Areas of high crime often have an increased need for mental health services for the victims and perpetrators of violent crime. Access to these types of services can vary significantly throughout the US, and geographic proximity is one barrier that an individual in need of treatment must overcome, which is especially difficult in rural areas. The long term goal of this study was to inform communities on gaps in the need for mental health services as they relate to crime rates in the state of Iowa. The objective is to measure the association between crime and mental health service geographic proximity at the census block level using ESRI CrimeRisk index scores and US Census data. Geographic proximity to mental health care facilities in Iowa was defined as the ratio of the number facilities within a 5, 10, and 30 miles radius of the center of all block groups in Iowa to the population size of that block group. There are disparities in crime and geographic proximity to mental health facilities. While more than 70% of Iowa’s block groups have a total crime index score below the national average, about 18% have total crime levels above the national average and some are very high at six or seven times the national average. There are also disparities in geographic proximity to mental health facilities, as much of the state has low geographic proximity to provider within 5 or 10 miles of their home and moderate geographic proximity within 30 miles of their home. Relative ratios produced by negative binomial models using a variety of different crime type index scores (total crime, murder, rape, assault) and predicting the facility-to-population ratio within a specified distance of block groups (5, 10, and 30 miles), showed that overall, the ratio of facilities-to-population increases as crime increases. For example, when predicting the facility-to-population ratio at 5 miles using the murder index scores, there was a relative ratio of 1.93 (CL= 1.76, 2.12), or a near doubling (93% increase) of the number of facilities when increasing each crime category Rurality is an effect measure modifier for the association between crime index scores and the facility-to-population ratio. The relative ratios tended to be highest in urban block groups and lower in isolated rural block groups. Additionally, the facilities-to-population relative ratios tend to be lower overall in areas of high violent crime like rape and murder, compared to areas of lower violent crime. From the geographically weight regression model, there was a large range in crime index scores and geographic proximity to mental health facilities in Iowa. The facility-to population relative ratios show that, despite that increases in crime in Iowa are associated with an increase in available mental health providers, increases are not equitable throughout the state and often depend on how rural an area is. The relative ratios also show that some types of violent crime, notably rape and assault, have smaller increases in geographic proximity to mental health facilities than other types of crime, which is concerning given the high rates of victimization and trauma associated with those crimes. By using model selection and geographically weighted regression, we can see that the model fit varies over space as does crime’s association with provider access, giving more resolution to these conclusions.

Facial fractures are commonly present in hospital patients admitted for trauma care. The establishment of clinical indicators for uncovering facial fractures has been insufficiently studied. The main objectives of this study were to determine midface facial fracture diagnostics, etiology, characteristics, indicators, related outcomes, and treatments within a trauma patient population. A clinical epidemiologic study was conducted using a retrospective observational design. Level I trauma center data was used from the years of 2007-2009. Key data sources were Iowa Methodist Trauma registry, radiographic scans and notes, electronic medical records, and billing records. A case-control and a retrospective cohort design were used to address study objectives. Analyses included bivariate comparative tests along with multivariate logistic regression modeling. The study demonstrated that the majority of facial fractures in the patient population were diagnosed with maxillofacial computed tomography scans. Patients had a median of 2 (interquartile range: 2-4) facial fractures with the orbit bones being the most commonly fractured bones. Of patients with fracture, 48% had a direct or indirect health outcome related to their fracture and 51% of patients had their fracture left to self-resolve with minimal self-care. Statistically significant indicators of facial fracture included the presence of periorbital contusion, open wound of the forehead, epistaxis, blood in ethmoid sinus, and blood in maxillary sinus, while motor vehicle collision appeared to have a disproportionately low relationship with fracture. Based on these risk factors, three potential risk groups for facial fracture were proposed, stratifying study patients into subpopulations per their estimated risk level. Study results will help clinicians better understand facial fracture. The revealed indicators and risk levels for facial fracture may serve to help determine when fractures may be present in similar trauma patient populations. Further research should be conducted to validate the internal validity as well as the generalizability of study results in other trauma centers and patients.

The Gambia is the smallest country in mainland Africa. Along with the rapid urbanization rate, motorization has increased rapidly as well, contributing to an increased number of road traffic crashes. Road traffic crashes are the 4th leading cause of in-patient deaths in adults in the Gambia and currently are a significant public health problem. This study utilized the Gambia Traffic Force’s data registry to become the first epidemiological study on road traffic injuries in the Gambia as well as the first to analyze the Gambia’s traffic data registry on a national level. Reported crashes from October 1st, 2014 to June 30, 2015 were converted from the paper-based data registry into an electronic database and analyzed statistically, and the location data were geocoded and plotted on the Gambian map. The results of this study showed that crashes involving pedestrian victims and crashes that occurred on unpaved roads were more likely to be associated with outcomes that were fatal or serious. When multiple vehicles were involved in a crash, the involvement of motorcycles and bicycles were more likely to lead to a fatal or serious injury. The mapped data showed that towards the center of each district, the number of crashes increased as pedestrian and vehicle density increased, but that injury severity outcomes were generally minor or none. In contrast, as pedestrian and vehicle density decreased, crash frequency decreased as well, but injury outcomes were more likely to be severe or fatal. The findings of the study also helped in identifying areas in policy and education that need improvement.

Infection with human immunodeficiency virus (HIV) and progression to acquired immune deficiency syndrome (AIDS) often result in neurologic and neuropsychiatric changes, although the prognostic information available for patients affected by HIV/AIDS-related neurologic diagnoses has been limited. The objective of the present study was to characterize the patterns and predictors of survival, including the impacts of antiretroviral therapy (ART) use and potential factors in healthcare access and disparity, among patients with one or more of the following conditions: cryptococcosis, toxoplasmosis, primary central nervous system lymphoma, progressive multifocal leukoencephalopathy, and HIV-associated dementia. To accomplish this, a cohort was drawn from the Iowa HIV/AIDS reporting system, and a non-independent, university-based cohort was then used to validate the analyses conducted for the statewide sample. Patterns of ART use were identified in each cohort using logistic regression, and survival analyses were conducted using Kaplan-Meier analysis, Cox regression, and accelerated failure time modeling. Survival was poor in both cohorts, although the university-based setting (University of Iowa Hospitals and Clinics) was associated with better overall survival. Of 230 persons in the statewide cohort, 77.0% were deceased by the end of the study period (1982-2008), and the median survival was 1.13 years (95% CI: 0.90 to 1.86 years, n=225). By contrast, 56.4% of the university-based cohort was deceased by the end of the study period (1984-2009), and the median survival in this group was 3.04 years (95% CI: 1.79 to 11.62 years, n=172). Both cohorts were predominantly male, non-Hispanic white, and residents of a small metropolitan area at the time of the AIDS diagnosis. ART use had a strong protective effect on survival in both cohorts. Use of ART among patients diagnosed during the era of highly active antiretroviral therapies (HAART) was associated with an 80% reduction in the rate of death (HR=0.20, 95% CI: 0.08 to 0.46) compared to the non-users diagnosed during the pre-HAART era (that is, prior to 1996), after adjustment for age, race, birth sex, healthcare facility type, opportunistic infection count, HIV transmission risk category, neurologic condition, years since AIDS diagnosis, and timing of neuro-AIDS in a Cox regression model. In the UIHC cohort, the adjusted expected survival time among ART/HAART users was 37.71 (95% CI: 14.44 to 99.48) times that among non-users. Women had significantly poorer outcomes than men in the statewide cohort (adjusted HR=2.31, 95% CI: 1.22 to 4.35), and a similar, non-significant trend was observed among university-based cases. Secondary analyses suggested that this difference persisted over the course of the epidemic and was not attributable to differential ART response among men and women. Evidence for a role of disease severity, psychosocial support, and/or psychiatric comorbidity in the differential survival of men and women was identified. This study provides useful prognostic data for patients and providers and may guide future research efforts aimed toward improved survival for neuro-AIDS patients. The survival disadvantage of women compared to men should be confirmed and the mechanisms underlying this disparity elucidated. Meanwhile, clinical and public health efforts might be directed towards screening, treatment, and support for women affected by neuro-AIDS, including potential assessment of comorbid psychiatric disorders.

The purpose of this study was to resolve a critical gap in depression literature through assessment of the temporal relationship between depression and low LDL. A systematic review and meta-analysis was conducted to investigate the overall cross-sectional association between serum LDL and depression. Inconsistent findings suggest that more work must be done to clarify the link between LDL and depression. Next, Cox regression was used to explore the association between LDL and the subsequent onset of depressive symptoms within a subset of the Women’s Health Initiative cohort and evaluate the potential for effect modification by lipid-lowering medication use. This study provides evidence toward an association between low LDL and the subsequent onset of depressive symptoms, with increased risk confined to LDL below 100 mg/dL. Elevated risk was not associated with lipid-lowering medication use. The final study examined the differences in the magnitude and direction of change in serum LDL levels among individuals experiencing new-onset depression, and examines the potential for physical activity, energy intake, and total body weight to mediate the depression-LDL relationship. This study provides no evidence of an association between depression and subsequent serum LDL changes. Altogether, this data suggests that LDL that is below 100 mg/dL without the use of lipid-lowering medication may predispose individuals to a greater risk of depression, and also suggests that low LDL is not likely a state brought about by physiological or behavioral changes following the onset of depression.

Thesis (M.S.C.E.) PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / BACKGROUND: Patient navigation programs were designed to address barriers to healthcare among underserved populations in order to reduce delays in cancer care delivery. While emerging data suggest modest effects of navigation on reducing delays, there is limited understanding of the association between barriers to care and clinical outcomes within patient navigation programs. OBJECTIVE: To investigate the impact of barriers on timely diagnostic care in the multicenter Patient Navigation Research Program (PNRP). STUDY DESIGN: Secondary analysis of data from the intervention arms of PNRP centers that navigated women for abnormal breast or cervical cancer screening tests from 2007 to 2010. METHODS: Analyses were performed separately for breast and cervical subjects. The main independent variables were (a) number of unique barriers to care (0, 1, 2, or 3+) documented during patient navigation encounters and (b) presence of socio-legal barriers (yes/no), those social problems related to meeting life’s most basic needs that are supported by public policy, regulation, and programming and thus potentially remedied through legal advice or advocacy. The outcome of interest was median time to diagnostic resolution, or the interval from index screening abnormality to diagnostic resolution, estimated using Kaplan-Meier cumulative incidence curves. Multivariable Cox proportional hazards regression with time to diagnostic resolution as the outcome examined the impact of barriers, controlling for socio-demographics and stratifying by study center. RESULTS: Among 2600 breast screening subjects, three-quarters had barriers to care (25% 1 barrier, 16% 2 barriers and 34% 3+ barriers). Among 1387 cervical screening subjects, slightly more than half had barriers (31% 1 barrier, 11% 2 barriers, and 13% 3+ barriers). Among breast subjects, we found the presence of barriers was associated with less timely resolution for any number of barriers compared to no barriers. Among cervical subjects, only the presence of 2 or more barriers was associated with less timely resolution. Both socio-legal and non socio-legal barriers were associated with delay among breast and cervical subjects. CONCLUSIONS: Navigated women with barriers resolve cancer screening abnormalities at a slower rate compared to those with no barriers. Further research is necessary to maximize the impact of patient navigation programs nationwide. / 2031-01-01

Branches of science such as epidemiology, clinical epidemiology, statistics and various statistical methods are by ground for activity of epidemiological-manager indicators. Incidence and prevalence are numbered among epidemiological-manager indicators. In condition of hospital Pelhřimov are these indicators written, analyzed and predicated for department of hospitalized in years 2005 -- 2007. At the same time is appraised use of capacities department of hospitalized, is made analyse and estimation of most often treated diagnosis and is watched progress their average time of treatment. The watching indicators are by one of series others records for manager decision-making by control of hospital.

Staphylococcus aureus causes an assortment of infections that range from mild skin infections to bacteremia or necrotizing pneumonia. Patients with S. aureus infections may suffer poor outcomes such as extended hospital stay and death. The goal of this study was to improve outcomes of patients with S. aureus infections by examining microbial characteristics of S. aureus associated with poor clinical outcomes, and comparative effectiveness of S. aureus treatment options for patients with S. aureus infections. Additionally, methods to prevent S. aureus infections among hospitalized patients were assessed. We performed a two-hospital retrospective cohort study to identify microbial characteristics, patient characteristics, or antimicrobial treatments that were predictors of mortality or length of stay among patients with methicillin-resistant S. aureus (MRSA) pneumonia. We found increased age (> 54 years) (hazard ratio [HR]: 4.49; 95% confidence interval [CI]: 1.64-12.33), intensive care unit (ICU) admission (HR: 5.25; CI: 1.52-18.21), and having a hospital-onset pneumonia (HR: 0.32; CI: 0.13-0.75) were associated with mortality while admission to the ICU (odds ratio [OR]: 7.34; CI: 3.58-15.04), increased age (> 54 years) (OR: 2.27; CI: 1.19-4.35), having a hospital-onset pneumonia (OR: 3.60; CI: 1.26-10.28), and receiving vancomycin (OR: 10.85; CI: 3.68-32.00) were predictors of increased length of stay. None of the tested microbial characteristics were associated with poor outcomes. We also completed a multicenter retrospective cohort study to compare the effect of beta-lactams versus vancomycin (both empiric and definitive therapy) on mortality for patients with methicillin-susceptible S. aureus (MSSA) bacteremia who were admitted to Veteran Affairs Medical Centers. We found an increased hazard of mortality for patients who received empiric treatment with a beta-lactam compared with vancomycin (HR: 1.19, 95% CI: 1.00-1.42). However, we observed a protective effect among patients who received definitive treatment with a beta-lactam compared with vancomycin (HR: 0.66; CI: 0.50-0.87). In 2007, 2009-2011, we administered surveys that focused on the implementation of the Institute for Healthcare Improvement's (IHI) MRSA bundle to reduce hospital-onset MRSA infections to infection preventionsts who worked in Iowa hospitals. By the end of the study period, most hospitals implemented a hand hygiene program (range: 87%-94%), placed infected (range: 97%-100%) or colonized patients (range: 77%-92%) on contact precautions, performed active surveillance culturing to identify colonized patients, and monitored the effectiveness of environmental cleaning (range: 23%-71%; P < 0.001). To improve patient outcomes, physicians should provide beta-lactams for definitive treatment of patients with MSSA bacteremia. However, the most effective method to improve outcomes is to prevent S. aureus infections from occurring. This study provides benchmark data that infection prevention staff in rural hospitals throughout the U.S. can use to compare their practices with Iowa hospitals.

Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA) has been characterized in swine workers and other high-risk groups in the United States, but little is known about non-high risk groups. We intend to determine the prevalence of S. aureus and MRSA colonization in Iowans at baseline, observe incident colonization events during follow-up, and determine the frequency of transmission within family units. We will also assess the oropharynx as a distinct colonization site within our population of healthy community members. A prospective, longitudinal cohort study was conducted, enrolling 263 individuals, comprising 95 family units, from Johnson County and Keokuk County. Participants self-collected swabs weekly, with adults providing nasal and oropharyngeal samples and minors providing nasal samples. S. aureus isolates were confirmed with catalase and coagulase tests, and StaphLatex agglutination assays. Molecular characteristics were determined through mecA and PVL polymerase chain reaction, and spa typing. Demographic and risk factor data were collected via self-report questionnaire at baseline. Of the 263 enrolled individuals, 78 adults (9 with MRSA) and 31 minors (1 with MRSA) were positive for S. aureus at baseline. This gives an overall S. aureus prevalence of 44.1% and 36.1% for adults and children respectively, with 5.1% and 1.2% of these isolates being MRSA respectively. Sensitivity for the nares was 57.7% while sensitivity for the oropharynx was 85.9%. Of adults submitting 14 or more sets of swabs, 13 (8.44%) were colonized in the oropharynx greater than 50% of samples while being colonized in the nares less than 50% of samples, indicating preferential oropharynx colonization. Risk factors identified for preferential oropharynx colonization were the number of positive environmental sites within the participant's home, size of the household, and race of the participant. Transmission events were observed for both adults and minors, with 3.95 events observed per participant year of follow-up for adults and 3.04 events per person year of follow-up for minors. Familial transmission events were observed at a rate of 0.77 events per person year of follow-up for adults, and 1.22 events per person year of follow-up for minors. We hypothesized oropharyngeal colonization would be important in healthy community members. This hypothesis is supported by the greater sensitivity observed at baseline when compared to the nares. The identification of 13 preferential oropharynx carriers also supports the hypothesis. Utilizing the results from this dissertation, our findings of the importance of environmental contamination in colonization of both the oropharynx and the nares support the use of environmental decontamination to prevent familial transmission of S. aureus. The results of this study confirm the oropharynx as a distinct and unique colonization site for S. aureus, but further studies are needed to determine the clinical ramifications.

With a birth prevalence of 1 in 1000, neural tube defects (NTD)s contribute considerably to morbidity and healthcare costs. Known genetic and environmental (non-inherited) risk factors for NTDs account for a small portion of risk, suggesting unidentified risk factors. In animal studies, maternal alcohol and pesticide exposures, independently, led to excess neural cell death, resulting in too few cells for neural tube closure. Human studies report no association between alcohol exposure and NTDs, but small to moderate positive associations for pesticide exposure. Such human etiologic studies of NTDs require a large base population, but frequently include only live births. Exclusion of cases by pregnancy outcomes may create ascertainment and response bias, complicating interpretation of findings. Using data from the National Birth Defects Prevention Study (NBDPS) and the Iowa Registry for Congenital and Inherited Disorders (IRCID), the independent effects of maternal periconceptional (1 month prior through 2 months postconception) alcohol and occupational pesticide exposure on the development of NTDs were examined, and differences in Iowa NTD cases were characterized by pregnancy outcome. Maternal reports of alcohol exposure were obtained for 1223 NTD case infants and 6807 control infants. Adjusted odds ratios, estimated using multivariate logistic regression, were near unity for NTDs by any maternal alcohol exposure, binge episode(s), and type(s) of alcohol consumed. Occupational pesticide exposure was assigned by industrial hygienists for mothers of 502 case and 2950 control infants. Adjusted odds ratios for any exposure and cumulative exposure to any pesticide, insecticides only, and insecticides + herbicides + fungicides were near unity for NTDs. Insecticide + herbicide exposure was positively associated with spina bifida. Among the 279 Iowa NTD case infants ascertained by the IRCID, 167 live births and 112 were other pregnancy outcomes (fetal deaths and elective terminations), which increased in proportion over time. Selected infant and maternal characteristics of live births and other pregnancy outcomes were similar. NBDPS eligibility varied significantly by pregnancy outcome, but participation rates did not. NTD case mothers were similar to Iowa NBDPS control mothers. Efforts were made to improve upon prior etiologic studies of these exposures and NTDs, including increased sample size and improved exposure specificity. Some exposure strata (e.g., herbicides only) and outcome strata (e.g., other rare subtypes) were limited by small numbers. All results may have been affected by response and ascertainment bias. Future studies should aim to use similarly detailed exposure classification methods, increase sample size in less prevalent NTD subtypes, and improve ascertainment of fetal deaths.