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Importance: Most patients with pathogenic or likely pathogenic (P/LP) variants for breast cancer have not undergone genetic testing., Objective: To identify patients meeting family history criteria for genetic testing in the electronic health record (EHR)., Design, Setting, and Participants: This study included both cross-sectional (observation date, February 1, 2024) and retrospective cohort (observation period, January 1, 2018, to February 1, 2024) analyses. Participants included patients aged 18 to 79 years enrolled in Renown Health, a large health system in Northern Nevada. Genotype was known for 38 003 patients enrolled in Healthy Nevada Project (HNP), a population genomics study., Exposure: An EHR indicating that a patient is positive for criteria according to the Seven-Question Family History Questionnaire (hereafter, FHS7 positive) assessing familial risk for hereditary breast and ovarian cancer (HBOC)., Main Outcomes and Measures: The primary outcomes were the presence of P/LP variants in the ATM, BRCA1, BRCA2, CHEK2, or PALB2 genes (cross-sectional analysis) or a diagnosis of cancer (cohort analysis). Age-adjusted cancer incidence rates per 100 000 patients per year were calculated using the 2020 US population as the standard. Hazard ratios (HRs) for cancer attributable to FHS7-positive status were estimated using cause-specific hazard models., Results: Among 835 727 patients, 423 393 (50.7%) were female and 29 913 (3.6%) were FHS7 positive. Among those who were FHS7 positive, 24 535 (82.0%) had no evidence of prior genetic testing for HBOC in their EHR. Being FHS7 positive was associated with increased prevalence of P/LP variants in BRCA1/BRCA2 (odds ratio [OR], 3.34; 95% CI, 2.48-4.47), CHEK2 (OR, 1.62; 95% CI, 1.05-2.43), and PALB2 (OR, 2.84; 95% CI, 1.23-6.16) among HNP female individuals, and in BRCA1/BRCA2 (OR, 3.35; 95% CI, 1.93-5.56) among HNP male individuals. Being FHS7 positive was also associated with significantly increased risk of cancer among 131 622 non-HNP female individuals (HR, 1.44; 95% CI, 1.22-1.70) but not among 114 982 non-HNP male individuals (HR, 1.11; 95% CI, 0.87-1.42). Among 1527 HNP survey respondents, 352 of 383 EHR-FHS7 positive patients (91.9%) were survey-FHS7 positive, but only 352 of 883 survey-FHS7 positive patients (39.9%) were EHR-FHS7 positive. Of the 29 913 FHS7-positive patients, 19 764 (66.1%) were identified only after parsing free-text family history comments. Socioeconomic differences were also observed between EHR-FHS7-negative and EHR-FHS7-positive patients, suggesting disparities in recording family history., Conclusions and Relevance: In this cross-sectional study, EHR-derived FHS7 identified thousands of patients with familial risk for breast cancer, indicating a substantial gap in genetic testing. However, limitations in EHR family history data suggested that other identification methods, such as direct-to-patient questionnaires, are required to fully address this gap.

Objective: To examine the emotional distress situation among hospitality industry workers and their access to and use of health care including telehealth services during the COVID-19 pandemic., Methods: A survey was administered on the Qualtrics platform both in English and Spanish from November 18, 2020, to November 30, 2020, through the Culinary Workers Union in Nevada. A total of 1182 union members participated in the survey, of whom 892 completed the survey. Descriptive and multivariable regression analyses were conducted., Results: Among 892 respondents, 78% were people of color; 71% were laid off or furloughed during the COVID-related shutdown, but most had access to health care. Further, 78.8% experienced at least 2 or more signs of emotional distress during the pandemic. Females and unemployment status were positively associated with experiencing emotional distress. About 43.5% received care through telehealth, although most did not prefer telehealth (74.2%). Only 18.3% of non-telehealth users were interested in telehealth and 15.0% had never heard about telehealth., Conclusions: Health insurance coverage is essential for access to health services regardless of employment status. Strengthening mental health services, including psychological counselling for hospitality workers, is needed in such public health emergency situations as the ongoing COVID-19 pandemic., Competing Interests: Conflict of Interest: No conflicts of interest reported by authors.

Background: We examine the extent to which acute and chronic health conditions motivate individuals to seek air quality information. We apply the theoretical elements of the Health Belief Model (HBM) to improve risk communication about ambient air pollution. We discuss the practical applications of HBM, in tandem with the principles of health communication, within an environmental health context., Methods: We test the predictive power of selected components related to the HBM (perceived susceptibility, perceived severity, and cues to action) for intentions to seek information about ambient air quality. We surveyed 325 individuals throughout Nevada where poor air quality poses a risk for vulnerable populations., Results: Ordinal logistic regression analyses showed that experiencing mucous membrane symptoms (eye itching, nose irritation, and dry throat/cough), perceived severity to future health threats, and having an at-risk member in the household positively and significantly predicted intentions to seek air quality information. Experiencing neuropsychological symptoms (fatigue, feeling heavy-headed, and nausea/dizziness), and having a cardiovascular or a respiratory condition did not have significant effects on reported intentions., Conclusions: We discuss how the results of this study can be integrated into health communication practices to increase public engagement with air quality information as a personal intervention measure.

Communities that are historically marginalized and minoritized were disproportionately impacted by the COVID-19 pandemic due to long-standing social inequities. It was found that those who experience social vulnerabilities faced a heightened burden of COVID-19 morbidities and mortalities and concerningly lower rates of COVID-19 vaccination. The CDC's Social Vulnerability Index (CDC-SVI) is a pivotal tool for planning responses to health crises such as the COVID-19 pandemic. This study explores the associations between CDC-SVI and its corresponding themes with COVID-19 vaccine uptake in Nevada counties. Additionally, the study discusses the utility of the CDC-SVI in the context of equitable vaccine uptake in a pandemic setting. We examined the linear association between the 2020 CDC-SVI (including the composite score and the four themes) and COVID-19 vaccine uptake (including initial and complete vaccinations) for the seventeen Nevada counties. These associations were further examined for spatial-varied effects. Each CDC-SVI theme was negatively correlated with initial and complete COVID-19 vaccine uptake (crude) except for minority status, which was positively correlated. However, all correlations were found to be weak. Excessive vaccination rates among some counties are not explained by the CDC-SVI. Overall, these findings suggest the CDC-SVI themes are a better predictor of COVID-19 vaccine uptake than the composite SVI score at the county level. Our findings are consistent with similar studies. The CDC-SVI is a useful measure for public health preparedness, but with limitations. Further understanding is needed of which measures of social vulnerability impact health outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Chien et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Cannabis-related emergency department visits have increased after legalization of cannabis for medical and recreational use. Accordingly, the incidence of emergency department visits due to cannabinoid hyperemesis syndrome in patients with chronic cannabis use has also increased. The aim of this study was to examine trends of emergency department visit due to cannabinoid hyperemesis syndrome in Nevada and evaluate factors associated with the increased risk for emergency department visit. The State Emergency Department Databases of Nevada between 2013 and 2021 were used for investigating trends of emergency department visits for cannabinoid hyperemesis syndrome. We compared patients visiting the emergency department due to cannabinoid hyperemesis syndrome with those visiting the emergency department due to other causes except cannabinoid hyperemesis and estimated the impact of cannabis commercialization for recreational use. Emergency department visits due to cannabinoid hyperemesis syndrome have continuously increased during the study period. The number of emergency department visits per 100,000 was 1.07 before commercialization for recreational use. It increased to 2.22 per 100,000 (by approximately 1.1 per 100,000) after commercialization in the third quarter of 2017. Those with cannabinoid hyperemesis syndrome were younger with fewer male patients than those without cannabinoid hyperemesis syndrome. A substantial increase in emergency department visits due to cannabinoid hyperemesis syndrome occurred in Nevada, especially after the commercialization of recreational cannabis. Further study is needed to explore factors associated with emergency department visits., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Soh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The COVID-19 pandemic intensified concerns regarding food and housing insecurity in the United States, particularly among vulnerable populations. After the pandemic prompted a shutdown of nonessential businesses in Nevada, unemployment rose dramatically as the gaming, tourism, and hospitality industries struggled. This study analyzed the results of two telephone surveys of Nevada adults' experiences in 2020 (n = 1000) and 2021 (n = 1002). The results demonstrate between 2020 and 2021 an 8.24 percentage point decline in food insecurity (FI) from 30.2% to 21.96% and a 12.58 percentage point increase in housing insecurity (HI) from 12.27% to 24.85%. Age, disability status, and certain categories of race/ethnicity and income were associated with both HI and FI in 2020, but disability was no longer significant in 2021. Instead, spouse/partner-status, living with children ≤ 18-years-old and receipt of SNAP benefits were significantly associated with FI in 2021. In particular, health status became a significant factor of both HI and FI. People of color experienced FI disparities compared to Whites. Asians/Hawaiians/Pacific Islanders were 3.22 times (95% CI 1.51, 6.86) more likely to experience FI in 2021 than Whites. A matched, longitudinal analysis also revealed that Whites experienced a significant 9.1 percentage point estimated decline in the probability of FI between 2020 and 2021. However, the reduction among non-White participants was statistically insignificant at 2.5 percentage points. Results indicate the importance of supporting the food and housing needs of people of color and individuals with disabilities. Further research should especially investigate the comparative FI rate among Asians/Hawaiians/Pacific Islanders in 2021 and offer solutions to the soaring prevalence of housing insecurity., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Postpartum depression affects 13% of women after childbirth in the United States. Mothers who experience depression are less likely to breastfeed than those who do not experience depression. On the other hand, breastfeeding may have a positive effect on maternal mental health., Research Aim: We aimed to analyze whether breastfeeding cessation is associated with postpartum depression symptoms among mothers of infants under six months old in Clark County, Nevada., Method: A cross-sectional study was conducted in 2021 using a purposive sample of 305 mother-infant dyads. Postpartum depression symptoms were assessed using the Patient Health Questionnaire-2 (PHQ-2), and the breastfeeding cessation was determined through a 24-hour dietary recall. Descriptive, bivariate, and multivariate logistic regression analyses were conducted., Results: Most participants were between 25 and 34 years old (n = 183, 60.0%), multiparous (n = 167, 55.1%), and had a vaginal delivery (n = 204, 70.6%). High frequency of postpartum depressive symptoms was found among mothers who were young (18-24 years) (24.2%), without a partner (25.0%), had unplanned pregnancies (12.7%), and were primiparous (13.2%). Breastfeeding cessation was independently associated with postpartum depressive symptoms (AOR = 3.30, 95% CI: 1.16-9.32) after controlling for sociodemographic, environmental, and obstetric characteristics., Conclusion: Breastfeeding cessation is strongly associated with postpartum depressive symptoms among mother-infant dyads in Nevada. Early identification of postpartum depressive symptoms and the promotion of breastfeeding can create a positive feedback loop to foster the well-being of mothers and infants., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Neupane et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Although abundant research has been carried out to investigate the underlying mechanisms that may cause neurocognitive challenges among middle-aged and older people living with HIV/AIDS (PLWH), to monitor the prevalence rates of HIV-related neurocognitive deficits, and to identify factors related to the improvement of diagnostic screening tools, classification and nosology, and clinical and rehabilitative treatment of HIV-Associated Neurocognitive Disorder (HAND); to date, there have been only a few studies that have explored and examined the awareness and work experiences HIV sector healthcare and service providers have related to HAND. To address this research gap, we conducted a qualitative, community-based participatory research study and interviewed 12 HIV sector providers in Southern Nevada, USA, from January to April 2022. After performing a thematic analysis of our interviews, we were able to identify two major themes and several sub-themes. Under our first major theme, provider awareness and knowledge, we identified four sub-themes: (1) prior knowledge and current awareness; (2) lived experiences of patients and clients with neurocognitive challenges; (3) lack of knowledge as a barrier to providing needed care; and (4) continuing education and professional development. Under our second major theme, prospective provider roles, we identified three sub-themes: (1) early detection; (2) direct and practical support; and (3) appropriate and timely referrals. In this article, we discuss our findings and lessons learned from our study, as well as their implications for the future work of researchers and providers in the HIV sector related to improving care and support for people aging with HIV/AIDS and experiencing neurocognitive challenges.

A Candida auris outbreak has been ongoing in Southern Nevada since August 2021. In this manuscript we describe the sequencing of over 200 C. auris isolates from patients at several facilities. Genetically distinct subgroups of C. auris were detected from Clade I (3 distinct lineages) and III (1 lineage). Open-source bioinformatic tools were developed and implemented to aid in the epidemiological investigation. The work herein compares three methods for C. auris whole genome analysis: Nullarbor, MycoSNP and a new pipeline TheiaEuk. We also describe a novel analysis method focused on elucidating phylogenetic linkages between isolates within an ongoing outbreak. Moreover, this study places the ongoing outbreaks in a global context utilizing existing sequences provided worldwide. Lastly, we describe how the generated results were communicated to the epidemiologists and infection control to generate public health interventions., Competing Interests: Authors FA, MS, KL and JS were employed by Theiagen Consulting LLC. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Gorzalski, Ambrosio, Massic, Scribner, Siao, Hua, Dykema, Schneider, Njoku, Libuit, Sevinsky, Van Hooser, Pandori and Hess.)

Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Real-time surveillance of infectious diseases at schools or in communities is often hampered by delays in reporting due to resource limitations and infrastructure issues. By incorporating quantitative PCR and genome sequencing, wastewater surveillance has been an effective complement to public health surveillance at the community and building-scale for pathogens such as poliovirus, SARS-CoV-2, and even the monkeypox virus. In this study, we asked whether wastewater surveillance programs at elementary schools could be leveraged to detect RNA from influenza viruses shed in wastewater. We monitored for influenza A and B viral RNA in wastewater from six elementary schools from January to May 2022. Quantitative PCR led to the identification of influenza A viral RNA at three schools, which coincided with the lifting of COVID-19 restrictions and a surge in influenza A infections in Las Vegas, Nevada, USA. We performed genome sequencing of wastewater RNA, leading to the identification of a 2021-2022 vaccine-resistant influenza A (H3N2) 3C.2a1b.2a.2 subclade. We next tested wastewater samples from a treatment plant that serviced the elementary schools, but we were unable to detect the presence of influenza A/B RNA. Together, our results demonstrate the utility of near-source wastewater surveillance for the detection of local influenza transmission in schools, which has the potential to be investigated further with paired school-level influenza incidence data., Competing Interests: Declaration of competing interest Dr. Carolina Koutras is an employee of R-Zero Systems., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

This study reports a new case of acanthocephalan (thorny-headed worm) eggs in a coprolite from Bonneville Estates Rockshelter in eastern Nevada and uses archaeological and ethnographic data to better understand long-term relationships between people and acanthocephalans. Acanthocephalans are parasitic worms that use arthropods as intermediate hosts in their multi-host life cycles. Though acanthocephaliasis is rare among humans today, cases have increased in the last decade, and the discovery of acanthocephalan eggs in coprolites from archaeological sites in the Great Basin suggests a deep, shared history. At Bonneville Estates Rockshelter, 9 acanthocephalan eggs were recovered using a modified rehydration-homogenization-micro-sieving protocol on a coprolite that was radiocarbon dated to 6,040 ± 60 14C BP (7,160-6,730 cal BP), pushing back the oldest evidence of human acanthocephalan infection by 3 millennia. Researchers have proposed that the paleoepidemiology of acanthocephalans may relate to subsistence practices due to overlap in locations of infection and areas where insects are part of traditional foodways. This paper considers the paleoepidemiology of acanthocephalan infection through the first combined review of paleoparasitological, ethnographic, and archaeological records in western North America. Ethnographic and archaeological records support the hypothesis that archaeological cases of human acanthocephaliasis may be linked to entomophagy. Additional parasitological analyses are advised to determine whether this distribution is the result of dietary practices, host ecology, taphonomic issues, sampling biases, or a combination of factors., (© American Society of Parasitologists 2023.)

Background-Mental health conditions and substance use are linked. During the COVID-19 pandemic, mental health conditions and substance use increased, while emergency department (ED) visits decreased in the U.S. There is limited information regarding how the pandemic has affected ED visits for patients with mental health conditions and substance use. Objectives-This study examined the changes in ED visits associated with more common and serious mental health conditions (suicidal ideation, suicide attempts, and schizophrenia) and more commonly used substances (opioids, cannabis, alcohol, and cigarettes) in Nevada during the COVID-19 pandemic in 2020 and 2021 compared with the pre-pandemic period. Methods-The Nevada State ED database from 2018 to 2021 was used ( n = 4,185,416 ED visits). The 10th Revision of the International Classification of Diseases identified suicidal ideation, suicide attempts, schizophrenia, and the use of opioids, cannabis, alcohol, and cigarette smoking. Seven multivariable logistic regression models were developed for each of the conditions after adjusting for age, gender, race/ethnicity, and payer source. The reference year was set as 2018. Results-During both of the pandemic years (2020 and 2021), particularly in 2020, the odds of ED visits associated with suicidal ideation, suicide attempts, schizophrenia, cigarette smoking, and alcohol use were all significantly higher than those in 2018. Conclusions-Our findings indicate the impact of the pandemic on mental health- and substance use-associated ED visits and provide empirical evidence for policymakers to direct and develop decisive public health initiatives aimed at addressing mental health and substance use-associated health service utilization, especially during the early stages of large-scale public health emergencies, such as the COVID-19 pandemic.

Candida auris transmission is steadily increasing across the United States. We report culture-based detection of C. auris in wastewater and the epidemiologic link between isolated strains and southern Nevada, USA, hospitals within the sampled sewershed. Our results illustrate the potential of wastewater surveillance for containing C. auris.

Introduction: The prescription opioid epidemic led to federal, state, and health system guidelines and policies aimed at mitigating opioid misuse, including presumptive urine drug testing (UDT). This study identifies whether a difference exists in UDT use among different primary care medical license types., Methods: The study used January 2017-April 2018 Nevada Medicaid pharmacy and professional claims data to examine presumptive UDTs. We examined correlations between UDTs and clinician characteristics (medical license type, urban/rural status, care setting) along with clinician-level measures of patient mix characteristics (proportions of patients with behavioral health diagnoses, early refills). Adjusted odds ratios (AORs) and predicted probabilities (PPs) from a logistic regression with a binomial distribution are reported. The analysis included 677 primary care clinicians (medical doctors [MD], physician assistants [PA], nurse practitioners [NP])., Results: Of those in the study, 85.1 % of clinicians did not order any presumptive UDTs. NPs had the highest proportion of UDT use (21.2 % of NPs), followed by PAs (20.0 % of PAs), and MDs (11.4 % of MDs). Adjusted analyses showed that being a PA or NP was associated with higher odds of UDT (PA: AOR: 3.6; 95 % CI: 3.1-4.1; NP: AOR: 2.5; 95 % CI: 2.2-2.8) compared to being an MD. PAs had the highest PP for ordering UDTs (2.1 %, 95 % CI: 0.5 %-8.4 %). Among clinicians who ordered UDTs, midlevel clinicians had higher mean and median UDT use (PA and NP mean: 24.3 % vs. MDs: 19.4 %; PA and NP median: 17.7 % vs. MDs: 12.5 %)., Conclusion: In Nevada Medicaid, UDTs are concentrated among 15 % of primary care clinicians who are frequently non-MDs. More research should include PAs and NPs when examining clinician variation in mitigating opioid misuse., Competing Interests: Declaration of competing interest The authors have no conflict of interest to report., (Published by Elsevier Inc.)

Candida auris is an opportunistic fungal pathogen and an emerging global public health threat, given its high mortality among infected individuals, antifungal resistance, and persistence in healthcare environments. This study explored the applicability of wastewater surveillance for C. auris in a metropolitan area with reported outbreaks across multiple healthcare facilities. Influent or primary effluent samples were collected over 10 weeks from seven sewersheds in Southern Nevada. Pelleted solids were analyzed using an adapted quantitative polymerase chain reaction (qPCR) assay targeting the ITS2 region of the C. auris genome. Positive detection was observed in 72 of 91 samples (79%), with higher detection frequencies in sewersheds serving healthcare facilities involved in the outbreak (94 vs 20% sample positivity). Influent wastewater concentrations ranged from 2.8 to 5.7 log 10 gene copies per liter (gc/L), and primary clarification achieved an average log reduction value (LRV) of 1.24 ± 0.34. Presumptive negative surface water and wastewater controls were non-detect. These results demonstrate that wastewater surveillance may assist in tracking the spread of C. auris and serve as an early warning tool for public health action. These findings provide the foundation for future application of wastewater-based epidemiology (WBE) to community- or facility-level surveillance of C. auris and other high consequence, healthcare-associated infectious agents.

Objective: We investigated the relationship between prenatal detection of significant congenital heart disease and elective termination of pregnancy over time in Nevada., Methods: We identified those prenatally or post-natally diagnosed with significant congenital cardiovascular malformations in Nevada with birth dates or estimated delivery dates between July 2012 and June 2021., Results: We identified 1246. Of 1246, 69 underwent fetal demise, 42 had elective termination, and 1135 were live-born. Of the 1135 live-born, 1090 had prenatal care, of which 718 (66%) overall had a prenatal diagnosis of significant congenital heart disease. However, prenatal detection statistically significantly increased over time from 45 to 82%, p  = .00001. Termination of pregnancy averaged 10% of those identified within the legal timeframe, and the rate did not statistically significantly increase with increasing prenatal detection rates, p  = .56. Of the 42 undergoing elective termination, 23 (55%) had syndromes or comorbidities vs. 280 (25%) of the 1135 live-births, p = .0003., Conclusions: In Nevada, despite a statistically significant increase in prenatal detection of significant congenital heart disease over time, termination of pregnancy rates did not increase. Nevertheless, those undergoing elective termination were more likely to have associated syndromes or comorbidities.

Context: Understanding COVID-19 vaccine acceptability among people experiencing homelessness is critical to improve vaccine coverage during the COVID-19 pandemic. Little is known about COVID-19 vaccine acceptability people experiencing unsheltered homelessness (PEUH)., Objective: To identify and describe motivators for receiving a COVID-19 vaccine and reasons for hesitancy, information sources utilized and trusted for vaccine decision making, logistical barriers to receiving vaccination, and what might increase comfortability to receive a COVID-19 vaccination among PEUH., Design: Cross-sectional survey design, implemented from March to June 2021., Setting: Two US cities: Las Vegas and Nevada (urban), and Orlando, Florida (suburban)., Participants: People experiencing predominantly unsheltered homelessness accessing handwashing stations and other wrap-around social services at program sites managed by Clean the World Foundation., Main Outcome Measures: The main outcome measures assessed included survey responses about current vaccine receipt (if participants have already received one or more doses of a COVID-19 vaccine), intention to receive a COVID-19 vaccine if not already received, motivators for receiving or wanting to receive a vaccine, reasons for hesitancy or uncertainty about receiving a vaccine, sources of information regarding COVID-19 vaccines, and actual or anticipated logistical barriers or challenges to receiving COVID-19 vaccines., Results: Among 864 participants, 465 (53.8%) were classified as "vaccine accepting," and 399 were classified "vaccine hesitant or undecided." The primary motivator to be vaccinated was to protect their health (212, 45.6%). Hesitant or undecided participants reported that vaccines were too new (269, 67.4%) or they needed more information (223, 55.9%) and were more likely to receive information from social media than accepting participants (80.0% vs 58.3%, P < .001). Logistical barriers to vaccination included distance to vaccination locations (85, 21.3%), lack of transportation (79, 19.8%), and limited time (64, 16%)., Conclusions: Vaccination efforts to reach PEUH should consider how information and logistical needs may be addressed., Competing Interests: The authors declare no conflicts of interest.

Genetic differences between SARS-CoV-2 variants raise concerns about reinfection. Public health authorities monitored the incidence of suspected reinfection in Clark County, Nevada, USA, during March 2020-March 2022. Suspected reinfections, defined as a second positive PCR test collected >90 days after an initial positive test, were monitored through an electronic disease surveillance system. We calculated the proportion of all new cases per week that were suspected reinfections and rates per 1,000 previously infected persons by demographic groups. The rate of suspected reinfection remained <2.7% until December 2021, then increased to ≈11%, corresponding with local Omicron variant detection. Reinfection rates were higher among adults 18-50 years of age, women, and minority groups, especially persons identifying as American Indian/Alaska Native. Suspected reinfection became more common in Clark County after introduction of the Omicron variant, and some demographic groups are disproportionately affected. Public health surveillance could clarify the SARS-CoV-2 reinfection burden in communities.

Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Stephen L. Guthery reports institutional grant funding from the National Institute for Digestive Diseases and Kidney Diseases (NIDDK) and institutional funding from NIDDK to the Childhood Liver Disease Research Network. No other potential conflicts of interest were disclosed.

Background: Cardiovascular events have been reported in the setting of coronavirus disease-19 (COVID-19). It has been hypothesized that systemic inflammation may aggravate arrhythmias or trigger new-onset conduction abnormalities. However, the specific type and distribution of electrocardiographic disturbances in COVID-19 as well as their influence on mortality remain to be fully characterized., Methods: Electrocardiograms (ECGs) were obtained from 186 COVID-19-positive patients at a large tertiary care hospital in Northern Nevada. The following arrhythmias were identified by cardiologists: sinus bradycardia, sinus tachycardia, atrial fibrillation (A-Fib), atrial flutter, multifocal atrial tachycardia (MAT), premature atrial contraction (PAC), premature ventricular contraction (PVC), atrioventricular block (AVB), and right bundle branch block (RBBB). The mean PR interval, QRS duration, and corrected QT interval were documented. Fisher's exact test was used to compare the ECG features of patients who died during the hospitalization with those who survived. The influence of ECG features on mortality was assessed with multivariable logistic regression analysis., Results: A-Fib, atrial flutter, and ST-segment depression were predictive of mortality. In addition, the mean ventricular rate was higher among patients who died as compared to those who survived. The use of therapeutic anticoagulation was associated with reduced odds of death; however, this association did not reach statistical significance., Conclusion: The underlying pathogenesis of COVID-19-associated arrhythmias remains to be established, but we postulate that systemic inflammation and/or hypoxia may induce potentially lethal conduction abnormalities in affected individuals. Longitudinal studies are warranted to evaluate the risk factors, pathogenesis, and management of COVID-19-associated cardiac arrhythmias., (© 2021 The Authors. Annals of Noninvasive Electrocardiology published by Wiley Periodicals LLC.)

Objective: The purpose of this study was to estimate associations between cumulative exposure to adverse childhood experiences (ACEs), protective factors, and co-occurrence among male and female juvenile offenders., Study Design: Cross-sectional study., Methods: Validated measures of ACEs, internal resilience, external youth assets, psychological distress, and substance abuse were collected from 429 youths involved in the juvenile justice system in Nevada. A three-level outcome variable was created using the psychological distress and substance use measures: no problems, one problem, or co-occurring problems. Hierarchical multinomial logistic regression models were used to determine the independent, direct, and moderating impact of the protective factors on ACEs and the outcome., Results: Internal resilience, family communication, school connectedness, peer role models, and non-parental adult role models were associated with lower odds of co-occurrence compared to having no problems (adjusted odds ratios [AORs] ranged from 0.11 to 0.33). When ACEs were added to the model, internal resilience and all assets except for one (non-parental adult role models) continued to offer protection against co-occurrence. Internal resilience was the only protective factor that significantly moderated the association between ACEs and co-occurrence (AOR, 0.24; 95% CI, 0.06, 0.99)., Conclusion: Most protective factors decreased co-occurring mental health and substance abuse problems in the presence of ACE exposure and internal resilience moderated the relationship between ACEs and co-occurrence. Juvenile justice systems should use positive youth development approaches to help prevent co-occurrence among youths., (Copyright © 2021 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: Although there is evidence that self-inflicted abdominal stab wounds are less severe than those from assault, it is unclear if this is true in other anatomic regions. This study compares severity and injury pattern between self-inflicted stab wounds (SISWs) and wounds from assault (ASW)., Materials and Methods: Stab wounds from our level I trauma registry from 2013 to 2018 were reviewed. Data included age, gender, self-inflicted versus assault, psychiatric or substance use history, anatomic location, operative intervention, injury severity, length of stay, and outcomes., Results: Over the study period, 1390 patients were identified. History of psychiatric diagnoses or previous suicide attempts was more frequent in SISWs (47% versus 6.5%, P < 0.01; 35% versus 0.4%, P < 0.01). SISWs had a higher incidence of wounds to the neck and abdomen (44% versus 11%, P < 0.01; and 34% versus 26%, P = 0.02). Overall, injuries from ASW had a higher injury severity score, but more procedures were performed on SISWs (46% versus 34%, P < 0.01). SISWs to the neck were more likely to undergo procedures (26% versus 15%, P = 0.04). Median hospital charges were higher in patients with SISWs ($58.6 K versus $39.4 K, P < 0.01)., Conclusions: SISWs have a distinct pattern of injuries, more commonly to the neck and abdomen, when compared with injuries resulting from ASW. The patients with SISWs have a higher rate of procedures, longer length of stay, and higher hospital charges despite low injury severity overall., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Cardiovascular disease (CVD) remains the number one cause of death in the US and Nevada is ranked 11th highest for CVD mortality. The study sought to examine the association between self-reported risk factors and CVD presence among adult Nevadans, between years 2011 and 2017., Methods: This is a cross-sectional, population-based study that utilized the 2011 and 2017 Nevada Behavioral Risk Factor Surveillance System data. Data were analyzed between 2019 and 2020., Results: A total of 5,493 and 3,764 subjects in 2011 and 2017, respectively were included. BMI (overweight/obesity) remained the most prevalent CVD risk factor. The second most common CVD risk factor was high cholesterol, followed by hypertension. Compared to females, males were 1.64 times more likely to have reported CVD in 2011, which increased to 1.92 in 2017. Compared to non-smokers, everyday smokers were 1.96 times more likely in 2011 and 3.62 times more likely in 2017. Individuals with high cholesterol status were 2.67 times more likely to have reported CVD compared to those with normal levels in 2011. In 2011, individuals with hypertension were 3.74 times more likely to have reported CVD compared to those who did not have hypertension. This relationship increased its magnitude of risk to 6.18 times more likely in 2017. In 2011, individuals with diabetes were 2.90 times more likely to have reported CVD compared to those without the condition., Conclusions: Public health and healthcare providers need to target preventable cardiovascular risk factors and develop recommendations and strategies locally, nationally, and globally., Competing Interests: The authors have declared that no competing interests exist.

Patients with signs of COVID-19 were tested through diagnostic RT-PCR for SARS-CoV-2 using RNA extracted from the nasopharyngeal/nasal swabs. To determine the variants of SARS-CoV-2 circulating in the state of Nevada, specimens from 200 COVID-19 patients were sequenced through our robust sequencing platform, which enabled sequencing of SARS-CoV-2 from specimens with even very low viral loads, without the need of culture-based amplification. High genome coverage allowed the identification of single and multi-nucleotide variants in SARS-CoV-2 in the community and their phylogenetic relationships with other variants present during the same period of the outbreak. We report the occurrence of a novel mutation at 323aa (314aa of orf1b) of nsp12 (RNA-dependent RNA polymerase) changed to phenylalanine (F) from proline (P), in the first reported isolate of SARS-CoV-2, Wuhan-Hu-1. This 323F variant was present at a very high frequency in Northern Nevada. Structural modeling determined this mutation in the interface domain, which is important for the association of accessory proteins required for the polymerase. In conclusion, we report the introduction of specific SARS-CoV-2 variants at very high frequency in distinct geographic locations, which is important for understanding the evolution and circulation of SARS-CoV-2 variants of public health importance, while it circulates in humans., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Neonatal abstinence syndrome (NAS) is a postnatal withdrawal syndrome among neonates born to mothers with drug dependence disorders. NAS poses a significant public health challenge nationally, with a six-fold increase in incidence (1.2 to 6.7 per 1000 hospital births/year) from 2000-2016. Besides national data, it is critical to quantify NAS at the state-level to identify target areas for prevention. The objectives of this study were to ascertain statewide burden, including county and regional distribution of NAS in Nevada during 2016-2018, and to investigate potential factors associated with NAS. This study utilized hospital administrative data, and a total of 100,845 inpatient pediatric discharges were examined to identify NAS cases. Statistical analyses included estimation of crude incidence rates per 1000 hospital births and multilevel logistic regression modeling. NAS incidence in Nevada decreased slightly from 8.6 to 7.7 per 1000 hospital births between 2016 and 2018, but the overall incidence of 8 was substantially higher than earlier estimates (4.8/1000 hospital births) reported for 2013. Incidence was disproportionately higher among white newborns (12, 95% CI 11.0,13.0) and Medicaid enrollees (13.2, 95% CI 11.0,15.0). Southern Nevada had the highest incidence rate of 8.2 per 1000 hospital births. Nearly 75% of NAS cases were residents of Clark County. Incidence rates of NAS parallel the growing opioid prescription rates in Nevada and highlight the need for adopting opioid control prescribing practices to combat this drug epidemic. These findings might help in designing and evaluating state- and system-level interventions introduced to combat the opioid epidemic.

Study Objective: Postoverdose interventions that deploy peer recovery support specialists to emergency departments (EDs) are a promising response to opioid overdoses among patients presenting in EDs. The objective of this study was to elicit patients' perspectives regarding the feasibility and acceptability of such an intervention and to ensure that their perspectives are represented in intervention design, implementation, and evaluation., Method: In 2019 the study investigators conducted focus groups with people who use opioids to elicit perspectives about a postoverdose intervention delivered in the ED by using a semistructured interview guide that asked about feasibility, acceptability, perceived benefits, and concerns. Focus groups were digitally recorded, transcribed, and analyzed for emerging themes., Results: Nine focus groups with 30 people who use opioids were conducted. Key findings that could improve feasibility and acceptability of the intervention include the following: the importance of balancing the urgency of seeing patients quickly with a need to accommodate the experience of precipitated withdrawal symptoms; the need to address privacy concerns; and the need to address concerns related to cost, insurance coverage, and sustainability. Perceived benefits of the intervention included the ability of the peer recovery support specialist to provide advocacy and support, serve as a model of hope and encouragement for behavior change, and fill key service gaps., Conclusion: Postoverdose interventions in the ED provide the opportunity to integrate harm reduction-based interventions into traditional biomedical care facilities. These interventions can fill gaps in services and provide additional care and comfort for people who use opioids, but design, implementation, and evaluation should be informed by a patient-centered care perspective., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Cadaveric and older radiographic studies suggest that concurrent cervical spine fractures are rare in gunshot wounds (GSWs) to the head. Despite this knowledge, patients with craniofacial GSWs often arrive with spinal motion restriction (SMR) in place. This study quantifies the incidence of cervical spine injuries in GSWs to the head, identified using computerized tomography (CT). Fracture frequency is hypothesized to be lower in self-inflicted (SI) injuries., Methods: Isolated craniofacial GSWs were queried from this Level I trauma center registry from 2013-2017 and the US National Trauma Data Bank (NTDB) from 2012-2016 (head or face abbreviated injury scale [AIS] >2). Datasets included age, gender, SI versus not, cervical spine injury, spinal surgery, and mortality. For this hospital's data, prehospital factors, SMR, and CTs performed were assessed. Statistical evaluation was done with Stata software, with P <.05 significant., Results: Two-hundred forty-one patients from this hospital (mean age 39; 85% male; 66% SI) and 5,849 from the NTDB (mean age 38; 84% male; 53% SI) were included. For both cohorts, SI patients were older (P < .01) and had increased mortality (P < .01). Overall, cervical spine fractures occurred in 3.7%, with 5.4% requiring spinal surgery (0.2% of all patients). The frequency of fracture was five-fold greater in non-SI (P < .05). Locally, SMR was present in 121 (50.2%) prior to arrival with six collars (2.5%) placed in the trauma bay. Frequency of SMR was similar regardless of SI status (49.0% versus 51.0%; P = not significant) but less frequent in hypotensive patients and those receiving cardiopulmonary resuscitation (CPR). The presence of SMR was associated with an increased use of CT of the cervical spine (80.0% versus 33.0%; P < .01)., Conclusion: Cervical spine fractures were identified in less than four percent of isolated GSWs to the head and face, more frequently in non-SI cases. Prehospital SMR should be avoided in cases consistent with SI injury, and for all others, SMR should be discontinued once CT imaging is completed with negative results.

Background: Health risks due to particulate matter (PM) from wildfires may differ from risk due to PM from other sources. In places frequently subjected to wildfire smoke, such as Reno, Nevada, it is critical to determine whether wildfire PM poses unique risks. Our goal was to quantify the difference in the association of adverse asthma events with PM on days when wildfire smoke was present versus days when wildfire smoke was not present., Methods: We obtained counts of visits for asthma at emergency departments and urgent care centers from a large regional healthcare system in Reno for the years 2013-2018. We also obtained dates when wildfire smoke was present from the Washoe County Health District Air Quality Management Division. We then examined whether the presence of wildfire smoke modified the association of PM 2.5 , PM 10-2.5 , and PM 10 with asthma visits using generalized additive models. We improved on previous studies by excluding wildfire-smoke days where the PM concentration exceeded the maximum PM concentration on other days, thus accounting for possible nonlinearity in the association between PM concentration and asthma visits., Results: Air quality was affected by wildfire smoke on 188 days between 2013 and 2018. We found that the presence of wildfire smoke increased the association of a 5 μg/m 3 increase in daily and three-day averages of PM 2.5 with asthma visits by 6.1% (95% confidence interval (CI): 2.1-10.3%) and 6.8% (CI: 1.2-12.7%), respectively. Similarly, the presence of wildfire smoke increased the association of a 5 μg/m 3 increase in daily and three-day averages of PM 10 with asthma visits by 5.5% (CI: 2.5-8.6%) and 7.2% (CI: 2.6-12.0%), respectively. We did not observe any significant increases in association for PM 10-2.5 or for seven-day averages of PM 2.5 and PM 10 ., Conclusions: Since we found significantly stronger associations of PM 2.5 and PM 10 with asthma visits when wildfire smoke was present, our results suggest that wildfire PM is more hazardous than non-wildfire PM for patients with asthma.

Medical professionals and students often feel as if they do not have enough understanding of the human papillomavirus (HPV) vaccine in order to recommend or obtain vaccination themselves. A 25-question online survey regarding knowledge and attitudes about the HPV vaccine was distributed among professional students, including all classes of medical students, at a Nevada university. First- and second-year medical students were administered the same survey 1 week after a new vaccine workshop. One third of respondents were aware of the link between HPV and oropharyngeal cancer, and 63% believed that the HPV vaccine should be mandatory. Reported full vaccination status (OR = 2.63 compared with no vaccination, 95% CI = 1.53, 4.53), awareness of the link to oropharyngeal cancer (OR = 1.85, 95% CI = 1.04, 3.29), and female sex (OR = 1.64, 95% CI = 1.00, 2.70) positively predicted whether a student believed the HPV vaccine should be mandatory. After an interactive workshop, first- and second-year medical students improved on HPV knowledge questions, comfort in HPV vaccine counseling, and having enough information to counsel on the HPV vaccine. Post-test knowledge scores surpassed those of current third- and fourth-year medical students, who never underwent such curriculum. Medical, physician assistant, graduate, and undergraduate students lack HPV knowledge, with a low percentage aware of oropharyngeal cancer as a result of HPV infection. An interactive curriculum implemented for first- and second-year medical students improved knowledge and comfort in counseling on HPV vaccination.

Acute chest pain is one of the most common presenting symptoms to the emergency department. Currently available risk scores are suboptimal in identifying low-risk patients eligible for early and safe discharge. Various, initially obtained clinical data have valuable discriminating power but are not being fully utilized. We developed a new scoring system based on 5 sets of variables; characteristics of Symptoms, history of Vascular disease,  Electrocardiography,  Age, and Troponin (SVEAT score). A total of 321 subjects presenting to the emergency department or admitted to the clinical decision unit at our institution with chest pain from May 2017 to August 2018 were prospectively recruited. The subjects were followed for 30 days for any major cardiovascular events (MACE); acute myocardial infarction, confirmed coronary artery disease requiring revascularization or medical therapy or death. A 30-day MACE occurred in 19.6% of the subjects. Predictive ability of SVEAT score for a 30-day MACE was compared with HEART and TIMI risk score using receiving-operator characteristic curve. The area under the curve of SVEAT score (0.98, 95% confidence interval [CI] 0.97 to 0.99) is higher than HEART (0.92, 95% CI 0.88 to 0.96) and TIMI score (0.88, 95% CI 083 to 0.93). Using SVEAT score of 4 as a cut off, 0.8% of the subjects developed a 30-day MACE compared with 1.4% and 1.5% of those classified as low-risk based on the HEART and TIMI score respectively. SVEAT score additionally identified larger proportion of low-risk (73.8%) than the HEART (45.2%) and TIMI risk score (40.1%), (p <0.01, for both)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The aggregation of Electronic Health Records (EHR) and personalized genetics leads to powerful discoveries relevant to population health. Here we perform genome-wide association studies (GWAS) and accompanying phenome-wide association studies (PheWAS) to validate phenotype-genotype associations of BMI, and to a greater extent, severe Class 2 obesity, using comprehensive diagnostic and clinical data from the EHR database of our cohort. Three GWASs of 500,000 variants on the Illumina platform of 6,645 Healthy Nevada participants identified several published and novel variants that affect BMI and obesity. Each GWAS was followed with two independent PheWASs to examine associations between extensive phenotypes (incidence of diagnoses, condition, or disease), significant SNPs, BMI, and incidence of extreme obesity. The first GWAS examines associations with BMI in a cohort with no type 2 diabetics, focusing exclusively on BMI. The second GWAS examines associations with BMI in a cohort that includes type 2 diabetics. In the second GWAS, type 2 diabetes is a comorbidity, and thus becomes a covariate in the statistical model. The intersection of significant variants of these two studies is surprising. The third GWAS is a case vs. control study, with cases defined as extremely obese (Class 2 or 3 obesity), and controls defined as participants with BMI between 18.5 and 25. This last GWAS identifies strong associations with extreme obesity, including established variants in the FTO and NEGR1 genes, as well as loci not yet linked to obesity. The PheWASs validate published associations between BMI and extreme obesity and incidence of specific diagnoses and conditions, yet also highlight novel links. This study emphasizes the importance of our extensive longitudinal EHR database to validate known associations and identify putative novel links with BMI and obesity., (Copyright © 2020 Schlauch et al.)

Background: Comorbidity rates and service needs are high among people living with HIV/AIDS (PLWHA). The effects of service utilization and unmet service needs on antiretroviral therapy (ART) adherence are not well understood. The purpose of this study was to investigate associations among PLWHA's service utilization, unmet service needs, and ART adherence., Methods: PLWHA (N=162) 18 years or older were recruited from a Nevada statewide needs assessment project in 2016. Participants completed a self-administered questionnaire on paper or online. The independent variables were service utilization and unmet service needs. The outcome variable was ART adherence. Multivariable logistic regression analyses were conducted to examine associations between the amount of utilized services and unmet service needs with ART adherence., Results: Only 12 (7.5%) participants reported they received all the needed services. The ART nonadherence group showed significantly higher unmet medical service needs compared to the ART adherence group (p=0.007). Unmet medical service needs (Adjusted Odds Ratio (AOR) 0.69, CI 0.53-0.90) and unmet support service needs (AOR 0.68, CI 0.48-0.97) were negatively associated with ART adherence. However, utilizing medical services (AOR 1.06, CI 0.87-1.30) and support services (AOR 0.88, CI 0.74-1.04) in the current year were not significantly associated with ART adherence., Conclusion: The results of this study indicate that health promotion programming should focus not only on introducing new services at the community level, but also work to optimize the availability and awareness of current services. Furthermore, health promotion programs should focus on filling service coverage gaps and improving the facilitation of services., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Objectives: The cost of treating the rare eosinophilic esophagitis (EoE) disease and its impact on patients' quality of life have not been well documented in the literature. This study seeks to fill this gap by comparing the cost of EoE with other well-known inflammatory diseases, including Crohn's disease (CD) and celiac disease (CeD)., Methods: A Mann-Whitney U test and multiple logistic regression were used to examine the cost of EoE in the state of Nevada across all hospital settings and its impact on quality of life compared with CD and CeD., Results: Several factors were associated with the overall cost of EoE in Nevada, including patients' age, sex and region (P < 0.001). EoE was significantly more expensive to treat in the pediatric group ($4001 EoE; $985 CD; $856 CeD), among men ($2532 EoE; $1500 CD; $1724 CeD), among those residing in the southern region of Nevada ($4501 EoE; $2538 CD; $1888 CeD), and among patients seeking medical care from outpatient clinics ($3298 EoE; $741 CD; $1686 CeD) (P < 0.001). Age, sex, region and hospital setting were all associated with having a positive EoE record compared with CeD or CD (P < 0.001)., Conclusions: Data from this study indicate that the EoE burden is significantly higher in cost for certain demographics and regions compared with CD and CeD in the state of Nevada, specifically among pediatric and male patients. These differences suggest that clinicians may encounter similar issues when treating EoE., (© 2020 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.)

Background: Current guidelines recommend that, when prescribing opioids, providers use urine drug testing (UDT) for harm reduction. Objective: To identify whether Medicaid beneficiaries in Nevada at increased risk for opioid misuse received UDT. Methods: We used Nevada Medicaid claims data (2017-2018) to describe UDT among three samples: opioid naïve patients ( N  = 11,326), opioid naïve patients with a second follow-up prescription ( N  = 8,910), and long-term opioid patients ( N  = 19,173). Predictors of opioid misuse include past diagnoses of mental health and substance use, demographic characteristics and potentially risky behaviors. Outcomes include receiving UDT prior to opioid prescription among the two naïve samples and within six months for the long-term sample. We report predicted probabilities (PP) from logistic regressions and hazard ratios (HR) and Kaplan-Meier curves. Results: A small percentage of patients received UDT (naïve sample: 2.5%; naïve with a second follow-up prescription sample: 3.5%; long-term sample: 9.9%). Adults with alcohol disorders and other substance use disorders had the highest PP of UDT, among both the naïve (alcohol related disorder: 3.1%; other substance use disorder: 7.7%) and the naïve with a second follow-up prescription (alcohol related disorder: 4.1%; other substance use disorder: 11.7%) samples. Among the long-term sample, similar predictors were significant. Conclusions: Although there was an association between having risk factors for opioid misuse (e.g. past alchohol disorders and other substance use disorder diagnoses) and receiving UDT, the percentage of patients who received UDT was unexpectedly low, pointing to the need to increase guideline adherence and implementation among providers who prescribe opioids.

To examine trends and contributing factors of opioid, heroin, and cannabis-associated emergency department (ED) visits in Nevada.The 2009 to 2017 Nevada State ED database (n = 7,950,554 ED visits) were used. Use of opioid, heroin, and cannabis, respectively, was identified by the International Classification of Diseases, 9th & 10th Revisions. Three multivariable models, one for each of the 3 dependent variables, were conducted. Independent variables included year, insurance status, race/ethnicity, use of other substance, and mental health conditions.The number of individuals with opioid, heroin, cannabis-associated ED visits increased 3%, 10%, and 23% annually from 2009 to 2015, particularly among 21 to 29 age group, females, and African Americans. Use of other substance (odds ratio [OR] = 3.91; 95% confidence interval [CI] = 3.84, 3.99; reference - no use of other substance), mental health conditions (OR = 2.48; 95% CI = 2.43, 2.53; reference - without mental health conditions), Medicaid (OR = 1.41; 95% CI = 1.38, 1.44; reference - non-Medicaid), Medicare (OR = 1.44; 95% CI = 1.39, 1.49; reference - non-Medicare) and uninsured patients (OR = 1.52; 95% CI = 1.49, 1.56; reference - insured) were predictors of all three substance-associated ED visits.With a steady increase in trends of opioid, heroin, and cannabis-associated ED visits in recent years, the main contributing factors include patient sociodemographic factors, mental health conditions, and use of other substances.

Background: We reviewed data on patients born with critical congenital heart disease in the state of Nevada and analyzed detection via prenatal diagnosis versus newborn pulse oximetry screening, location of birth, and gestational age at birth., Methods: We inquired our databases and electronic health records for all patients with critical congenital heart disease born in Nevada between January 2016 and May 2019., Results: We identified 218 live born patients. Of the 218, average gestational age was 38 weeks (±2.2 weeks). Of the 218, 171 (78%) were prenatally diagnosed, 37 (17%) were diagnosed by immediate postnatal signs and symptoms, 8 (4%) had false-negative pulse oximetry screens that resulted in post-hospital discharge presentations, and 2 (1%) had positive pulse oximetry screens. The eight post-hospital discharge presentations included four in extremis, two with extreme cyanosis, and two dying at home. Of the 171 prenatally diagnosed patients, 157 (92%) were born at the Nevada hospital with the congenital cardiac unit., Conclusion: To the best of our knowledge, our results represent the highest statewide, general population prenatal detection of critical congenital heart disease in the United States. Our high prenatal detection rate led to the majority of patients being born at the Nevada facility with the congenital heart unit, limiting intrastate neonatal transports. On average, patients were born at term. Further, in Nevada, state-mandated, universal pulse oximetry screening resulted in more false-negative results than positive results.

Background: Motor vehicle crashes (MVCs) remain a leading cause of death for US law enforcement officers. One large agency implemented a crash prevention program with standard operating policy changes, increased training, and a marketing campaign. This was a scientific evaluation of that crash prevention program., Methods: MVC and motor vehicle injury (MVI) data for law enforcement officers were compared using an autoregressive integrated moving average (ARIMA) model. Two law enforcement agencies who had not implemented a crash prevention program were controls., Results: After program implementation, overall, MVC rates significantly decreased 14% from 2.2 MVCs per 100 000 miles driven to 1.9 (P = .008). MVC rates did not decrease in the control agencies. Overall, MVI rates significantly decreased 31% from 3.4 per 100 officers to 2.1 (P = .0002). MVC rates did not decrease in the control agencies. MVC rates for patrol officers significantly decreased 21% from 3.1 per 100 000 miles to 2.4. MVI rates for patrol officers significantly decreased 48% from 3.2 per 100 officers to 1.6 (P < .0001)., Conclusions: Crash and injury rates can be reduced after implementation of a crash prevention program and the largest impacts were seen in patrol officers., (© 2019 Wiley Periodicals, Inc.)

Colorectal cancer (CRC) is the third greatest cancer burden in the United States. The remarkably diverse Mountain West state of Nevada has uncharacteristically high CRC mortality compared to other Western states. We aimed to study the determinants of the CRC excess burden by using data from the Nevada Central Cancer Registry from 2003-2013. Five-year cause-specific age-adjusted survival from colorectal cancer was calculated and stratified by sex, race/ethnicity and region of Nevada. Cox Proportional Hazards regression modelling was used to study the impact of demographic, social, and clinical factors on CRC survival in Nevada, assessing follow-up as accurately as possible. The extent to which differences in survival can be explained by receipt of stage-appropriate treatment was also assessed. 12,413 CRC cases from 2003-2013 in Nevada were analyzed. Five-year CRC survival was low: 56.0% (95% CI: 54.6-57.5) among males and 59.5% (95% CI: 58.0-61.1) among females; significantly lower than national 5-year survival of 65.1% and 66.5%, respectively. Low survival was driven by populous Southern Nevada; after adjustment for all covariates, Southern Nevadans were at 17% higher risk of death than their counterparts in Northwestern Nevada (HR:1.17; 95% CI:1.08-1.27). Many patients did not receive stage-appropriate treatment, although this only partly explained the poor survival, uniformly low for every race/ethnicity in Nevada. The observed disparity for this one state within a single nation merits public health attention; regardless of the state or region of residence, all Americans deserve equal opportunity for optimum health outcomes in the face of a cancer diagnosis. The current study provides baseline information critical to clinicians, public health professionals, and all relevant stakeholders as they attempt to discern why Nevada's outcomes are vastly divergent from its neighboring Western states and make plans for remediation., Competing Interests: The authors have declared that no competing interests exist.

Background: The commercial sexual exploitation of children (CSEC) is a major global issue that affects over two million children each year (Polaris Project, 2014). Large metropolitan cities, such as Las Vegas, have high rates of child prostitution (Shared Hope International, 2009)., Objective: The purpose of the current study is to elucidate to what extent interpersonal relationships and contextual factors (e.g. abuse within the home, substance abuse, etc.) influence commercial sexual exploitation., Participants and Setting: Participants for this study include 26 CSEC survivors located within the state of Nevada., Methods: The current study utilizes a qualitative content analysis approach to analyze interview transcripts gathered from CSEC survivors. Three stages of analysis were conducted to assess the relationships that influenced the participants' sexual exploitation, as well as the contextual factors shared by the participants., Results: Analyses indicated that three types of relationships led to commercial sexual exploitation: friends, family, and boyfriends. Of the three relationship typologies, friends were the most common (n = 14). As for contextual factors, it was common for participants to have been abused within their home (n = 15) or to have run away from home (n = 20)., Conclusions: The narratives provided in this study show that CSEC survivors do not often willingly engage in trading sex; rather this decision is influenced by a need to escape familial abuse or they are forced to trade sex by someone whom they share a relationship., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objectives: Population-based research on the relationship between concussions and self-harm, depression, and suicidal behaviors among adolescents is limited. Methods: A statewide Youth Risk Behavior Surveillance Survey (YRBSS) was conducted among students from 98 high schools in Nevada in 2017. Students were asked if they had a concussion from playing a sport as well as their mental health outcomes 12 months before the survey. Weighted multiple logistic regression was used to assess the relationship between experiencing a concussion and adverse mental health outcomes. Results: Among 3427 students who were physically active at least 60 minutes per day on 5 or more days per week, or played on at least one sport team, 19.5% (95% CI: 17.31%-21.60%) reported they had a concussion during the past 12 months. After controlling for sex, age, race/ethnicity, and academic performance, students who had a concussion had higher odds of: self-harm [aOR = 1.59 (1.16-2.17), p = .003], depressive symptoms [aOR = 1.48 (1.12-1.94), p = .006], attempted suicide [aOR = 3.10 (2.12-4.53), p < .001] and injury from attempted suicide [aOR = 2.61 (1.31-5.20, p = .006]. Conclusions: Students who experience a concussion may be at increased risk for poor mental health outcomes, including suicide attempts. Psychological evaluation following a concussion should complement medical evaluation and treatment..

We documented bronchopneumonia in seven mountain goat ( Oreamnos americanus) kid mortalities between 2011 and 2015 following a pneumonia epizootic in bighorn sheep ( Ovis canadensis) and sympatric mountain goats in the adjacent East Humboldt Range and Ruby Mountains in Elko County, Nevada, US. Gross and histologic lesions resembled those described in bighorn lambs following all-age epizootics, and Mycoplasma ovipneumoniae was detected with real-time PCR in the lower and upper respiratory tracts of all kids. Mannheimia haemolytica, with one isolate being leukotoxigenic, was cultured from the upper respiratory tract of five kids, and in one kid, a leukotoxigenic strain of Mannheimia glucosida was isolated from both upper and lower respiratory tracts. During this same period, 75 mountain goats within the two populations were marked and sampled for respiratory pathogens, and M. ovipneumoniae, leukotoxigenic Bibersteinia trehalosi, and Mannheimia haemolytica were identified. The M. ovipneumoniae recovered from the kid mortalities shared the same DNA sequence-based strain type detected in the adult goats and sympatric bighorn sheep during and after the 2009-10 pneumonia outbreak. Clinical signs in affected kids, as well as decreased annual kid recruitment, also resembled reports in bighorn lambs from some herds following all-age pneumonia-associated die-offs. Mycoplasma ovipneumoniae, Pasteurellaceae spp., and other respiratory bacterial pathogens should be considered as a cause of pneumonia with potential population-limiting effects in mountain goats.

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.