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Background Emergency departments (EDs) play an essential role in the timely initiation of HIV post-exposure prophylaxis (PEP) for sexual assault victims. Methods Retrospective analysis of sexual assault victims evaluated and offered HIV PEP in an urban academic ED between January 1, 2005 and January 1, 2018. Data on demographics, comorbidities, nature of sexual assault, initial ED care, subsequent healthcare utilization within 28 days of initial ED visit, and evidence of seroconversion within 6 months of the initial ED visit were obtained. Predictors of subsequent ED visit and follow-up in the infectious diseases clinic were evaluated using logistic regression analysis. Results Four hundred twenty-three ED visits met criteria for inclusion in this study. Median age at ED presentation was 25 years (IQR 21–34 years), with the majority of victims being female (95.5%), Black (63.4%), unemployed (66.3%) and uninsured (53.9%); psychiatric comorbidities (38.8%) and substance abuse (23.6%) were common. About 87% of the patients accepted HIV PEP (368 of 423 ED visits). Age (OR 0.97, 95% CI 0.94–0.99, p = 0.025) and sexual assault involving >1 assailant (OR 0.48, 95% CI 0.26–0.88, p = 0.018) were associated with lower likelihood of HIV PEP acceptance. Ten patients (2.7%) followed up with the infectious disease clinic within 28 days of starting HIV PEP; 70 patients (19%) returned to the ED for care during the same time period. Psychiatric comorbidity (OR 2.48, 95% CI 1.43–4.30, p = 0.001) and anal penetration (OR 2.02, 95% CI 1.10–3.70, p = 0.024) were associated with greater likelihood of repeat ED visit; female gender (OR 0.30, 95% CI 0.11–0.85, p = 0.023) was associated with lower likelihood of repeat visit. Completion of HIV PEP was documented for 14 (3.3%) individuals. Conclusions While ED patient acceptance of HIV PEP after sexual assault was high, infectious disease clinic follow-up and documented completion of PEP remained low. Innovative care models bridging EDs to outpatient clinics and community support services are needed to optimize transitions of care for sexual assault victims, including those receiving HIV PEP.

This study employs risk terrain modeling to identify the spatial correlates of aggravated assault and homicide in St. Louis, MO. We build upon the empirical literature by (1) replicating recent research examining the role of vacancy in the concentration of criminal violence and (2) examining whether the environmental correlates of violence vary between north and south St. Louis, a boundary that has long divided the city along racial and socioeconomic lines. Our results indicate that vacancy presents a strong, consistent risk for both homicide and aggravated assault and that this pattern emerges most clearly in the northern part of the city which is majority African American and has suffered chronic disinvestment. The concentration of criminal violence in South City is driven primarily by public hubs including housing, transportation, and schools. Our results underscore the importance of vacancy as a driver of the spatial concentration of violent crime and point to potential heterogeneity in risk terrain modeling results when applied to large metropolitan areas. Situational crime prevention strategies would be well served to consider such spatial contingencies as the risk factors driving violent crime are neither uniformly distributed across space nor uniform in their impact on criminal violence.

Introduction Women with gestational diabetes are 7 times more likely to develop type 2 diabetes and require lifelong diabetes screening. Loss of health coverage after pregnancy, as occurs in states that did not expand Medicaid, limits access to guideline-driven follow-up care and fosters health inequity. This study aims to understand the factors associated with the receipt of postpartum diabetes screening for women with gestational diabetes in a state without Medicaid expansion. Methods Electronic health record and Medicaid claims data were linked to generate a retrospective cohort of 1,078 women with gestational diabetes receiving care in Federally Qualified Health Centers in Missouri from 2010 to 2015. In 2019–2020, data were analyzed to determine the factors associated with the receipt of recommended postpartum diabetes screening (fasting plasma glucose, 2-hour oral glucose tolerance test, or HbA1c in specified timeframes) using a Cox proportional hazards model through 18 months of follow-up. Results Median age in this predominantly urban population was 28 (IQR=24−33) years. Self-reported racial or ethnic minorities comprised more than half of the population. Only 9.7% of women were screened at 12 weeks, and 20.8% were screened at 18 months. Prenatal certified diabetes education (adjusted hazard ratio=1.74, 95% CI=1.22, 2.49) and access to public transportation (adjusted hazard ratio=1.70, 95% CI=1.13, 2.54) were associated with increased screening in a model adjusted for race/ethnicity, the total number of prenatal visits, the use of diabetes medication during pregnancy, and a pregnancy-specific comorbidity index that incorporated age. Conclusions This study underscores the importance of access to public transportation, prenatal diabetes education, and continued healthcare coverage for women on Medicaid to support the receipt of guideline-recommended follow-up care and improve health equity.

Background The national rate of syphilis has increased among persons who inject drugs (PWID). Missouri is no exception, with increases in early syphilis (ES), congenital syphilis, and PWID, especially in nonurban counties. Methods Disease intervention specialist records for ES cases in Missouri (2012–2018) were examined. Drug use was classified as injection drug use (IDU) (opioid or methamphetamine) or non-IDU (opioid, methamphetamine, or cocaine). Rates were compared based on residence, sex of sex partner, and drug use. Results Rates of ES in Missouri increased 365%, particularly in small metropolitan and rural areas (1170%). Nonurban areas reported a higher percentage of persons with ES who used injection drugs (12%–15%) compared with urban regions (2%–5%). From 2012 to 2018, women comprised an increasing number of ES cases (8.3%–21%); 93% of women were of childbearing age. Increasingly more women in rural areas with ES also reported IDU during this time (8.4%–21.1%). Conclusions As syphilis increases in small metropolitan and rural regions, access to high-quality and outreach-based sexual health services is imperative. Healthcare policy to equip health departments with harm reduction services and drug treatment resources offers an opportunity to impact both syphilis increases as well as health outcomes associated with IDU.

Background Emergency Departments (EDs) are a care source for patients with sexually transmitted diseases (STDs). St. Louis, MO reports among the highest rates of gonorrhea and chlamydia infection. We examined STD treatment in a high-volume urban ED, in St. Louis MO, to identify factors that may influence treatment. Methods A retrospective chart review and analysis was conducted on visits to a high volume, academic ED in St. Louis, MO where patients received a gonorrhea/chlamydia nucleic acid amplification test (NAAT) with a valid matching test result over two years. Using multiple logistic regression, we examined available predictors for under and overtreatment. Results NAATs were performed on 3.3% of all ED patients during the study period. Overall prevalence was 6.9% for gonorrhea (95% CI: 6.2, 7.7) and 11.6% for chlamydia (95% CI: 10.6, 12.5). Race was not a statistically significant predictor for undertreatment but Black patients were significantly more likely to be overtreated compared to White patients. (OR 1.83, 95% CI: 1.5, 2.2). Females were more likely to be undertreated when positive for infection compared to males (OR 7.34, 95% CI: 4.8, 11.2) and less likely to be overtreated when negative for infection (OR 0.27, 95% CI: 0.2, 0.3). Conclusion The burden of STDs in a high-volume academic ED was significant and treatment varied across groups. Attention should be paid to particular groups, specifically women and patients reporting Black as their race, to ensure appropriate treatment is administered. Patients would benefit from targeted STD management protocols and training in the ED.

The objective of this study is to evaluate whether pregnant women receive appropriate treatment, undertreatment, or overtreatment in the emergency department (ED) when they are tested for chlamydia and gonorrhea as compared to non-pregnant women. In a retrospective cohort study, we analyzed visits made to an urban ED from 1 July 2012 to 30 June 2014, with testing for chlamydia and gonorrhea (n = 3908). Using multiple logistic regression, we compared undertreatment and overtreatment in women controlling for pregnancy, age, race, and sexually transmitted infection International Statistical Classifications of Diseases (ICD)-9 coded diagnosis. Pregnant women were significantly more likely to be undertreated when positive for infection as compared to non-pregnant women (OR 2.94; 95% CI, 1.47–5.95) and significantly less likely to be overtreated when negative for infection (OR 0.40; 95% CI, 0.31–0.53) as compared to non-pregnant women. Pregnant women may not be receiving appropriate treatment when they present to the ED with chlamydia or gonorrhea. Attention should be paid to this group when administering chlamydia and gonorrhea treatment to ensure appropriate care and follow-up.

Background In the US, health policies accompanying the COVID-19 pandemic led to restricted healthcare access and decreased clinical services. Low public health funding was a barrier to accessing sexual healthcare before the pandemic and intensified during restrictions. Surveillance of the sexual healthcare landscape can inform program development to improve sexual health. Methods We collected information from clinics offering STI testing in the St. Louis region, Missouri, USA twice during 2020: in the spring during the first pandemic lockdown and in the fall as restrictions eased. Clinics were interviewed about sexual health services and categorized into three categories: open fully with no changes; modified if hours open and/or the ability to accept walk-ins were reduced; or fully closed. We also collected chlamydia rates by zip code and categorized zip codes as low (0–174 cases per 100,000); medium (175–653); or high (654–1291) prevalence. Results Of the 112 clinics, 47 are federally qualified health centers (serve the un-and underinsured); 16 were local public health authorities; and the remaining 49 include community, school, and private settings. In the fall, 29% of clinics were open, 55% modified, 5% closed compared with spring when 7% of clinics were open, 63% were modified, 17% were closed. There was a 450% and 200% increase in the number of clinics that were open in high and medium prevalence zip codes respectively in the fall compared to the spring. Forty-nine clinics remain modified or closed in medium and high prevalence zip codes. Discussion The COVID pandemic has a significant effect on sexual health care in a metropolitan region of the US; that effect is lasting, especially in areas of medium and high chlamydia rates. Health systems must consider how the pandemic has impacted care provided for all major public health problems, including STIs/HIV or risk worsening sexual health.

Objective The Surgical Council on Resident Education (SCORE) web portal provides a uniform, comprehensive, competency-based curriculum for general surgery residents. One of SCORE's principal founding goals was to provide equal opportunity for access of educational resources at programs across the United States which reported having a range of resources. We aimed to determine if there was a difference in portal usage by trainees in independent versus university programs, and across geographic areas. Methods Using analytic software, we measured SCORE usage by trainees in 246 subscribing programs from August 2015 to March 2017. The primary outcome was the average duration of SCORE use per login. Secondary outcomes were the geographic region of each program, and university versus independent designation. Encounters lasting >8 hours (comprising 7% of the data set) were excluded to eliminate the likelihood of failure to log off the portal. Results Over the study period, there were 669,501 SCORE sessions with 22% of these lasting 1 to 5 minutes, 33% lasting 6 to 30 minutes, and 28% lasting 31 to 120 minutes. Between the university (64.4% of encounters) and independent (35.6% of encounters) program types, there was no significant difference in average visit length overall, or in the normally-distributed designated time categories (t test -1.0, p = 0.3). When mean encounter length per program was compared by geographic regions, there was also no difference in the three time categories (ANOVA p = 0.9, 0.2, and 0.5, respectively). Conclusions Most (50%) of SCORE encounters lasted 30 minutes of less, confirming prior work that shows trainees use the portal in relatively short bursts of activity. While there were more encounters from university program trainees (proportional with their greater numbers), the mean duration of an individual encounter did not significantly differ by program type as a whole or by region. These results suggest that SCORE is an equally accessible educational resource and is used by surgical trainees, regardless of program type or geographic region.

BACKGROUND Rates of sexually transmitted diseases (STDs) including chlamydia and gonorrhea are increasing in the United States while public health funding for STD services is decreasing. Individuals seek care in various locations including the emergency department (ED). The objective of this study is to investigate whether there are more physically proximal clinic-based STD care locations available to individuals who present to the ED in a major metropolitan area. METHODS Addresses of EDs, clinics, and patients 13 years or older in St. Louis City or County given a nucleic acid amplification test and assigned an STD diagnosis (n = 6100) were geocoded. R was used to analyze clinics within 5 radii from the patients' home address and assess missed clinic opportunities (open, no charge, with walk-in availability) for those living in an urban versus suburban area. RESULTS In urban areas, 99.1% of individuals lived closer to a clinic than the ED where they sought STD services; in suburban areas, 82.2% lived closer to a clinic than the ED where they presented. In the region, 50.6% lived closer to the health department-based STD care location than the hospital where they presented. Up to a third of ED patient visits for STD care could have occurred at a clinic that was closer to the patient's home address, open, no charge, and available for walk-in appointments. CONCLUSIONS Clinic availability is present for most of the individuals in our study. Clinics providing STD services can increase advertising efforts to increase public awareness of the services which they provide.

Background Gestational diabetes increases risk for type 2 diabetes seven-fold, creating a large public health burden in a young population. In the US, there are no large registries for tracking postpartum diabetes screening among women in under-resourced communities who face challenges with access to care after pregnancy. Existing data from Medicaid claims is limited as women often lose this coverage within months of delivery. In this study, we aim to leverage data from electronic health records and administrative claims to better assess postpartum diabetes screening rates among low income women. Methods A retrospective population of 1078 women with gestational diabetes who delivered between 1/1/2010 and 10/8/2015 was generated by linking electronic health record data from 21 Missouri Federally Qualified Health Centers (FQHCs) with Medicaid administrative claims. Screening rates for diabetes were calculated within 12 weeks and 1 year of delivery. Initial screening after the first postpartum year was also documented. Results Median age in the final population was 28 (IQR 24–33) years with over-representation of black non-Hispanic and urban women. In the final population, 9.7% of women had a recommended diabetes screening test within 12 weeks and 18.9% were screened within 1 year of delivery. An additional 125 women received recommended screening for the first time beyond 1 year postpartum. The percentage of women who had a postpartum visit (83.9%) and any glucose testing (40.6%) in the first year far exceeded the proportion of women with recommended screening tests. Conclusions Linking electronic health record and administrative claims data provides a more complete picture of healthcare follow-up among low income women after gestational diabetes. While screening rates are higher than reported with claims data alone, there are opportunities to improve adherence to screening guidelines in this population. Electronic supplementary material The online version of this article (10.1186/s12889-019-6475-0) contains supplementary material, which is available to authorized users.

Introduction Firearm injuries are a public health epidemic in the United States, yet a comprehensive national database for patients with firearm injuries does not exist. Here we describe the methods for a study to develop and query a new regional database of all patients who present to a St. Louis level I trauma hospital with a violent injury, the St. Louis Hospital-Based Violence Intervention Program Data Repository (STL-HVIP-DR). We hypothesize that the STL-HVIP-DR will facilitate identification of patients at risk for violent injury and serve as a comparison population for participants enrolled in clinical trials. Methods The STL-HVIP-DR includes all visits made for violent injury to four level I trauma hospitals in St. Louis, Missouri between January 1, 2010 and December 31, 2019. Two health systems representing the four participating hospitals executed a data sharing agreement to aggregate clinical data on firearm injuries, stabbings, and blunt assaults. Dataset variables include demographic hospital and timestamp, medical, and insurance information. Results A preliminary cross-sectional query of the STL-HVIP-DR reveals 121,955 patient visits among the four partner level I trauma hospitals for a violent injury between 2010 and 2019. This includes over 18,000 patient visits for firearm injury. Discussion The STL-HVIP-DR repository fills a critical gap regarding identification and outcomes among individuals who are violently injured, especially those with non-lethal firearm injuries. It is our hope that the methods presented in this paper will serve as a primer to develop repositories to help target violence prevention services in other regions., Highlights • Firearm injuries are a public health epidemic in the United States. • Data repositories for violent injury may help track firearm injury and recidivism. • Here we describe the methods to develop a novel data repository for violent injury. • These data have the potential to identify patients at risk for violent injury. • These data can be applied for resource allocation of violence prevention services.

Problem The current coronavirus disease 2019 (COVID‐19) pandemic underscores the need for building and sustaining public health data infrastructure to support a rapid local, regional, national, and international response. Despite a historical context of public health crises, data sharing agreements and transactional standards do not uniformly exist between institutions which hamper a foundational infrastructure to meet data sharing and integration needs for the advancement of public health. Approach There is a growing need to apply population health knowledge with technological solutions to data transfer, integration, and reasoning, to improve health in a broader learning health system ecosystem. To achieve this, data must be combined from healthcare provider organizations, public health departments, and other settings. Public health entities are in a unique position to consume these data, however, most do not yet have the infrastructure required to integrate data sources and apply computable knowledge to combat this pandemic. Outcomes Herein, we describe lessons learned and a framework to address these needs, which focus on: (a) identifying and filling technology “gaps”; (b) pursuing collaborative design of data sharing requirements and transmission mechanisms; (c) facilitating cross‐domain discussions involving legal and research compliance; and (d) establishing or participating in multi‐institutional convening or coordinating activities. Next steps While by no means a comprehensive evaluation of such issues, we envision that many of our experiences are universal. We hope those elucidated can serve as the catalyst for a robust community‐wide dialogue on what steps can and should be taken to ensure that our regional and national health care systems can truly learn, in a rapid manner, so as to respond to this and future emergent public health crises.

Chlamydia and gonorrhea infection rates are rising in the United States, and the emergency department (ED) is increasingly a site where individuals seek care for these infections, sometimes more than once. This article investigates how individuals who use the ED more than once and receive chlamydia and gonorrhea care differ from individuals who are single users of the ED, as well as characteristics associated with being a repeat user of the ED.We analyzed 46,964 visits made by individuals who attended 1 of 4 EDs from January 1, 2010, to May 31, 2016, and received a test for chlamydia and gonorrhea infection. We used negative binomial regression to test the ability of age, sex, race, infection status, and insurance status to predict number of visits.Individuals who used the ED more than once and received chlamydia and gonorrhea care were at their first visit more likely to be younger (incident rate ratio [IRR], 0.98; 95% confidence interval [CI], 0.97-0.98 per year) nonpregnant female (IRR, 1.23; 95% CI, 1.06-1.42), black (IRR, 1.27; 95% CI, 1.04-1.57), and have no or public insurance compared with single users of the ED.Individuals likely to make multiple visits to the ED and receive chlamydia and gonorrhea care may be identifiable on their first visit and potentially directed elsewhere during subsequent visits for more comprehensive and potentially less expensive sexually transmitted disease care.

Background: Gestational diabetes (GDM) increases risk for type 2 diabetes seven fold. Women with a history of GDM should be screened for diabetes at 4-12 weeks postpartum and every 1-3 years thereafter. We aimed to characterize factors associated with diabetes screening by 12 weeks and 1 year postpartum in a cohort of low-income women with GDM. Methods: A retrospective cohort of 1078 women with GDM who delivered from 2010-2015 was generated by linking electronic health record data from 21 Missouri Federally Qualified Health Centers (FQHCs) with Medicaid administrative claims. Screening rates for diabetes were calculated within 12 weeks and one year of delivery. Two multivariable logistic regression models were constructed to determine associations with recommended screening at these time points. Models were adjusted for age, race/ethnicity, comorbidities, prenatal care, previous birth, and distance from home to health center. Results: Median age was 28 years and 64% of women were racial and ethnic minorities (41% black non-Hispanic). Recommended postpartum screening occurred in 9.7% of women by 12 weeks and 18.9% by 1 year. At 12 weeks and 1 year postpartum, having a prenatal certified diabetes educator visit (12 weeks: aOR 1.9 95% CI 1.1-3.5; 1 year aOR 2.2 95% CI 1.3-3.5) and prior medication for GDM (12 weeks: aOR 2.5 95% CI 1.4-4.3; 1 year aOR 2.7 95% CI 1.7-4.2) were strongly associated with diabetes screening. At 1 year, living in an area with public transportation increased odds of screening two-fold (aOR 2.0 95% CI 1.1-3.8) and each additional encounter with the health system after delivery increased odds of screening by 16% (95% aOR 11-21%). Discussion: Multiple factors are associated with postpartum screening for diabetes in populations with limited resources. Future interventions to increase screening should focus on enhancing access to prenatal certified diabetes education and addressing barriers related to transportation and health system access. Disclosure C.J. Herrick: Stock/Shareholder; Spouse/Partner; Cardinal Health. Y. Yan: None. A. Trolard: None. B.P. Cooper: None. M. Keller: None. M.A. Olsen: Consultant; Self; Pfizer Inc. Research Support; Self; Merck & Co., Inc., Pfizer Inc., Sanofi Pasteur. Funding National Institute of Diabetes and Digestive and Kidney Diseases (1P30DK092950, UL1TR000448, KL2TR000450); National Center for Advancing Translational Science (KL2TR002346, UL1TR002345); Agency for Healthcare Research and Quality (R24HS19455); National Cancer Institute (KM1CA156708)

Introduction Sexually Transmitted Infections (STIs) remain prevalent in urban populations and are often diagnosed in emergency departments (ED). However, the burden of STI-care on urban EDs is not well characterised. Methods We conducted a retrospective study of patients seeking acute care for STI-related complaints at a large urban academic ED in the Midwestern US from July, 2012 to June, 2014. All ED patients evaluated for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (Ct) infection by nucleic acid amplification testing were examined for demographic characteristics, testing rates, and STI prevalence. Results Approximately 183,000 ED patient visits occurred during the study period. Of these, 6,518 visits (3.6%) resulted in STI testing for 5,431 patients. For tested patients, 77% were female, 83% African-American, and median age was 26.3(IQR 22.1–34.5). Overall prevalence was 6.8% for GC and 11.8% for Ct among patients tested. Among patients positive for GC, Ct, or both, 55.04–74.5% were female and 60.5–72.2% were ≤24 years. A total of 758 patients (14%) were tested more than once in the ED during the study period and defined as “super-users”. These super-users made up 28% of the total visits during the study period. Super-users were more likely to be female, African American and older adolescents (age 20–24) (p < 0.001). Super-users were more likely than non-super-users to have a positive test for GC (p < 0.001) and Ct (p < 0.001)], and had GC prevalence more than twice that of non-super-users (13.1% vs 5.7%, p < 0.001). Conclusion Our study revealed a significant burden of STI-related diagnoses, especially GC, in the urban ED setting. ED super-users were more likely to have a positive test than those tested patients only once, and may represent a higher risk population. Additional research is needed to understand the unique patient population presenting to urban EDs for STI care and inform tailored intervention strategies. Disclosure of interest All authors report no disclosures.