, chloride, and gross alpha, and three for manganese) and nine exceedances of health advisories (all for sodium). Regulatory responses to PFAS contamination of wells in four states included mention of deeper wells as an alternate water source only for nonresidential users in NC and residential users in Vermont. The bedrock aquifer is currently used by some residents and may be a viable alternative to shallower groundwater, though arsenic treatment may be beneficial at some deep wells and long-term sustainability of the aquifer should be evaluated. PRACTITIONER POINTS: GenX concentrations decreased with increasing depth in four aquifers near a PFAS plant. A few exceedances of drinking water standards and health advisories were found in deep bedrock wells. New bedrock wells could be part of the response to PFAS issues in shallower wells. In the long term, deep bedrock wells might be a less expensive option for some residents., (© 2024 The Author(s). Water Environment Research published by Wiley Periodicals LLC on behalf of Water Environment Federation.)

The behavioral health system's peer support workforce must be adequately trained to perform peer support services, but evidence of the adequacy of their training needs to be improved. With survey data from 667 certified peer support specialists (CPSS) from North Carolina, Kentucky, Virginia, and Tennessee, this study used (a) binomial probability test to assess perceptions about the adequacy of the workforce's training, (b) latent profile analysis to identify patterns and predictors of perceptions about the SAMHSA core competencies covered in their training, and (c) thematic analysis to identify additional training needs. Most respondents identified as White (72%), female (73%), and had some college education (83%). Most of the workforce (> 90%) felt prepared to provide services, regardless of their state. Highly and moderately sufficient coverage emerged as two distinct response patterns regarding coverage of the SAMSHA core competencies, with respondents' years of experience, state of residence, education level, race, and sense of preparedness predicting the probability of fitting into either profile. Participants desired additional training in trauma-informed practices, motivational interviewing, and new treatment approaches. Peers' experiences and perspectives were similar across different states. The findings suggest booster training sessions or continuing education opportunities are needed to maintain a robust and well-prepared peer support workforce. States should consider reciprocity agreements to enable the trained workforce to practice across states. A key implication for the training content is the need to incorporate contemporary issues relating to mental health and substance use disorders to better meet behavioral health needs., (© 2024. National Council for Mental Wellbeing.)

Newspaper sentiment and framing have the power to represent and inform public opinion on a variety of important issues. This study examines local news articles after Hurricane Florence struck North Carolina in the United States in September 2018 to understand the framing efforts undertaken by the outlets that produced these reports, as well as their impact on news sentiment towards the flood recovery efforts of the Federal Emergency Management Agency (FEMA). The results indicate that while most articles published in the wake of Florence have a neutral sentiment, there are a significant number of both positively and negatively coded articles that illuminate important information about how the public engaged with and comprehended the role of FEMA during recovery from the disaster, and how the media chose to cover its involvement. Such scrutiny will continue to inform how public, private, and government actors understand FEMA's role and whether it achieves its goals in the future., (© 2022 The Authors Disasters © 2022 ODI.)

Purpose: The aim of this study was to bibliometrically analyze the 100 most-cited articles published in the Veterinary Ophthalmology (VO) journal., Methods: Web of Science was searched for citations of VO articles published in 1998-2022. Tissue and species studied, and first and last author domicile and affiliation were recorded for the 100 most-cited articles and descriptively analyzed., Results: Altogether, the 100 most-cited VO articles have cited a total of 5483 times. Most commonly, these were devoted to the cornea (23%), multiple tissues (19%), and glaucoma (16%). Studies on dogs (36%), horses (17%), and multiple species (15%) were most often cited. Most first/last authors were from the USA (n = 113), Brazil (n = 13), and France and Germany (n = 7 each), and most frequently affiliated with the University of Florida (n = 36), University of Wisconsin-Madison (n = 15), and Animal Health Trust, North Carolina State University, and Ohio State University (n = 6 each). KN Gelatt (n = 9), DE Brooks (n = 6), and FJ Ollivier and EO MacKay (n = 5 each) were the most frequent first or last authors. The greatest number of citations was for articles with KN Gelatt (n = 555), FJ Ollivier (n = 411), and DE Brooks (n = 372) as first or last authors. "The comparative morphology of the tapetum lucidum" by FJ Ollivier et al. (2002) is the most frequently cited article in VO history (n = 178)., Conclusions: This study provides insight into the impact of publishing in VO and a more comprehensive understanding of trends and the most influential contributions to VO., (© 2023 The Authors. Veterinary Ophthalmology published by Wiley Periodicals LLC on behalf of American College of Veterinary Ophthalmologists.)

Untreated behavioral health conditions among the perinatal population are associated with high mortality and morbidity. We examined trends of behavioral health conditions and treatment received by perinatal Medicaid beneficiaries and described the characteristics of providers treat-ing these beneficiaries from 2017 to 2022. Results indicated that 24.4% of beneficiaries had a behav-ioral health diagnosis, 13.8% received a psycho-tropic prescription, and 7.1% received a behavioral health service., Competing Interests: Disclosure of interests: Dr. Gary Maslow receives grant support from Substance Abuse Mental Health Services Administration (SAMHSA), NC Medicaid, North Carolina Department of Health and Human Services, and Healthy Blue and has received research funding from Pfizer, the National Institutes of Health, and the Arc of North Carolina. Dr. Mary Kimmel was a PI on an investigator-led study with Sage Therapeutics, which ended over a year ago. Her spouse has some stock in Abbvie., (Copyright ©2024 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Background: Hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis is associated with improved survival. Provision of HCC surveillance is low in the US, particularly in primary care settings., Aims: To evaluate current hepatitis C virus (HCV) and HCC surveillance practices and physician attitudes regarding HCC risk-stratification among primary care and subspecialty providers., Methods: Using the Tailored Design Method, we delivered a 34-item online survey to 7654 North Carolina-licensed internal/family medicine or gastroenterology/hepatology physicians and advanced practice providers in 2022. We included the domains of HCV treatment, cirrhosis diagnosis, HCC surveillance practices, barriers to surveillance, and interest in risk-stratification tools. We performed descriptive analyses to summarize responses. Tabulations were weighted based on sampling weights accounting for non-response and inter-specialty comparisons were made using chi-squared or t test statistics., Results: After exclusions, 266 responses were included in the final sample (response rate 3.8%). Most respondents (78%) diagnosed cirrhosis using imaging and a minority used non-invasive tests that were blood-based (~ 15%) or transient elastography (31%). Compared to primary care providers, subspecialists were more likely to perform HCC surveillance every 6-months (vs annual) (98% vs 35%, p < 0.0001). Most respondents (80%) believed there were strong data to support HCC surveillance, but primary care providers did not know which liver disease patients needed surveillance. Most providers (> 70%) expressed interest in potential solutions to improve HCC risk-stratification., Conclusions: In this statewide survey, there were great knowledge gaps in HCC surveillance among PCPs and most respondents expressed interest in strategies to increase appropriate HCC surveillance., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

By examining the strengths, limitations, and implications of different payment models we seek to inform policymakers, practitioners, and educators on the path toward patient-cen-tered, efficient, and sustainable primary health care deliv-ery. Health care payment model reform should be viewed as an investment in future health asset capacity and equity production rather than an immediate return on investment for short-term health care cost reduction., Competing Interests: Acknowledgments: The author reports no potential conflicts of interest., (Copyright ©2024 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

High-functioning teams can positively impact health care delivery and support population health. The authors discuss enabling and interfering factors that impact team-based care delivery and how the AHEC system can promote inter-professional education and practice across North Carolina., Competing Interests: Acknowledgments: All authors declare that they have no conflicts of interest., (Copyright ©2024 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Onsite wastewater treatment systems (OWTSs) and private wells are commonly used in Eastern North Carolina, USA. Water from private wells is not required to be tested after the initial startup, and thus persons using these wells may experience negative health outcomes if their water is contaminated with waste-related pollutants including bacteria, nitrate or synthetic chemicals such as hexafluoropropylne oxide dimer acid and its ammonium salt (GenX). Water samples from 18 sites with OWTSs and groundwater wells were collected for nitrate, Escherichia coli (E. coli), total coliform, and GenX concentration analyses. Results showed that none of the 18 water supplies were positive for E. coli, nitrate concentrations were all below the maximum contaminant level of 10 mg L -1 , and one well had 1 MPN 100 mL -1 of total coliform. However, GenX was detected in wastewater collected from all 18 septic tanks and 22% of the water supplies tested had concentrations that exceeded the health advisory levels for GenX. Water supplies with low concentrations of traditionally tested for pollutants (nitrate, E. coli) may still pose health risks due to elevated concentrations of emerging contaminants like GenX and thus more comprehensive and routine water testing is suggested for this and similar persistent compounds., (© 2024 The Authors This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence (CC BY 4.0), which permits copying, adaptation and redistribution, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/).)

Background: A fluorochemical facility near Fayetteville, North Carolina, emitted per- and polyfluoroalkyl ether acids (PFEAs), a subgroup of per- and polyfluoroalkyl substances (PFAS), to air., Objective: Analyze PFAS in private wells near the facility and in blood from well users to assess relationships between PFEA levels in water and serum., Methods: In 2019, we recruited private well users into the GenX Exposure Study and collected well water and blood samples. We targeted 26 PFAS (11 PFEAs) in water and 27 PFAS (9 PFEAs) in serum using liquid chromatography-mass spectrometry. We used regression modeling to explore relationships between water and serum PFAS. For the only PFEA detected frequently in water and serum, Nafion byproduct 2, we used generalized estimating equation (GEE) models to assess well water exposure metrics and then adjusted for covariates that may influence Nafion byproduct 2 serum concentrations., Results: We enrolled 153 participants ages 6 and older (median = 56 years) using 84 private wells. Most wells (74%) had ≥6 detectable PFEAs; median ∑PFEAs was 842 ng/L (interquartile range = 197-1760 ng/L). Low molecular weight PFEAs (PMPA, HFPO-DA [GenX], PEPA, PFO2HxA) were frequently detected in well water, had the highest median concentrations, but were not detectable in serum. Nafion byproduct 2 was detected in 73% of wells (median = 14 ng/L) and 56% of serum samples (median = 0.2 ng/mL). Cumulative dose (well concentration × duration at address) was positively associated with Nafion byproduct 2 serum levels and explained the most variability (10%). In the adjusted model, cumulative dose was associated with higher Nafion byproduct 2 serum levels while time outside the home was associated with lower levels., Impact: PFAS are a large class of synthetic, fluorinated chemicals. Fluorochemical facilities are important sources of environmental PFAS contamination globally. The fluorochemical industry is producing derivatives of perfluoroalkyl acids, including per- and polyfluoroalkyl ether acids (PFEAs). PFEAs have been detected in various environmental samples but information on PFEA-exposed populations is limited. While serum biomonitoring is often used for PFAS exposure assessment, serum biomarkers were not good measures of long-term exposure to low molecular weight PFEAs in a private well community. Environmental measurements and other approaches besides serum monitoring will be needed to better characterize PFEA exposure., (© 2023. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Equality, freedom, and the security of a free state were key formative tenets that the founders of our nation sought to enshrine in its founding documents. Now it is once again time to act in the pursuit of these goals to address the profound impact of firearms. More than ever, we need open lines of discussion and communication that draw people together and help us find collective solutions that build on the ideals on which America was founded. The articles in this edition of the NCMJ demonstrate the breadth and depth of approaches to addressing the firearm injury and death crisis we all face., Competing Interests: Disclosure of interests: The authors report no conflicts of interest., (Copyright ©2023 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

A 2022 white paper released by the state of North Carolina recommends a public health approach to reducing firearm injury and death. This commentary describes the impetus, rationale, process, and context for releasing the white paper and identifies progress and next steps in this effort., Competing Interests: Disclosure of interests: The authors report no conflicts of interest., (Copyright ©2023 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Hospital-based violence intervention programs provide an example of the multifaceted approach needed to address violence as a public health issue. In North Carolina, several health care systems have joined the call to create programs that address the needs of victims of violence and promote the healing process., Competing Interests: Funding: Atrium Health and Duke University Hospital receive teaching and technical assistance from the HAVI to support the development and growth of the HVIP programs. Atrium Health’s HVIP is funded by the City of Charlotte and Atrium Health. Duke University’s VRP is funded by Duke Health and ARPA funds administered by the North Carolina Department of Health and Human Services., (Copyright ©2023 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

States across the country have been experiencing a steady decline in public health nursing workforce, including North Carolina (NC)., Objectives: To better understand retention in the NC Public Health Nurses (PHNs) workforce through an assessment of perceptions of the working environment, stress, intent to stay, and job satisfaction., Design: A cross-sectional online survey using closed and open-ended questions., Sample: The study population comprised of non-supervisory PHNs (n = 672) working at NC local health departments (LHD)., Measurements: Retention problem, working environment, and job satisfaction measures were adapted from the revised Casey-Fink Registered Nurse Retention Survey© (2009) to fit public health settings., Results: Despite high levels of job satisfaction (79.76%, n = 473), 53% of respondents (n = 323) acknowledged a retention problem within their LHD; 35.32% (n = 203) planned to/considered leaving their position in the next 3 years for reasons other than retirement. ANOVAs and Kruskal Wallis Test results showed that those planning to leave had statistically lower scores on perceived working environment and job satisfaction and demonstrated higher negative stress levels., Conclusion: Like other states, NC is experiencing a PHN shortages predicted to worsen in coming years. To retain the current workforce, LHDs need to work to improve PHNs working environment, increase PHNs' pay, and alleviate stressors., (© 2021 Wiley Periodicals LLC.)

Objective: Because of the growing concern about the potential effects of traumatic brain injuries (TBIs) on a child's developing brain and the potential impact of lifetime depression and risk behaviors associated with TBI, further exploration is warranted., Setting and Participants: Data (N = 4917) from the 2017 North Carolina Behavioral Risk Factors Surveillance System (BRFSS)., Design: Cross-sectional., Main Measures: Examine whether a lifetime history of TBI with loss of consciousness (LOC) or having a history of TBI with LOC prior to 18 years of age was associated with a greater likelihood of lifetime depression, current binge drinking, and current cigarette and e-cigarette smoking., Results: Respondents with a history of TBI with LOC had 2.1 (95% CI, 1.6-2.8) times higher odds of lifetime depression and 1.7 to 1.8 (95% CI, 1.02-2.97) times higher odds of all risk behaviors than those without a lifetime history of TBI with LOC. There were no statistical differences between age of first TBI with LOC and lifetime depression, binge drinking, cigarette smoking, and e-cigarette use after controlling for key demographics., Conclusion: These findings underscore the importance of increasing awareness among healthcare providers of the prevalence of lifetime depression and risk behaviors among individuals with a history of TBI and the need for improved screening and referrals to evidence-based services., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Mentally ill and emotionally disturbed offenders comprise a significant component of those whose criminal conduct has swept them into the criminal justice system, including a subset who are tried and convicted of capital murder. The present study employs the population of capital cases advanced to penalty phase in the state of North Carolina (1990-2009) to examine whether presentation to the jury of the statutory mitigators of extreme mental and emotional disturbance and capacity impaired, and specific mental illness diagnoses, often referred to as mental disorders, at the sentencing phase mitigate against a sentence of death. Mental disorders included mood disorders, psychotic disorders, anxiety disorders, brain disorders, multiple mental illness diagnoses, learning disabilities, and personality disorders. Results from these 835 cases indicate that with the exception of one, the diagnosis of a learning disability, the capital jury's acceptance of various mental health conditions does not effectively mitigate against a capital sentence. In addition, jury rejection of a diagnosis of mental illness or the two mental health statutory mitigators, capacity impaired and extreme emotional disturbance, as a mitigating factor has a counter-mitigating effect in that it significantly increases the odds of a death penalty recommendation by about 85-200%., (© 2020 John Wiley & Sons, Ltd.)

Background: Missed prevention opportunities are a financial burden to the US health care system and result in excess consumption of resources, reduced quality of life, increased morbidity, and premature death., Local Problem: High staff turnover and inefficient practices at a local health department caused long patient wait times and missed opportunities for preventive health care. The project aim was to improve timeliness through Right Care in a lower socioeconomic reproductive health clinic while decreasing patient cycle time by 10% in 90 days., Methods: We used four plan-do-study-act cycles incorporating tests of change that focused on team and patient engagement and two process changes. The interventions included a care coordination huddle, an infant feeding decision aid to better understand patient values, a sexual health screening tool to identify prevention opportunities, and a redesigned patient-centered discharge process to improve efficiency., Results: Over 90 days, the receipt of Right Care increased while patient cycle time decreased by 2.6%. The team improved function with a mean huddle effectiveness score increase from 2 to 4.4 (1-5 Likert scale). Intent to breastfeed increased by 49% (35%-52%), and identification of preventive care needs increased by 320% (15%-63%). Preventive care follow-up remained unchanged at 26% with the new discharge process, identifying weaknesses in the health department referral systems., Conclusions: Standardized tools and processes improved primary prevention opportunities at a local health department while reducing patient cycle time. The tools improved documentation of intent to exclusively breastfeed, increased preventive care identification, and streamlined the discharge process; while demonstrating a systems-level gap for long-term follow-up., (© 2020 Wiley Periodicals, Inc.)

This study examines how Black and Hispanic parents' report of intergroup relations measured through group identity, linked fate, competition, and conflict are related to their utilization of Head Start services in a region that experienced Hispanic population growth. Surveys were conducted with 227 Black and 130 Hispanic parents in poverty in a mid-sized city in the South. For Hispanic parents, a sense of linked fate within their ethnic group is associated with a lower likelihood of enrollment, however, measures of intergroup relations are not related to the Head Start enrollment status of Black parents. Implications for policies on preschool expansion are discussed., (© 2019 Wiley Periodicals, Inc.)

The authors examined the relationships between sexual assault and psychiatric disorders in a sample of 1,157 women 18-64 years old in the North Carolina site of the NIMH Epidemiologic Catchment Area Program. The results suggest that sexual assault is a risk factor for a number of psychiatric disorders. In addition, several characteristics of the assault among sexual assault victims were significantly related to one or more psychiatric disorders. However, there was no clear pattern relating characteristics of the assault to the risk of specific psychiatric disorders.

Background: Wastewater monitoring data can be used to estimate disease trends to inform public health responses. One commonly estimated metric is the rate of change in pathogen quantity, which typically correlates with clinical surveillance in retrospective analyses. However, the accuracy of rate of change estimation approaches has not previously been evaluated., Objectives: We assessed the performance of approaches for estimating rates of change in wastewater pathogen loads by generating synthetic wastewater time series data for which rates of change were known. Each approach was also evaluated on real-world data., Methods: Smooth trends and their first derivatives were jointly sampled from Gaussian processes (GP) and independent errors were added to generate synthetic viral load measurements; the range hyperparameter and error variance were varied to produce nine simulation scenarios representing different potential disease patterns. The directions and magnitudes of the rate of change estimates from four estimation approaches (two established and two developed in this work) were compared to the GP first derivative to evaluate classification and quantitative accuracy. Each approach was also implemented for public SARS-CoV-2 wastewater monitoring data collected January 2021-May 2023 at 25 sites in North Carolina, USA., Results: All four approaches inconsistently identified the correct direction of the trend given by the sign of the GP first derivative. Across all nine simulated disease patterns, between a quarter and a half of all estimates indicated the wrong trend direction, regardless of estimation approach. The proportion of trends classified as plateaus (statistically indistinguishable from zero) for the North Carolina SARS-CoV-2 data varied considerably by estimation method but not by site., Discussion: Our results suggest that wastewater measurements alone might not provide sufficient data to reliably track disease trends in real-time. Instead, wastewater viral loads could be combined with additional public health surveillance data to improve predictions of other outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Detection and monitoring of per- and polyfluoroalkyl substances (PFAS) in aquatic environments has become an increasingly higher priority of regulatory agencies as public concern for human intake of these chemicals continues to grow. While many methods utilize active sampling strategies ("grab samples") for precise PFAS quantitation, here we evaluate the efficacy of low-cost passive sampling devices (Solid Phase Adsorption Toxin Tracking, or SPATTs) for spatial and temporal PFAS assessment of aquatic systems. For this study, passive samplers were initially deployed in North Carolina along the Cape Fear River during the summer and fall of 2016 and 2017. These were originally intended for the detection of microcystins and monitoring potentially harmful algal blooms, though this period also coincided with occurrences of PFAS discharge from a local fluorochemical manufacturer into the river. Additional samplers were then deployed in 2022 to evaluate changes in PFAS fingerprint and abundances. Assessment of PFAS showed legacy compounds were observed across almost all sampling sites over all 3 years (PFHxS, PFOS, PFHxA, etc.), while emerging replacement PFAS (e.g., Nafion byproducts) were predominantly localized downstream from the manufacturer. Furthermore, samplers deployed downstream from the manufacturer in 2022 noted sharp decreases in observed signal for replacement PFAS in comparison to samplers deployed in 2016 and 2017, indicating mitigation and remediation efforts in the area were able to reduce localized fluorochemical contamination., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Multiple external stressors are known to have adverse impacts on health and development. Certain groups are more vulnerable and/or more likely to be exposed toenvironmental, psychological, and social stressors simultaneously. Yet, few studies have examined combined exposure to environmental toxicants and psychosocial stress. Here, we integrated environmental chemical exposure data collected using silicone wristbands and self-report social stressor data within the Brain and Early Experience (BEE) perinatal cohort to understand co-exposure to environmental chemicals and social stress. Silicone wristbands were worn for one week by mothers throughout central North Carolina who were 6 months postpartum (n = 97). Exposure to 110 environmental chemicals across eight chemical classes was quantified on silicone wristbands using gas chromatography mass spectrometry. Social stress was evaluated using eight established self-report questionnaires (e.g., Brief Symptom Inventory, Perceived Stress Scale), quantifying experiences such as race-related stress, economic strain, and relationship conflict. Hair cortisol levels were measured as an additional metric of stress. The chemical exposure landscape and associations among chemical exposure, demographic characteristics, and social stress were characterized through individual variable analyses, cluster and data reduction, and compiled scoring approaches to comprehensively evaluate chemical and social stress burdens. We found that chemicals contain co-occurring patterns largely based on chemical class, with phthalates representing the chemical class with highest exposure and polychlorinated biphenyls the lowest. Chemicals showed differential exposure across racial groups, with diethyl phthalate, triphenyl phosphate, and tris(3,5-dimethyl phenyl) phosphate at higher levels in Black participants compared with White participants. Integrating social stressor profiling with chemical exposure data identified one particularly vulnerable subset of participants in which high chemical exposure burden coincided with high experiences of racism and economic stress. These findings demonstrate co-occurring chemical and social stress, warranting further investigation to better understand how these combined stressors may contribute to disparities in maternal and child health., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Crash type, a key contributory factor of crash injury severity level, is typically included in crash severity models as an explanatory variable. However, certain unobserved factors could influence both the crash type and crash injury severity simultaneously. As such, there could exist an endogenous effect of crash type on crash injury severity. The present paper investigates this hypothesis using data from highway ramp areas. These locations tend to be crash-prone because of the frequent lane changes and speed differentials associated with merging, diverging, and weaving of vehicles at those locations. Conventional approaches used in past ramp safety studies modeled crash type and crash injury severity separately, not addressing the endogenous effect of crash type on crash severity at these locations. In this study, a random parameter recursive bivariate probit model is proposed to model the crash type (hit-object and rollover) and crash injury severity at ramp areas simultaneously and to account for any endogenous effect of crash type. The study used highway crash data from ramp areas at highway located in North Carolina from 2016 to 2018. The results indicate that the proposed model can and does capture the endogenous effect of crash type. The likelihood of injury for a rollover crash would be underestimated if endogeneity were not considered. Other exogenous variables including aberrant driving behavior, safety belt, road surface condition, lighting condition, area type, crash location, and ramp type that affect the type and injury severity of crashes at highway ramp areas were identified. The exogenous variables that are significant only for the crash type, such as vehicle type, and speed limit, were detected to have indirect effects on the crash injury severity. Furthermore, the effects of individual heterogeneity of the explanatory variables are considered. Female drivers and old drivers are statistically significant in the means of random parameters. The findings shed light on the potential need and effectiveness of prospective traffic management and control measures to mitigate crash risk at highway ramp areas., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: Black emerging adults (18-28 years) have the highest risk of short sleep duration and obesity. This increased risk may be partly explained by greater stress levels, which may result from race-related stress (racial discrimination and heightened race-related vigilance) or living in more disadvantaged home and neighbourhood environments. Insufficient sleep may also impact obesity risk via several weight-related mechanisms including energy balance, appetite and food reward, cortisol profiles and hydration status. This paper describes the rationale, design and methods for the Sleep, Health Outcomes and Body Weight (SHOW) study. This study aims to prospectively assess the effects of sleep, race-related stress and home/neighbourhood environments on weight-related mechanisms and obesity markers (body weight, waist circumference and fat mass) in 150 black emerging adults., Methods and Analysis: The SHOW study follows a measurement burst design that includes 3, 7-day data collection bursts (baseline, 6-month and 12-month follow-ups). Sleep is measured with three methods: sleep diary, actigraphy and polysomnography. Energy balance over 7 days is based on resting and postprandial energy expenditure measured via indirect calorimetry, physical activity via accelerometry and self-reported and ad libitum energy intake methods. Self-reported methods and blood biomarkers assess fasting and postprandial appetite profiles and a behavioural-choice task measures food reward. Cortisol awakening response and diurnal cortisol profiles over 3 days are assessed via saliva samples and chronic cortisol exposure via a hair sample. Hydration markers are assessed with 24-hour urine collection over 3 days and fasting blood biomarkers. Race-related stress is self-reported over 7 days. Home and neighbourhood environments (via the Windshield Survey) is observer assessed., Ethics and Dissemination: Ethics approval was granted by the University of North Carolina at Greensboro's Institutional Review Board. Study findings will be disseminated through peer-reviewed publications, presentations at scientific meetings and reports, briefs/infographics for lay and community audiences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To identify predictors of referral and completion of germline genetic testing among newly diagnosed ovarian cancer patients, with a focus on geographic social deprivation, oncologist-level practices, and time between diagnosis and completion of testing., Methods: Clinical and sociodemographic data were abstracted from medical records of patients newly diagnosed with ovarian cancer between 2014 and 2019 in the University of North Carolina Health System. Factors associated with referral for genetic counseling, completion of germline testing, and time between diagnosis and test results were identified using multivariable regression., Results: 307/459 (67%) patients were referred for genetic counseling and 285/459 (62%) completed testing. The predicted probability of test completion was 0.83 (95% CI: 0.77-0.88) for patients with a referral compared to 0.27 (95% CI: 0.18-0.35) for patients without a referral. The predicted probability of referral was 0.75 (95% CI: 0.69-0.82) for patients at the 25th percentile of ZIP code-level Social Deprivation Index (SDI) and 0.67 (0.60-0.74) for patients at the 75th percentile of SDI. Referral varied by oncologist, with predicted probabilities ranging from 0.47 (95% CI: 0.32-0.62) to 0.93 (95% CI: 0.85-1.00) across oncologists. The median time between diagnosis and test results was 137 days (IQR: 55-248 days). This interval decreased by a predicted 24.46 days per year (95% CI: 37.75-11.16)., Conclusions: We report relatively high germline testing and a promising trend in time from diagnosis to results, with variation by oncologist and patient factors. Automated referral, remote genetic counseling and sample collection, reduced out-of-pocket costs, and educational interventions should be explored., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Radon is a naturally occurring radioactive gas that poses significant health risks to humans, including increased risk of lung cancer. This study investigates the association of neighborhood-level socioeconomic variables with radon testing and radon exposure levels in North Carolina between 2010 and 2020. Our analysis of the two largest commercial household radon tests reveals that 67% of census tracts had testing rates below 10 tests per 1000 population, indicating low testing prevalence. Low radon levels (<2 pCi/L) were detected in 74.1% of the tracts (n = 1626), while medium levels of 2-4 pCi/L and ≥4 pCi/L were observed in 17.2% (n = 378) and 1.6% (n = 36) of the tracts. A generalized spatial regression model was employed to analyze the association between neighborhood-level socioeconomic variables and radon testing rates (per 1000 households), controlling for median radon testing results. The results show a positive correlation (P-value <0.001) of testing rate with various indicators of neighborhood affluence including education level, income, and occupation. In contrast, neighborhood disadvantage, including poverty, unemployment, and public assistance, was associated with a lower radon-testing rate (P-value <0.001). These findings highlight the need for targeted interventions to address socioeconomic disparities in radon testing and promote awareness and access to testing resources in lower socio-economic neighborhoods. Improving testing rates can effectively address radon-related health risks in North Carolina and across the U.S., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Zhenchun Yang reports financial support was provided by Duke University, United States. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Evaluating the forthcoming impacts of climate change is important for formulating efficient and flexible approaches to water resource management. General Circulation Models (GCMs) are primary tools that enable scientists to study both past and potential future climate changes, as well as their impacts on policies and actions. In this work, we quantify the future projected impacts of hydroclimatic extremes on the coastal, risk-prone Tar-Pamlico River basin in North Carolina using GCMs from the Sixth International Coupled Model Intercomparison Project (CMIP6). These models incorporate projected future societal development scenarios (Shared Socioeconomic Pathways, SSPs) as defined in the Intergovernmental Panel on Climate Change (IPCC) Sixth Assessment Report (AR6). Specifically, we have utilized historical residential expansion data, the Soil and Water Assessment Tool Plus (SWAT+), the Standardized Precipitation Index (SPI), and the Interquartile Range (IQR) method for analyzing extremes from 2024 to 2100. Our findings include: (1) a trend toward wetter conditions is identified with an increase in flood events toward 2100; (2) projected increases in the severity of flood peaks are found, quantified by a rise of 21% compared to the 2000-2020 period; (3) downstream regions are forecast to experience severe droughts up to 2044; and (4) low-lying and coastal regions are found as particularly susceptible to higher flood peaks and more frequent drought events between 2045 and 2100. This work provides valuable insights into the anticipated shifts in natural disaster patterns and supports decision-makers and authorities in promoting adaptive strategies and sustainable policies to address challenges posed by future climate changes in the Tar-Pamlico region and throughout the state of North Carolina, United States., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Exposures to polyaromatic hydrocarbons (PAHs) contribute to cancer in the fire service. Fire investigators are involved in evaluations of post-fire scenes. In the US, it is estimated that there are up to 9000 fire investigators, compared to approximately 1.1 million total firefighting personnel. This exploratory study contributes initial evidence of PAH exposures sustained by this understudied group using worn silicone passive samplers., Objectives: Evaluate PAH exposures sustained by fire investigators at post-fire scenes using worn silicone passive samplers. Assess explanatory factors and health risks of PAH exposure at post-fire scenes., Methods: As part of a cross-sectional study design, silicone wristbands were distributed to 16 North Carolina fire investigators, including eight public, seven private, and one public and private. Wristbands were worn during 46 post-fire scene investigations. Fire investigators completed pre- and post-surveys providing sociodemographic, occupational, and post-fire scene characteristics. Solvent extracts from wristbands were analyzed via gas chromatography-mass spectrometry (GC-MS). Results were used to estimate vapor-phase PAH concentration in the air at post-fire scenes., Results: Fire investigations lasted an average of 148 minutes, standard deviation ± 93 minutes. A significant positive correlation (r=0.455, p<.001) was found between investigation duration and PAH concentrations on wristbands. Significantly greater time-normalized PAH exposures (p=0.039) were observed for investigations of newer post-fire scenes compared to older post-fire scenes. Regulatory airborne PAH exposure limits were exceeded in six investigations, based on exposure to estimated vapor-phase PAH concentrations in the air at post-fire scenes., Discussion: Higher levels of off-gassing and suspended particulates at younger post-fire scenes may explain greater PAH exposure. Weaker correlations are found between wristband PAH concentration and investigation duration at older post-fire scenes, suggesting reduction of off-gassing PAHs over time. Exceedances of regulatory PAH limits indicate a need for protection against vapor-phase contaminants, especially at more recent post-fire scenes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

This article explores the current and potential applications of AI in care management and health care administration through the experience of Acentra Health. By discussing various AI use cases, this paper highlights how AI can augment the capabilities of healthcare professionals and streamline operations. Ethical considerations, legal compliance, and the future implications of AI in the health care sector are also examined., Competing Interests: Acknowledgments: Disclosure of interests. All authors are employees of Acentra Health., (Copyright ©2024 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Regular testing of coastal waters for fecal coliform bacteria by shellfish sanitation programs could provide data to fill large gaps in existing coastal water quality monitoring, but research is needed to understand the opportunities and limitations of using these data for inference of long-term trends. In this study, we analyzed spatiotemporal trends from multidecadal fecal coliform concentration observations collected by a shellfish sanitation program, and assessed the feasibility of using these monitoring data to infer long-term water quality dynamics. We evaluated trends in fecal coliform concentrations for a 20-year period (1999-2021) using data collected from spatially fixed sampling sites (n = 466) in North Carolina (USA). Findings indicated that shellfish sanitation data can be used for long-term water quality inference under relatively stationary management conditions, and that salinity trends can be used to investigate management-driven bias in fecal coliform observations collected in a particular area., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Community health workers are responsible for finding, processing, and transferring health information to communities with limited access to health-related resources, including farmworkers. This paper is the culmination of an undergraduate student research project to explore the learning processes and preferences of farmworker-serving community health workers in the USA. The project was designed for students from farmworker or agricultural backgrounds at two North Carolina universities and was supported by a North Carolina Department of Health and Human Services workforce development grant. Semi-structured interviews were conducted, in person and virtually, with a convenience sample of 17 current and former community health workers. The interview data were analysed thematically and identified a preference for a combination of learning styles, with visual and hands-on learning being the most preferred. Community health workers also identified the importance of learning preferences in relation to their responsibilities as health educators. This study provides librarians, along with public health and medical professionals, with useful information about learning preferences to inform the creation of new and varied learning materials for community health workers., (© 2024 The Authors. Health Information and Libraries Journal published by John Wiley & Sons Ltd on behalf of Health Libraries Group.)

Researchers continue to accept the untested assumption that the difference between black and white infant mortality rates is largely attributable to race-linked differences in teenage pregnancies (Wise, 1984). The basic notion is that the inordinately high black teenage pregnancy rate (because of its association with low birth weight births) accounts for this difference. This paper tests this key assumption directly and finds only partial support for it. It then argues that the key to the black-white difference in infant mortality is poverty, not teenage pregnancy. Using data from the state of North Carolina, the results suggest that poverty, not race, plays the crucial role in infant mortality.

Efforts to prevent perinatal mortality and morbidity are traditionally directed at the pregnant woman. It is during the prenatal period that the mother's health status is closely monitored; her exposure to substances known to be harmful to the fetus is assessed, and intensive patient education on behaviors likely to benefit the unborn child is offered. Unfortunately, the initiation of prenatal care may already be too late to prevent spontaneous abortions, congenital anomalies, and some causes of low birthweight. Until routine prepregnancy care is available to all women of childbearing age, many opportunities for the primary prevention of poor reproductive outcomes will be lost. This paper describes the rationale for prepregnancy or preconceptional counseling and the specific purposes it should serve. A model program providing such services is described, and findings for a low socioeconomic population involved in the model program are given.

Hospital length of stay (LOS) in the USA has been increasing since the start of the COVID-19 pandemic, with numerous negative outcomes, including decreased quality of care, worsened patient satisfaction and negative financial impacts on hospitals. While many proposed factors contributing to prolonged LOS are challenging to modify, poor coordination of care and communication among clinical teams can be improved.Geographical cohorting of provider teams, patients and other clinical staff is proposed as a solution to prolonged LOS and readmissions. However, many studies on geographical cohorting alone have shown no significant impact on LOS or readmissions. Other potential benefits of geographical cohorting include improved quality of care, learning experience, communication, teamwork and efficiency.This paper presents a retrospective study at Duke University Hospital (DUH) on the General Medicine service, deploying a bundled intervention of geographical cohorting of patients and their care teams, twice daily multidisciplinary rounds and incremental case management support. The quality improvement study found that patients in the intervention arm had 16%-17% shorter LOS than those in the control arms, and there was a reduction in 30-day hospital readmissions compared with the concurrent control arm. Moreover, there was some evidence of improved accuracy of estimated discharge dates in the intervention arm.Based on these findings, the health system at DUH recognised the value of geographical cohorting and implemented additional geographically based medicine units with multidisciplinary rounds. Future studies will confirm the sustained impact of these care transformations on hospital throughput and patient outcomes, aiming to reduce LOS and enhance the quality of care provided to patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In March 2020, the COVID-19 public health emergency com¬pelled NC Medicaid to implement Appendix K flexibilities to change the 1915(c) Home & Community-Based Services Waivers. This paper will examine the impact of these flex¬ibilities and the subsequent decision to sunset them, with a focus on the Innovations Waiver., Competing Interests: Acknowledgments: No conflicts of interest were disclosed., (Copyright ©2024 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)