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Context: While public health programs and policies have worked to reduce lead exposure, lead poisoning remains a major preventable public health concern in the United States., Objective: In Clark County, Nevada, blood lead level (BLL) screening has historically been sparse. Thus, the purpose of this study was to evaluate the impact of the Southern Nevada Childhood Lead Poisoning & Prevention Program (CLPPP) in increasing screening efforts and identifying children with elevated blood lead levels (EBLLs)., Main Outcomes: The proportion of children screened after the implementation of the CLPPP and the number of children identified with detectable BLLs., Results: A total of 43 028 BLL results for children younger than 6 years were assessed from 2006 to 2011. More than 19% of children tested during the project period had a detectable BLL. The number of BLL tests for children younger than 6 years increased from 4180 in 2005-2006 to 9304 in just the second year of CLPPP implementation. Once the initial implementation grant was over and additional funding was unavailable, the BLL screening once again declined to 5541 in 2016-2017., Conclusion: Evaluation of CLPPP activities suggests that outreach and education efforts, funded by the Centers for Disease Control and Prevention, played a significant role in increasing blood lead screening in Southern Nevada. However, despite these efforts, less than 5% of all children younger than 6 years were screened, which has declined further after the end of federal support.

Illegal drug abuse, particularly prescription drug abuse is a growing problem in the United States. Research on adolescent drug abuse is based on national self-reported data. Using local coroner data, quantitative prevalence of illegal substance toxicology and trends can be assessed to aid directed outreach and community-based prevention initiatives. Retrospective analysis was conducted on all cases aged 12-17 years referred to the Office of the Medical Examiner, Clark County from 2005 to 2015 (n = 526). The prevalence of illegal opioid use in this population was 13.3%. The most commonly used drug was tetrahydrocannabinol (THC) in 29.7%. Illegal-prescription opioids and benzodiazepines were used approximately 1.7 times as much as all other illegal-drugs, excluding THC combined. The largest proportion of illicit prescription drug users were accidental death victims (p = 0.02, OR = 2.02). Drug trends by youth are ever evolving and current specific data is necessary to target prevention initiatives in local communities., (Copyright © 2018 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Background: Previously documented elevated hypertension rates among Las Vegas hotel room cleaners are hypothesized to be associated with job strain., Methods: Job strain was assessed by questionnaire. Ambulatory blood pressure (ABP) was recorded among 419 female cleaners from five hotels during 18 waking hours. Multiple linear regression models assessed associations of job strain with ABP and pulse pressure for 18-h, work hours, and after work hours., Results: Higher job strain was associated with increased 18-h systolic ABP, after work hours systolic ABP, and ambulatory pulse pressure. Dependents at home but not social support at work attenuated effects. Among hypertensive workers, job strain effects were partially buffered by anti-hypertensive medication., Conclusions: High job strain is positively associated with blood pressure among female hotel workers suggesting potential for primary prevention at work. Work organizational changes, stress management, and active ABP surveillance and hypertension management should be considered for integrated intervention programs., (© 2018 Wiley Periodicals, Inc.)

Purpose: Cancer survivorship clinics manage cancer-related health complications and are available primarily in urban areas. We examine how demographic, clinical, and geographic-based characteristics are associated with attendance at the only pediatric survivorship clinic in a largely rural, multistate region., Methods: One thousand eight hundred sixteen cancer survivors were diagnosed at age ≤ 25 from 1986 to 2005 while living in the region. Cox models incorporating death as a competing risk and generalized estimating equations calculated hazards ratios (HR) for characteristics measured at the clinic's opening. Subjects were followed from the clinic opening their first visit, death, emigration from the catchment area, or December 31, 2014., Results: Five percent of survivors visited the clinic. Attendance is positively associated with a leukemia or lymphoma diagnosis (HR = 3.32, 95% confidence interval [CI] = 1.72-6.78 vs CNS tumors), previous relapse (HR = 1.78, 95% CI = 1.00-3.19), and residing >100 mi from the clinic (HR = 2.05, 95% CI 1.03-4.10). Survivors aged ≥ 31 years at clinic opening (HR = 0.19, 95% CI = 0.07-0.54) are less likely to attend than younger survivors. Residence between 16 and 100 mi had an inverse association with attendance, although not significant., Conclusion: Survivorship clinics are not widely attended by survivors in this catchment region. Efforts should be made to recruit survivors aged ≥ 31 and diagnosed with CNS tumors. Distance has a complex association with attendance, which could be attributed to the limited availability of preventative services in regions > 100 mi from the clinic., Implications for Cancer Survivors: Survivors living in this catchment region may not be receiving care necessary to prevent severe late effects.

Uber, the world's largest ridesharing company, has reportedly provided over 2 billion journeys globally since operations began in 2010; however, the impact on motor vehicle crashes is unclear. Theoretically, ridesharing could reduce alcohol-involved crashes in locations where other modes of transportation are less attractive than driving one's own vehicle while under the influence of alcohol. We conducted interrupted time-series analyses using weekly counts of injury crashes and the proportion that were alcohol-involved in 4 US cities (Las Vegas, Nevada; Reno, Nevada; Portland, Oregon; and San Antonio, Texas). We considered that a resumption of Uber operations after a temporary break would produce a more substantial change in ridership than an initial launch, so we selected cities where Uber launched, ceased, and then resumed operations (2013-2016). We hypothesized that Uber's resumption would be associated with fewer alcohol-involved crashes. Results partially supported this hypothesis. For example, in Portland, Uber's resumption was associated with a 61.8% reduction (95% confidence interval: 38.7, 86.4) in the alcohol-involved crash rate (an absolute decrease of 3.1 (95% confidence interval: 1.7, 4.4) alcohol-involved crashes per week); however, there was no concomitant change in all injury crashes. Relationships between ridesharing and motor vehicle crashes differ between cities over time and may depend on specific local characteristics., (© The Author(s) 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: In the United States, about 38,000 cases of nonfatal workplace injuries were reported in 2015, in the category of 'mechanical work' (plumbing, heating, and air conditioning); this is nearly identical to the number of cases reported under 'building construction'., Objective: This paper analyzes the types and rates of injuries and illnesses of mechanical contractors of southern Nevada, including the nature of the injuries and illnesses, body parts affected by injuries, causes of injuries, and factors affecting the injury rates., Methods: To obtain data, a survey consisting of questions regarding the number of injuries and types of injuries was conducted with 31 mechanical contractors of southern Nevada involved in plumbing, piping, heating, refrigeration, and air conditioning., Results: The injury rate for larger mechanical contractors (n = 16), in terms of number of employees and annual revenue, was significantly lower than for smaller mechanical contractors (n = 15). Mechanical contractors who worked on residential buildings (n = 13) had significantly higher rates of injuries than those involved with industrial (n = 7) or commercial buildings (n = 10). Results showed that sprains and strains (31%) were dominant injuries, and the major causes were from parts and materials (39%), hand tools (16%), contact with objects (14%), and falls (7%)., Conclusions: The study concluded that the injury rate for these mechanical contractors was found to be higher than that reported by the Occupational Safety and Health Administration for specialty trade contractors.

Background: Gun shows are an important source of firearms, but no adequately powered studies have examined whether they are associated with increases in firearm injuries., Objective: To determine whether gun shows are associated with short-term increases in local firearm injuries and whether this association differs by the state in which the gun show is held., Design: Quasi-experimental., Setting: California., Participants: Persons in California within driving distance of gun shows., Measurements: Gun shows in California and Nevada between 2005 and 2013 (n = 915 shows) and rates of firearm-related deaths, emergency department visits, and inpatient hospitalizations in California., Results: Compared with the 2 weeks before, postshow firearm injury rates remained stable in regions near California gun shows but increased from 0.67 injuries (95% CI, 0.55 to 0.80 injuries) to 1.14 injuries (CI, 0.97 to 1.30 injuries) per 100 000 persons in regions near Nevada shows. After adjustment for seasonality and clustering, California shows were not associated with increases in local firearm injuries (rate ratio [RR], 0.99 [CI, 0.97 to 1.02]) but Nevada shows were associated with increased injuries in California (RR, 1.69 [CI, 1.16 to 2.45]). The pre-post difference was significantly higher for Nevada shows than California shows (ratio of RRs, 1.70 [CI, 1.17 to 2.47]). The Nevada association was driven by significant increases in firearm injuries from interpersonal violence (RR, 2.23 [CI, 1.01 to 4.89]) but corresponded to a small increase in absolute numbers. Nonfirearm injuries served as a negative control and were not associated with California or Nevada gun shows. Results were robust to sensitivity analyses., Limitation: Firearm injuries were examined only in California, and gun show occurrence was not randomized., Conclusion: Gun shows in Nevada, but not California, were associated with local, short-term increases in firearm injuries in California. Differing associations for California versus Nevada gun shows may be due to California's stricter firearm regulations., Primary Funding Source: National Institutes of Health; University of California, Berkeley; and Heising-Simons Foundation.

Study Objective: To determine if insulin detemir administration time affects the frequency of hypoglycemia (blood glucose level <70 mg/dl) in hospitalized patients., Design: Retrospective cohort study., Patients: A total of 357 adults (aged 18-89 yrs) who received insulin detemir for at least 48 hours while hospitalized between January 1, 2014, and December 31, 2015, were included. Patients were categorized into one of three groups according to insulin detemir administration time: detemir given once/day between 7 a.m. and 10 a.m. (AM group [71 patients]), detemir given once/day between 6 p.m. and 10 p.m. (PM group [158 patients]), and detemir given twice/day (BID group [128 patients])., Setting: Community hospital., Measurements and Main Results: The primary outcome was the percentage of patient days with any occurrence of hypoglycemia. The key secondary outcomes included the percentages of patients who experienced any hypoglycemic event, severe hypoglycemia, hypoglycemia requiring treatment, and refractory hypoglycemia; time of hypoglycemia; and percentage of patients experiencing one or more episodes of hyperglycemia. The AM group had a lower proportion of days with hypoglycemia compared with the PM group (7.9% vs 11.9%, p=0.008). There was a nonsignificant trend toward a lower proportion of days with hypoglycemia in the BID group compared with the PM group (9.1% vs 11.9%, p=0.0302). No significant differences in percentage of patient days with hyperglycemia and rates of severe hypoglycemia, hypoglycemia requiring treatment, or refractory hypoglycemia were noted among the three groups., Conclusion: Administration of detemir in the morning may reduce the occurrence of hypoglycemia in hospitalized patients. Institutions that include detemir on their formularies may consider evaluating the incidence of hypoglycemia and modifying administration schedules as part of their medication safety program., (© 2017 Pharmacotherapy Publications, Inc.)

Breast cancer is the second deadliest cancer for women in the demographically unique mountainous west state of Nevada. This study aims to accurately characterize breast cancer survival among the diverse women of the flourishing Silver State. Nevada Central Cancer Registry data was linked with the National Death Index and the Social Security Administration Masterfile. Overall 5-year age-adjusted cause-specific survival, survival stratified by race/ethnicity, and stage-specific survival stratified by region of Nevada were calculated. Adjusted hazard ratios were computed with Cox proportional hazards regression. 11,111 cases of breast cancer were diagnosed from 2003 to 2010. Overall 5-year breast cancer survival in Nevada was 84.4 %, significantly lower than the US, at 89.2 %. Black and Filipina women had a higher risk of death than white women. Poor survival in the racially and ethnically diverse Las Vegas metropolitan area, with a large foreign-born population, drives Nevada's low overall survival. System-wide changes are recommended to reduce the racial/ethnic disparities seen for black and Filipina women and improve outcomes for all.

Context: Cardiometabolic abnormalities underlie many health risks associated with obesity., Objective: We determined the relationship between cardiometabolic abnormalities, sociodemographic characteristics, and modifiable risk factors among adults in Southern Nevada., Design: We included 2415 participants older than 20 years from the Behavioral Risk Factor Surveillance System surveys conducted in 2011, 2013, and 2015 in Southern Nevada. Cardiometabolic abnormalities were assessed on the combined basis of blood pressure, cholesterol, and diabetes status. Logistic regression stratified by body mass index status was used to examine cardiometabolic abnormalities in different body mass index classes., Main Outcome Measure: Odds ratio estimates for cardiometabolic abnormalities after accounting for sociodemographic and health behavior characteristics., Results: Cardiometabolic abnormalities followed a socioeconomic gradient, although adjustment for lifestyle variables attenuated the associative link. Non-Hispanic black (vs white) race did not elevate cardiometabolic abnormalities risk among nonobese adults, yet conferred a multivariable-adjusted odds ratio of 2.18 (95% confidence interval [CI], 1.03-4.61) among obese adults. By comparison, odds of cardiometabolic abnormalities among nonobese adults were 2.42 (95% CI, 0.99-5.92) times higher for Hispanics and 2.83 (95% CI, 1.23-6.55) times higher for other or multiracial minorities. Among obese adults, male gender (odds ratio: 1.84; 95% CI, 1.03-3.27) and former (odds ratio: 2.09; 95% CI, 1.14-3.85) smoker status were associated with cardiometabolic abnormalities independent of other covariates., Conclusions: The present data support intervention strategies tailored to reinforce and promote positive health behaviors among disadvantaged groups. There were variable patterns of ethnic group disparities in clustered cardiometabolic abnormalities across body mass index classes. Targeted prevention approaches incorporating an explicit health equity perspective may help mitigate observed differences.

Background: Both the map3 Cellular Allogeneic Bone Graft® and recombinant human bone morphogenetic protein 2 (rhBMP-2, Infuse®) were developed to provide an alternative to iliac crest autograft, thus eliminating the morbidity associated with its harvest. The recent literature concerning adverse events associated with the use of rhBMP-2, however, highlights the need for a safe and effective alternative. The multipotent adult progenitor cells (MAPC) found in map3 allograft may provide this alternative. The purpose of this study is to report 1-year outcomes of patients treated via anterior lumbar interbody fusion (ALIF) using either map3 Cellular Allogeneic Bone Graft or rhBMP-2 for bony fusion., Methods: This was a retrospective evaluation of 41 patients treated via ALIF with either map3 or rhBMP-2 in a polyetheretherketone cage with posterior stabilization at 1, 2, or 3 consecutive levels (L3-S1). Patients were equally divided between treatment groups. The Oswestry Disability Index (ODI) and visual analog scores (VAS) for pain were documented as part of the standard of care. An independent radiologist assessed bridging of bone, disc height, and lordosis. Primary outcome measures included radiographic analysis of fusion by plain film and CTs. Secondary clinical outcomes included visual analogue scale for neck and arm pain and low back disability index scores., Results: The overall fusion rate was 91%, with no significant difference between groups. Improvements in ODI and VAS were observed among all patients (p < 0.001), with no significant difference between groups for ODI (p = 0.966) or VAS (p = 0.251). There was no significant difference in terms of changes to disc height and lordosis between groups (p < 0.05). The rhBMP-2 group had increased post-operative complications when compared to the map3 group, but the low numbers precluded statistical analysis., Conclusion: Improvements in radiographic and clinical findings were observed in both treatment groups one-year postoperatively. Map3 allograft demonstrated equivalent fusion rates to rhBMP-2. A review of surgical supply costs at the treatment facility favored map3 allograft for the treatment of patients with DDD undergoing an ALIF in 1-3 levels compared to rhBMP-2. Further studies to evaluate long-term outcomes and post-operative complications are required.

Objective: The majority of pediatric asthma is atopic, but whether pediatric obese asthma is atopic is indeterminate in the literature. In Nevada, children become sensitized to aeroallergens, a risk factor for asthma, at young ages. Additionally, Nevada children have high rates of obesity. Our objective is to determine whether elevated body mass index (BMI) is associated with asthma severity, allergen sensitization, and polysensitization., Methods: Medical records from a pediatric allergy clinic provided BMI percentile, physician-diagnosed asthma severity, skin prick test data, and sociodemographics such as age, race, sex, and insurance status from asthmatic patients. Descriptive statistics and binary and multinomial logistic regression were conducted., Results: In this population (N = 125) aged 1-16, 61% were male, 65% were white, and 74% had private health insurance. Sixty-five percent of children were under/healthy weight and 29% were overweight/obese. Asthma symptoms were moderate in 66% of the population, and severe in 18%. Nearly 85% of this population was atopic, and 82% were polysensitized. Sensitization and polysensitization occurred in all weight categories. Asthma severity and elevated BMI were not associated significantly. Overweight/obese children (≥85 th percentile) had lower odds of allergen sensitization (adjusted odds ratio 0.26, 95% CI = 0.85-0.78, p = 0.016) and polysensitization (adjusted odds ratio 0.30, 95% CI = 0.11-0.85, p = 0.023) than healthy weight children (<85 th percentile)., Conclusion: Although overweight children did show allergen sensitization, those who were overweight had lower odds of allergen sensitization and lower odds of polysensitization, as compared to normal weight asthmatic children. Elevated BMI was not a significant predictor of asthma severity.

Background: Regional trends for ST-segment elevation myocardial infarction (STEMI) treatment is not known in the state of Nevada., Hypothesis: Great disparity exists for treatment for STEMI in different geographical areas of Nevada. There is a great potential to improve treatment and outcomes of STEMI patients in the State of Nevada., Methods: Admissions to non-federal hospitals in the state of Nevada, using 2011 to 2013 discharge data from the Nevada State Inpatient Data Base (acquired from Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality), were analyzed. Outpatient-onset STEMI patients were identified. The state of Nevada was divided into three divisions based on population densities, defined as population per square mile. Division A included counties with population density of <50 per square mile, Division B included counties with population density of 50 to 200 per square mile, and Division C included counties with population density of >200 per square mile. Trends in use of STEMI-related therapies and the impact on in-hospital mortality rates were compared., Results: Almost 20% of the patients with outpatient-onset STEMI do not get any STEMI-related therapy and have significantly higher mortality rate. Patients from Division A do not have direct access to percutaneous coronary intervention (PCI) centers. These patients receive less STEMI-related therapies. Low-volume PCI centers had equivalent mortality rates for STEMI patients who got PCI, compared to high-volume PCI centers., Conclusions: Policies must be created and processes streamlined so all STEMI patients in Nevada receive appropriate treatment., (Copyright © 2017. Published by Elsevier B.V.)

Background: Associations between sleep duration and cardiovascular conditions have been inconsistent. Both short and long sleep duration are associated with increased risk for diabetes, hypertension, obesity, high cholesterol, depression, and overall metabolic dysfunction; all of which are cardiovascular disease risk factors. This study aimed to determine if deficient or excessive sleep duration is associated with cardiovascular conditions., Methods: Data were obtained from the 2013 Behavioral Risk Factor Surveillance System for the state of Nevada. A total of 5101 participants completed the survey and answered questions as to whether they had ever had a cardiovascular condition ie, myocardial infarction, coronary heart disease or angina, and stroke. Multiple logistic regression was implemented during analyses and yielded four models including demographics, co-morbidity, behavior, and final significant variables., Results: Six significant predictor variables were identified in the final model. Sleep duration was statistically significant (p < 0.0001). Individuals having deficient sleep, eg, 1-4 h a night, were 2.4 times more likely to have a cardiovascular condition versus those sleeping 7-9 h per night (OR = 2.412, CI = 1.139, 5.107). As for individuals who sleep excessively, eg, 10-18 h a night, they were nearly 7.2 times more likely to have a cardiovascular condition, compared to individuals who receive a normal night's sleep (OR = 7.170, CI = 3.284, 15.654)., Conclusions: Both deficient and excessive sleep duration were significantly associated with a cardiovascular condition, even after adjustment for covariates. The findings from this study can be used as additional evidence to encourage further research on improving sleep by developing future treatment therapies, and recommendations, that may help lower the risk of cardiovascular disease conditions., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective To provide preliminary descriptive data on caregiver and child weight status, parenting styles, feeding styles, and feeding practices of a small American Indian sample. Methods Participants included a subsample of American Indian caregivers (n = 23) identified from a larger study that was conducted in five states. Using previously validated instruments, means, standard deviations, and ranges for general parenting styles, feeding styles, and feeding practices were explored. Results In general, most caregivers reported healthy feeding practices. Most caregivers scored higher on responsive compared to restrictive or permissive in general parenting. Of the sample, 12 caregivers (52.2 %) were classified in the indulgent feeding style category, 5 caregivers (21.7 %) were classified as authoritative, 5 (21.7 %) uninvolved, and 1 (4.3 %) authoritarian. Conclusions More investigations are needed to explore questions raised by this study about using common tools that measure childhood obesity with American Indian families.

To better understand the potential avian diseases in Greater Sage-grouse ( Centrocercus urophasianus ) in the Great Basin in Nevada, US, we collected 31 blood samples March-April 2014 and tested for antibodies to eight viruses and two bacteria. Specifically, sera were tested for antibodies to avian leukosis virus type A, B, and J (ALV-A, ALV-B, and ALV-J, respectively), infectious bursal disease virus, infectious bronchitis virus, reticuloendothelial virus, avian influenza virus (AIV), West Nile virus, Pasteurella multocida (PM), and Salmonella enterica serovar Pullorum. Serum antibodies against ALV-A and -B (1/31, 3%), ALV-J (5/31, 16%), PM (1/31, 3%), and AIV (2/31, 6%) were detected by enzyme-linked immunosorbent assay (ELISA). While ELISA tests used have only been validated in domestic poultry, the serologic data should be used as a potential indicator of the range of bacterial and viral infectious agents that can infect the Greater Sage-grouse.

Objectives: Over the past few years, the United States has seen the rapid growth of dedicated musculoskeletal urgent care centers owned and operated by individual orthopaedic practices. In June of 2014, our practice opened the first dedicated orthopaedic urgent care in the region staffed by physician assistants and supervised by orthopaedic surgeons. Our hypothesis is that such centers can safely improve orthopaedic care for ambulatory orthopaedic injuries, decrease volume for overburdened emergency departments (EDs), reduce wait times and significantly decrease the cost of care while improving access to orthopaedic specialists., Design: Retrospective review., Setting: Level 2 trauma center and physician-owned orthopaedic urgent care., Patients: Consecutive series of patients seen in the hospital ED (n = 87,629) and orthopaedic urgent care (n = 12,722)., Intervention: None., Outcomes: ED wait time, total visit time, time until being seen by provider, time until consultation with orthopaedic surgeon, total visit charges, and effect on orthopaedic practice revenue., Results: During the 12 months of study, 12,722 patients were treated in our urgent care. The average urgent care wait time until being seen by a provider was 17 minutes compared with 45 minutes in hospital ED. Total visit time was 43 minutes in the urgent care and 156 minutes in the hospital ED. Time to being seen by an orthopaedic specialist was 1.2 days for urgent care patients compared with 3.4 days for ED patients. The average charge for an urgent care visit was $461 compared with $8150 in hospital ED. During the course of study, urgent care treatment reduced charges to health care system by $97,819,458. Hospital ED orthopaedic volume did decrease as expected but total ED patient volume remained the same. There was no measureable effect on hospital ED wait times. Hospital surgical case volume did not change over the period of study and the orthopaedic census remained stable. Urgent care construction, marketing, administration, imaging, and labor costs totaled $1,664,445. Urgent care revenue from evaluation and management, imaging, durable medical equipment, and casting totaled $2,577,707. Practice revenue from follow-up care of patients who entered practice through the urgent care totaled $7,657,998., Conclusion: Dedicated musculoskeletal urgent care clinics operated by orthopaedic surgery practices can be extremely beneficial to patients, physicians, and the health care system. They clearly improve access to care, whereas significantly decreasing overall health care costs for patients with ambulatory orthopaedic conditions and injuries. In addition, they can be financially beneficial to both patients and orthopaedic surgeons alike without cannibalizing local hospital surgical volumes., Level of Evidence: Therapeutic Level III.

Objectives: The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospitalbased PAs on orthopaedic trauma care at a level II community hospital., Design: Retrospective case series., Setting: Level II trauma center., Patients/participants: One thousand one hundred four trauma patients with orthopaedic injuries., Intervention: PA involvement., Main Outcome Measurements: Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients., Results: At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P . 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27)., Conclusions: Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well., Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Bundled Payments for Care Improvement (BPCI) initiative is the latest cost-saving program developed by the Center for Medicare and Medicaid Innovation. This model is intended to create a system for higher quality and more coordinated care at a lower cost to Medicare. It is currently an optional program for physician groups, hospitals and post-acute care providers to benefit financially from improved care models and cost containment measures. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care. Under this initiative, there are certain fraud and abuse waivers in place that allow gainsharing among BPCI organizations and approved providers so long as certain requirements are met. Our practice entered this initiative for total joint arthroplasty episodes of care as well as the hip and femur fracture episode of care. The first year experience demonstrated that a significant learning curve is required. Keys for success include appropriate patient selection for elective surgery, implant pricing control, adherence to preoperative and postoperative protocols, diligent postcare care management, and appropriate choice of metrics to maximize gainsharing potential. Ultimately, the BPCI program has been a successful venture, saving our hospitals over $1.6 million in 2015. In the process, this provided an additional revenue stream for our physicians while decreasing the overall cost of care.

Implant costs comprise the largest proportion of operating room supply costs for orthopedic trauma care. Over the years, hospitals have devised several methods of controlling these costs with the help of physicians. With increasing economic pressure, these negotiations have a tremendous ability to decrease the cost of trauma care. In the past, physicians have taken no responsibility for implant pricing which has made cost control difficult. The reasons have been multifactorial. However, industry surgeon consulting fees, research support, and surgeon comfort with certain implant systems have played a large role in slowing adoption of cost-control measures. With the advent of physician gainsharing and comanagement agreements, physicians now have impetus to change. At our facility, we have used 3 methods for cost containment since 2009: dual vendor, matrix pricing, and sole-source contracting. Each has been increasingly successful, resulting in massive savings for the institution. This article describes the process and benefits of each model.

This study reports descriptive data assessing the prevalence of various risk factors and associations among pregnancy-related death by unnatural causes (PRUD), namely suicide, homicide and accidental causes in the city of Las Vegas. In 7215 women referred for autopsy, results showed PRUD 0.1% (n = 37) was more common in the Caucasian race 45.9% (n = 17), and ages 20-30 years 43.2% (n = 16). We also identified high prevalence of mental illness 51.3% (n = 19) and low prenatal care 37.8% (n = 14), particularly in our suicide cohort 100.0% (n = 13), and 15.3% (n = 2) respectively. Our study demonstrates the first investigation to identify the relationship between mental illness, particularly mood and substance disorders with pregnancy-related unnatural death., (Copyright © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

We investigated the prevalence of Bartonella washoensis in California ground squirrels (Otospermophilus beecheyi) and their fleas from parks and campgrounds located in seven counties of California. Ninety-seven of 140 (69.3%) ground squirrels were culture positive and the infection prevalence by location ranged from 25% to 100%. In fleas, 60 of 194 (30.9%) Oropsylla montana were found to harbor Bartonella spp. when screened using citrate synthase (gltA) specific primers, whereas Bartonella DNA was not found in two other flea species, Hoplopsyllus anomalus (n = 86) and Echidnophaga gallinacea (n = 6). The prevalence of B. washoensis in O. montana by location ranged from 0% to 58.8%. A majority of the gltA sequences (92.0%) recovered from ground squirrels and fleas were closely related (similarity 99.4-100%) to one of two previously described strains isolated from human patients, B. washoensis NVH1 (myocarditis case in Nevada) and B. washoensis 08S-0475 (meningitis case in California). The results from this study support the supposition that O. beecheyi and the flea, O. montana, serve as a vertebrate reservoir and a vector, respectively, of zoonotic B. washoensis in California.

Background: Despite today's heightened concern over opioid overdose, the lack of population-based data examining clinical and contextual factors associated with opioid use represents a knowledge gap with relevance to prevention and treatment interventions. We sought to quantify rates of emergency department (ED) visits and inpatient hospitalizations for harmful opioid effects and their sociodemographic differentials as well as clinical correlates in Southern Nevada, using ED visit and hospital inpatient discharge records from 2011 to 2013., Methods: Cases were identified by ICD-9-CM diagnosis codes for opioid poisoning and opioid-type drug dependence and abuse as well as poisoning and adverse effect E-codes. Comorbid conditions, including pain-related diagnoses, major chronic diseases, affective disorders, sleep disorders, sexually transmitted infections and viral hepatitis were assessed from all available diagnosis fields. Counts by age-race per zip code were modeled by negative binomial regression. Opioid injuries were further examined as a function both of neighborhood income and individual characteristics, with mixed-effects logistic regression to estimate the likelihood for an adverse outcome., Results: Opioid intoxications and comorbidities were more common in low-income communities. The multivariable-adjusted rate for opioid-related healthcare utilization was 42 % higher in the poorest vs. richest quartile during the study period. The inter-quartile (quartile 1 vs. 4) rate increases for chronic bodily pains (44 %), hypertension (89 %), renal failure/diabetes (2.6 times), chronic lower respiratory disease (2.2 times), and affective disorders (57 %) were statistically significant. Chronic disease comorbidity was greater among non-Hispanic blacks, whereas abuse/dependence related disorders, alcohol or benzodiazepine co-use, chronic bodily pains, and affective disorders were more prevalent among non-Hispanic whites than nonwhites., Conclusions: There were consistent patterns of disparities in healthcare utilization across sociodemographic groups for opioid-associated disorders. Further initiatives to evaluate the determinants of overdose and abuse and to implement targeted response efforts are needed.

Clark County, Nevada had a 52% increase in newly diagnosed HIV infections in young people age 13-24 with 83% of the new diagnoses in this age group being men who have sex with men (MSM). HIV testing and counseling is critical for HIV prevention, care and treatment, yet young people are the least likely to seek HIV testing. The purpose of this study was to identify barriers and facilitators to HIV testing experienced by young MSM in Clark County, Nevada. We conducted a qualitative focus group discussion to identify barriers and facilitators to HIV testing among eleven young MSM in March, 2015. The primary barrier to HIV testing identified by the group was a lack of awareness or knowledge about testing for HIV. Other barriers within the person included: fear of results, fear of rejection, and fear of disclosure. Barriers identified within the environment included: access issues, stigma, and unfriendly test environments for young people. In addition to increasing awareness, intervention to increase HIV testing among MSM young people should incorporate access to testing in environments where the adolescents are comfortable and which reduces stigma. HIV testing sites should be convenient, accessible and young person/gay friendly.

Background: Interpregnancy interval is a risk factor for various adverse birth outcomes including birth defects. We investigated the relationship between interpregnancy interval and birth defects., Methods: We conducted a retrospective cohort study using linked data from Nevada Birth Outcomes Monitoring System and birth certificate data for 124,341 singleton live births, of which 4641 infants had 7192 birth defects, among Nevada resident women between 2006 and 2011. We used logistic regression to assess factors independently associated with birth defects., Results: Women who had an interpregnancy interval of 36 months or more, adjusted odds ratio (AOR) = 1.16, 95% confidence interval [CI], 1.01-1.33, were more likely to have an infant with a birth defect compared with women with an interpregnancy interval of 18 to 23 months. Other independent risk factors for birth defects included male infants, AOR = 1.34, 95% CI, 1.26-1.42; maternal age (30-34 years) and advanced maternal age (35 years and older), AOR = 1.10, 95% CI, 1.01-1.19 and AOR = 1.29, 95% CI, 1.18-1.42, respectively; being a Black woman, AOR = 1.46, 95% CI, 1.32-1.61; three and four or more previous births, AOR = 1.12, 95% CI, 1.02-1.23 and AOR = 1.24, 95% CI, 1.11-1.38, respectively; smoking, AOR = 1.23, 95% CI, 1.10-1.38; and prescription drug use, AOR = 1.14, 95% CI, 1.07-1.21., Conclusion: A long interpregnancy interval is an independent risk factor for birth defects. It may be helpful for maternal and child health programs and health care providers to highlight the deleterious effects of a long interpregnancy interval., (© 2015 Wiley Periodicals, Inc.)

Background: The impact of adverse childhood experiences (ACEs) on adult alcohol consumption is well-established, but little is known about the association with alcohol use during pregnancy., Methods: Using data from the 2010 Nevada Behavioral Risk Factor Surveillance System, we assessed the relationship between ACEs and alcohol use during pregnancy in a representative sample of 1,987 adult women. An established ACEs scale was used to assess a range of childhood physical, emotional, and sexual abuse and household dysfunction (range, 0-8). Weighted logistic regression was used to assess the relationship between ACE scores and alcohol use during pregnancy after controlling for drinking before pregnancy and other covariates., Results: Six percent of participants reported drinking alcohol during pregnancy. After controlling for race/ethnicity, age, employment status, smoking status, and prepregnancy alcohol use, increasing ACEs were positively associated with higher odds of alcohol use during pregnancy (1 ACE: adjusted odds ratio [AOR], 2.92; 95% CI, 1.08-7.87), (2-3 ACEs: AOR, 3.52; 95% CI, 1.46-8.48), and (≥4 ACEs: AOR, 4.79; 95% CI, 2.14-10.72). Prepregnancy drinking was also strongly associated with alcohol use during pregnancy (AOR, 11.95; 95% CI, 5.02-28.43)., Conclusions: We found evidence of a dose-response relationship between ACEs and alcohol use during pregnancy that remained even after controlling for prepregnancy drinking and other covariates. Screening women of childbearing age as well as pregnant women for ACEs may be an effective way to identify and address many of the emotional, behavioral, and physical sequelae of childhood adversity., (Copyright © 2015 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Methylphenidate, an amphetamine-like prescription medication for attention deficit hyperactivity disorder (ADHD) was suspected as being abused among methadone maintenance treatment (MMT) patients. We tested its presence in the routine urine monitoring of all patients in both Tel Aviv and Las Vegas MMT clinics. Data on demographic and addiction history, ADHD (Wender Utah Rating Scale), cognitive impairment (Mini Mental State Exam), and lifetime DSM-IV-TR psychiatric diagnosis from admission were retrieved, and retention following 6 months. None of the 190 patients in Las Vegas tested positive for methylphenidate, while 14.7% (45/306) did in Tel Aviv. Abusers were less educated (p = 0.01), had higher ADHD scores (p = 0.02), lower cognitive scores (p = 0.05), and a higher benzodiazepine (BDZ) abuse rate (p < 0.0005), with no difference in age, gender, duration in MMT, cannabis, opiates, and cocaine abuse and infectious disease. Of the methylphenidate abuse 42.2% have take-home methadone dose privileges. Not like opiate use, being methylphenidate positive did not relate to 6-months retention. Compared to Tel Aviv, Las Vegas patients were more educated, with lower BDZ, and cocaine abuse. The greater abuse of methylphenidate among ADHD subjects might indicate their using it as self-medication, raising a possible indication for its prescription for that subgroup of MMT patients. The high rate of methylphenidate abuse in Israel needs future study., (Copyright © 2015 Elsevier Inc. All rights reserved.)

We retrospectively analyzed a combination of prenatally detected and postnatally diagnosed patients with heterotaxic situs that included those with situs inversus, bilateral left-sidedness, and bilateral right-sidedness for the period between April 2002 and July 2014. We found a statistically higher prevalence in the Hispanic population of Southern Nevada of 2.7/10,000 live births (95 % confidence intervals of 1.7-3.9) versus the non-Hispanic population of 1.6/10,000 live births (95 % confidence intervals of 1.1-2.1), p = 0.04. Additionally, we noted a high prenatal detection rate of 68 % over the 12-year period of time, rising to 100 % over the last 2 years.

This study assesses cervical cancer disparities between Blacks and Whites in terms of stage at diagnosis in a Mountain West state. A total of 1,408 women diagnosed with cervical cancer between 1995 and 2010 were identified from the Nevada Central Cancer Registry. Logistic regression modeling examined the effect of race on stage at diagnosis in both Nevada and the Surveillance, Epidemiology and End Results (SEER) population. After controlling for the main confounders, no significant differences in stage at diagnosis were observed between Black and White females in Nevada (aOR 0.91; 95% CI 0.57-1.43). In contrast, Black women in SEER areas had a 21% higher odds of being diagnosed at an advanced stage compared to Whites. Our findings suggest a favorable disparity balance for cervical cancer in Nevada where Blacks are largely recent arrivals in relation to the remaining US, where Blacks have long been established.

Background: Inhalation of asbestos and other mineral fibers is known causes of malignant mesothelioma (MM) and lung cancers. In a setting of occupational exposure to asbestos, MM occurs four to eight times more frequently in men than in women, at the median age of 74 years, whereas an environmental exposure to asbestos causes the same number of MMs in men and women, at younger ages., Methods: We studied the geology of Nevada to identify mineral fibers in the environment. We compared MM mortality in different Nevada counties, per sex and age group, for the 1999 to 2010 period., Results: We identified the presence of carcinogenic minerals in Nevada, including actinolite asbestos, erionite, winchite, magnesioriebeckite, and richterite. We discovered that, compared with the United States and other Nevada counties, Clark and Nye counties, in southern Nevada, had a significantly higher proportion of MM that occurred in young individuals (<55 years) and in women., Conclusions: The elevated percentage of women and individuals younger than 55 years old, combined with a sex ratio of 1:1 in this age group and the presence of naturally occurring asbestos, suggests that environmental exposure to mineral fibers in southern Nevada may be contributing to some of these mesotheliomas. Further research to assess environmental exposures should allow the development of strategies to minimize exposure, as the development of rural areas continues in Nevada, and to prevent MM and other asbestos-related diseases.

Objective: Ethnicity may influence the occurrence of specific cardiac malformations., Design: We retrospectively analyzed the occurrence of isolated total anomalous pulmonary venous connection in the Hispanic and non-Hispanic populations of Southern Nevada over a 10-year period from 2003 to 2013., Results: The mean cases per 100,000 live births among Hispanics was 19.8 (99% confidence interval 5.9-33.7) and among non-Hispanics was 2.5 (99% confidence interval 0.4-4.6), P = 0.007., Conclusions: We found a significantly higher incidence of isolated total anomalous pulmonary venous connection in Hispanics vs. non-Hispanics., (© 2014 Wiley Periodicals, Inc.)

Background: Inpatient quality deficits have important implications for the health and well-being of patients. They also have important financial implications for payers and hospitals by leading to longer lengths of stay and higher intensity of treatment. Many of these costly quality deficits are particularly sensitive to nursing care., Objective: To assess the effect of nurse staffing on quality of care and inpatient care costs., Design: Longitudinal analysis using hospital nurse staffing data and the Healthcare Cost and Utilization Project State Inpatient Databases from 2008 through 2011., Subjects: Hospital discharges from California, Nevada, and Maryland (n=18,474,860)., Methods: A longitudinal, hospital-fixed effect model was estimated to assess the effect of nurse staffing levels and skill mix on patient care costs, length of stay, and adverse events, adjusting for patient clinical and demographic characteristics., Results: Increases in nurse staffing levels were associated with reductions in nursing-sensitive adverse events and length of stay, but did not lead to increases in patient care costs. Changing skill mix by increasing the number of registered nurses, as a proportion of licensed nursing staff, led to reductions in costs., Conclusions: The study findings provide support for the value of inpatient nurse staffing as it contributes to improvements in inpatient care; increases in staff number and skill mix can lead to improved quality and reduced length of stay at no additional cost.

Abstract Mycoplasmas are an important cause of upper respiratory tract disease (URTD) in desert tortoises (Gopherus agassizii) and have been a main focus in attempts to mitigate disease-based population declines. Infection risk can vary with an animal's population of origin, making screening tests popular tools for determining infection status in individuals and populations. To provide additional methods for investigating URTD we developed quantitative PCR (qPCR) assays specific for agents causing clinical signs of URTD: Mycoplasma agassizii, Mycoplasma testudineum, and Testudinid herpesvirus 2 (TeHV2) and tested necropsied desert tortoises housed at the Desert Tortoise Conservation Center in Las Vegas, Nevada, USA, as well as wild desert tortoises (n=3), during 2010. Findings were compared with M. agassizii enzyme-linked immunosorbent assay (ELISA) data. Based on qPCR, the prevalence of M. agassizii was 75% (33/44) and the prevalence of TeHV2 was 48% (20/42) in the evaluated population. Both agents were also present in the wild tortoises. Mycoplasma testudineum was not detected. The M. agassizii ELISA and qPCR results did not always agree. More tortoises were positive for M. agassizii by nasal mucosa testing than by nasal flush. Our findings suggest that mycoplasmas are not the only agents of concern and that a single M. agassizii ELISA or nasal flush qPCR alone failed to identify all potentially infected animals in a population. Caution should be exercised in using these tests for disposition decisions.

Although much research suggests that ethnic identity is positively correlated with psychological health for ethnic minority women, research examining ethnic identity's relationships to thin-ideal internalization, weight concerns, and eating concerns is sparse. Consequently, this study examined these relationships in European American, African American, Latina, and Asian American college women (N=816). As expected, univariate analyses of variance indicated that European American women scored lowest on ethnic identity and highest on eating and weight concerns, whereas African American women scored lowest on thin-ideal internalization. Hierarchical regression analyses indicated that ethnic identity was negatively associated with eating and weight concerns, while body mass index and thin-ideal internalization were positively associated. Ethnic identity moderated the relationship between thin-ideal internalization and eating concerns such that the relationship was stronger for participants with lower ethnic identity. These results suggest ethnic identity may be a direct or interactive protective factor against eating concerns in ethnically diverse college women., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

The objective of this study was to evaluate the relationship between treatment service quality, perceived improvement in social, functional, and material well-being and reduction in gambling behaviors among clients of Nevada state-funded pathological gambling treatment programs. Utilizing survey data from 361 clients from 2009 to 2010, analyses revealed that client satisfaction with treatment services is positively associated with perceived improvements in social, functional, and material well-being, abstinence from gambling, reduction in gambling thoughts and reduction in problems associated with gambling, even after controlling for various respondent characteristics. These findings can be useful to treatment program staff in managing program development and allocating resources.

Motor vehicle collisions and crashes are a leading cause of death among Nevada residents aged 5-34 years, representing 14% of all injury deaths in that age group in 2010. During 2008-2011, a total of 173 pedestrian deaths from motor vehicle collisions occurred in Nevada, accounting for 16% of motor vehicle deaths in the state. Approximately 75% (2 million persons) of Nevada residents live in Clark County, which includes the city of Las Vegas. To analyze pedestrian traffic deaths in Clark County among residents, visitors, and homeless persons, the Southern Nevada Health District used coroner's office data and death certificate data for the period 2008-2011. The results indicated that the average annual pedestrian traffic death rates from motor vehicle collisions during this period were 1.4 per 100,000 population for residents, 1.1 for visitors, and 30.7 for homeless persons. Among the three groups, time of day, location of motor vehicle collisions, and pedestrian blood alcohol concentration (BAC) differed. Effective interventions to increase roadway safety, such as lowering speed limits in areas with greater pedestrian traffic, targeting interventions during hours when alcohol-impaired walking is more likely, and modifying roadway designs to increase protection of pedestrians, might decrease pedestrian deaths among all three groups.

On October 12, 2012, the Nellis Air Force Base Public Health Flight (Nellis Public Health), near Las Vegas, Nevada, was notified by the Mike O'Callaghan Federal Medical Center (MOFMC) emergency department (ED) of three active-duty military patients who went to the ED during October 10-12 with fever, vomiting, and hemorrhagic diarrhea. Initial interviews by clinical staff members indicated that all three patients had participated October 6-7 in a long-distance obstacle adventure race on a cattle ranch in Beatty, Nevada, in which competitors frequently fell face first into mud or had their heads submerged in surface water. An investigation by Nellis Public Health, coordinated with local and state health officials, identified 22 cases (18 probable and four confirmed) of Campylobacter coli infection among active-duty service members and civilians. A case-control study using data provided by patients and healthy persons who also had participated in the race showed a statistically significant association between inadvertent swallowing of muddy surface water during the race and Campylobacter infection (odds ratio = 19.4; p<0.001). Public health agencies and adventure race organizers should consider informing race attendees of the hazards of inadvertent ingestion of surface water.

Objectives: We compared exposure to secondhand smoke (SHS) and attitudes toward smoke-free bar and nightclub policies among patrons of lesbian, gay, bisexual, and transgender (LGBT) and non-LGBT bars and nightclubs., Methods: We conducted randomized time-location sampling surveys of young adults (aged 21-30 years) in 7 LGBT (n = 1113 patrons) and 12 non-LGBT (n = 1068 patrons) venues in Las Vegas, Nevada, in 2011, as part of a cross-sectional study of a social branding intervention to promote a tobacco-free lifestyle and environment in bars and nightclubs., Results: Compared with non-LGBT bars and nightclubs, patrons of LGBT venues had 38% higher adjusted odds of having been exposed to SHS in a bar or nightclub in the past 7 days but were no less likely to support smoke-free policies and intended to go out at least as frequently if a smoke-free bar and nightclub law was passed., Conclusions: The policy environment in LGBT bars and nightclubs appears favorable for the enactment of smoke-free policies, which would protect patrons from SHS and promote a smoke-free social norm.

Objectives: From May 2006 to August 2008, the Southern Nevada Health District identified eight tuberculosis (TB) cases in six adults and two children in a Hispanic community. We conducted an outbreak investigation to determine the extent of TB transmission and prevent additional cases., Methods: We investigated TB cases in Nevada and Arizona with the outbreak genotype or cases with suspected epidemiologic links to this cluster but without genotyping data. We reviewed medical records and interviewed patients and contacts. Subsequently, genotype surveillance was conducted for approximately four years to monitor additional outbreak-related cases., Results: Eight outbreak cases were identified among six adults and two children. All patients were Hispanic and five were U.S.-born. The index patient was diagnosed while detained in Immigration and Customs Enforcement custody but deported before treatment completion. He was lost to follow-up for two years, during which time he served as the source for six secondary TB cases, including his own child. Along with the index patient, five patients reportedly engaged in the sale or use of methamphetamine. Follow-up surveillance in the two states identified eight additional cases with the outbreak genotype; three had epidemiologic links to the index case., Conclusions: We found that incomplete TB treatment led to extensive TB transmission. We recommend thorough discharge planning and active measures to ensure continuity of care and TB treatment completion for people in custody at higher risk for loss to follow-up, which likely includes those engaged in the sale or use of illicit substances.

Background: Substantial disparities in colorectal cancer (CRC) survival among racial-ethnic groups, especially between Blacks and Whites, have been extensively documented in the Northeast, California and South of the United States. The purpose of this study was to ascertain the determinants of colorectal cancer racial-ethnic survival disparities in a state of the Mountain West region, Nevada., Methods: The study population consisted of a cohort of 12,181 men and women with a first primary invasive carcinoma in the colon and rectum diagnosed between 1995 and 2007, identified through the Nevada Central Cancer Registry and followed for vital status until 31 December 2007. Likelihood ratio chi-square statistics were used to compare the sociodemographic and clinical characteristics for race-ethnicity. Cox proportional regression modeling and partial likelihood tests were used to estimate the hazard ratios and assess interaction effects in CRC cause-specific death., Results: Blacks and Hispanics were more likely to be diagnosed with distant stage disease, 22.4% and 21.5% respectively, compared to 17.9% in Whites. No difference was observed between racial-ethnic groups for diagnoses in regional stage. Univariate analysis yielded a 20.1% higher risk of CRC death for Blacks compared to Whites [95% CI = 1.05-1.37]. Adjustment for tumor stage, sex, age, diagnosis period, tumor sublocation, marital status, and economic status in the multivariate model showed a persistently increased risk of CRC death for Blacks (HR = 1.17, 95% CI = 1.02-1.33) in relation to Whites., Conclusions and Implications: Survival disparities persisted among Blacks in our study even after adjusting for common demographic and tumor factors. Further determinants of survival disparities between race/ethnicities, such as course of treatment, should be investigated. Additionally, more public health intervention programs should tailor CRC screening awareness towards minorities as well as ensuring equal access to health care and quality treatment.

Background and Objective: To date, there are no known published studies that prospectively followed hospice patients receiving hydromorphone to evaluate the development of hydromorphone-induced neuroexcitation (HINE). The first objective of this study was to determine the incidence of HINE. The second objective was to identify factors influencing the presence or absence of HINE symptoms in hospice patients., Methods: This was a noninterventional, prospective study. This study population included hospice patients 18 years of age or older who were admitted to one of two Nathan Adelson Hospice inpatient units in Las Vegas, Nevada, and were initiated on a scheduled regimen of hydromorphone. A total of 156 patients were enrolled and analyzed in this study. Data collection was performed by the study investigators using a standard data tracking form, including hospice diagnosis, gender, renal function, hydromorphone regimen, and whether or not the patient experienced neuroexcitatory symptoms. Data collection occurred from November 2010 to March 2011., Results and Conclusions: Based on the data collected in this study, it appears that the likelihood of HINE does increase with larger doses, increasing age, increasing serum creatinine, and the presence of malignant neoplasm. However, after adjusting for the variables in the logistic regression model, diagnosis of malignant neoplasm was not a significant predictor of HINE. Future studies may focus on evaluating metabolite levels, such as hydromorphone-3-glucuronide (H3G), in patients developing HINE symptoms. This may help to determine if the metabolites of opioids, such as H3G, are involved in the development of the neurotoxic symptoms.

Objectives: Infections caused by respiratory viruses are associated with recurrent epidemics and widespread morbidity and mortality. Routine surveillance of these pathogens is necessary to determine virus activity, monitor for changes in circulating strains, and plan for public health preparedness. The Southern Nevada Health District in Las Vegas, Nevada, recruited five pediatric medical practices to serve as sentinel sites for the Pediatric Early Warning Sentinel Surveillance (PEWSS) program., Methods: Sentinel staff collected specimens throughout the year from ill children who met the influenza-like illness case definition and submitted specimens to the Southern Nevada Public Health Laboratory for molecular testing for influenza and six non-influenza viruses., Results: Laboratory results were analyzed and reported to the medical and general communities in weekly bulletins year-round. PEWSS data were also used to establish viral respiratory seasonal baselines and in influenza vaccination campaigns. The surveillance program was evaluated using the Centers for Disease Control and Prevention's (CDC's) Updated Guidelines for Evaluating Public Health Surveillance Systems. PEWSS met three of six program usefulness criteria and seven of nine surveillance system attributes, which exceeded the CDC Guidelines evaluation criteria for a useful and complete public health surveillance program., Conclusion: We found that PEWSS is a useful and complete public health surveillance system that is simple, flexible, accessible, and stable.

Objectives: This research examined worry in medical students at various stages of training with reference to worries related to academic and clinical training, finances and relationships with peers. The study focused on gender differences in worries, testing the notion that being married or being in a long-term or cohabitating relationship with a partner would be linked to increased worry among women, but decreased worry among men. Additional goals included examining the relationship between worry and the seeking of counselling, and investigating the disadvantage for medical students associated with living with parents., Methods: Data collected serially on class cohorts at one western US medical school yielded 868 responses from medical students, which were analysed using general linear models, generalised linear models and generalised estimation equations., Results: Among four types of worry, academic and financial worries were similarly dominant (p < 0.001); financial worries were found to increase over the course of medical training (p < 0.001). Men reported more worry than women (p < 0.001). Gender differences were qualified by marital status (p = 0.007). Being married was linked to higher levels of academic and financial worry among women, whereas for men marriage was linked to lower academic, but higher financial worry (p < 0.001). Living with parents was always associated with a higher level of worry (p < 0.0001). Married male students were more likely to seek counselling than unmarried male students, whereas this pattern was reversed for female students (p = 0.002)., Conclusions: This study confirms that both academic and financial stress represent the greatest sources of worry in medical students. It also represents the first research to demonstrate higher levels of worry in male than female medical students, which may be evidence of women's increased representation in the medical school population. These data also support the persistence of traditional gender roles in the marriages of medical students; marriage is related to an increased psychological burden in women in comparison with men., (© 2013 John Wiley & Sons Ltd.)

Purpose: The purpose of this qualitative study was to explore nutritional behaviors and attitudes among Latino women with type 2 diabetes., Methods: Women over 18 years old and previously diagnosed with type 2 diabetes were recruited to participate in semi-structured qualitative interviews in their homes in Los Angeles, California, and Las Vegas, Nevada. Recruitment was conducted through flyers posted in local businesses. Interviews were conducted in Spanish or English. Data were transcribed and analyzed using an iterative process that involves reading interview transcripts and designating themes that arise from the data., Results: Acquisition of nutritional knowledge and behavioral capability were positively associated with observational learning, formal nutritional education, and culturally competent meal planners. The use of traditional remedies and the consultation of naturistas reveal a tendency toward medical pluralism. In the home environment, husbands had the greatest influence on Latina women's attitudes and perceived choices., Conclusions: The social environment, including support and reinforcement, is critical for Latinas' nutritional success. Observational learning is critical for Latinas' behavioral capability.

Millions of people are exposed to arsenic in drinking water, which at high concentrations is known to cause lung cancer in humans. At lower concentrations, the risks are unknown. We enrolled 196 lung cancer cases and 359 controls matched on age and gender from western Nevada and Kings County, California in 2002-2005. After adjusting for age, sex, education, smoking and occupational exposures, odds ratios for arsenic concentrations ≥85 µg/L (median = 110 µg/L, mean = 173 µg/L, maximum = 1,460 µg/L) more than 40 years before enrollment were 1.39 (95% CI = 0.55-3.53) in all subjects and 1.61 (95% CI = 0.59-4.38) in smokers. Although odds ratios were greater than 1.0, these increases may have been due to chance given the small number of subjects exposed more than 40 years before enrollment. This study, designed before research in Chile suggested arsenic-related cancer latencies of 40 years or more, illustrates the enormous sample sizes needed to identify arsenic-related health effects in low-exposure countries with mobile populations like the U.S. Nonetheless, our findings suggest that concentrations near 100 µg/L are not associated with markedly high relative risks.

Purpose: Tobacco use is the leading cause of preventable death worldwide. If current trends persist, tobacco will kill more than 8 million people worldwide by 2030 and 1 billion by the end of the century. The purpose of this study was to determine trends in tobacco/marijuana use in Nevada adolescents and their effect on dental health status. Relative comparative data were compared with nationally reported data., Methods: Retrospective data in this cohort study was from an ongoing statewide, school-based, dental health screening initiative that was conducted across 8 years (2002-2010) in public/private middle/high schools in Nevada. A total of 66,941 dental health screenings of adolescents between ages 13-18 were conducted. Self-reported data were collected on tobacco/marijuana use. Descriptive statistics and trends were reported. Means (SE) were computed for caries prevalence and severity. Effect size was reported on dental caries and use of tobacco/marijuana., Results: Overall, percentage prevalence of tobacco use was approximately the same as the national average; however, there were significantly higher rates of marijuana use (12.0% vs. 3.3%). Prevalence and severity of dental caries was significantly higher in those who used tobacco/marijuana than those who did not across all variables and across all 8 years controlling for gender, race/ethnicity, where they lived, and exposure to secondhand smoke., Conclusions: Tobacco use negatively affected dental health status with marijuana having the largest negative effect. The findings from this study identified the need for tobacco/marijuana prevention services targeting adolescents residing in the geographic areas most at risk., (Copyright © 2013 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

The prevalence of mental illness and suicide among female adolescents involved with the juvenile justice system is alarmingly high and there is a need to identify risk factors that may be amenable to intervention. This study examined the independent association between dating violence and poor mental health (psychological distress and attempted suicide) among 305 female adolescents involved with the juvenile justice system in Nevada. Overall, 28% of the sample met the criteria for clinically significant psychological distress and 18% had attempted suicide with intent to die. After controlling for well-established risk factors such as sexual orientation, childhood abuse, and substance abuse, dating violence remained independently associated with psychological distress and attempted suicide. These findings suggest that mental health programming for this population may be more effective if it includes a focus on dating violence.