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Background: Black Americans are more likely to experience hospitalization from COVID-19 compared with White Americans. Whether this excess risk differs by age, sex, obesity, or diabetes, key risk factors for COVID hospitalization, among an integrated population with uniform healthcare access, are less clear., Methods: We identified all adult members (≥ 18 years) of Kaiser Permanente Georgia (KPGA) diagnosed with COVID-19 between January 1, 2020, and September 30, 2021 (N = 24,564). We restricted the analysis to members of Black or White race identified from electronic medical records. Our primary outcome was first hospitalization within 30 days of COVID-19 diagnosis. To assess the association between race and 30-day hospitalization, we performed multivariable logistic regression adjusting for several member and neighborhood-level characteristics, and tested for interactions of race with age, sex, diabetes, and obesity. A regression-based decomposition method was then used to estimate how much of the observed race disparity in 30-day hospitalization could be explained by member and neighborhood-level factors., Results: Overall, 11.27% of Black KPGA members were hospitalized within 30 days of a COVID diagnosis, as compared with 9.44% of White KPGA members. Black (vs. White) KPGA members had a 34% (aOR: 1.32 [95% CI: 1.19-1.47]) higher odds of 30-day hospitalization following COVID-19 after accounting for clinical differences. The odds of 30-day hospitalization in Black vs. White KPGA members did not differ significantly by sex (men: 1.46 [1.25-1.70]; women: 1.24 [1.07-1.43]), by age (18-29 years: 1.33 [0. 841-2.10]; 30-49 years: 1.26 [1.02-1.56]; ≥ 50 years: 1.24 [1.10-1.41]); by diabetes status (with diabetes: 1.38 [1.16-1.66]; without diabetes: 1.26 [1.11-1.44]), or by obesity (with obesity: 1.31 [1.15-1.50]; without obesity: 1.28 [1.06-1.53]). Factors that, if Black and White KPGA members had the same level of exposure, would be most likely to reduce the Black-White disparity in 30-day hospitalization from COVID-19 were obesity, history of flu vaccine, and neighborhood-level income and social vulnerability., Conclusions: Early in the pandemic, Black (vs. White) members of an integrated health system had higher odds of being hospitalized within 30 days of COVID-19 diagnosis and this excess risk was similar by sex, age, and comorbidities. Factors that explained the largest proportions of race-based disparities were obesity, receipt of flu vaccine, and neighborhood-level social determinants of health. These findings suggest that social determinants of health, or other unmeasured factors, may be drivers of racial disparities in COVID-19 outcomes., Competing Interests: Declarations. Ethics Approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by KPGA Institutional Review Board (IRB# 00000406) and Emory University Institutional Review Board (IRB#: MOD004-STUDY00001631). Consent to Participate: A waiver of consent was obtained for the use of this de-identified dataset. Consent for Publication: A waiver of consent for publication was obtained to publish aggregate results from this de-identified dataset. Conflict of Interest: The authors declare no competing interests., (© 2023. W. Montague Cobb-NMA Health Institute.)

Purpose: Low-dose computed tomography lung cancer screening is effective for reducing lung cancer mortality. It is critical to understand the lung cancer screening practices for screen-eligible individuals living in Alabama and Georgia where lung cancer is the leading cause of cancer death. High lung cancer incidence and mortality rates are attributed to high smoking rates among underserved, low income, and rural populations. Therefore, the purpose of this study is to define sociodemographic and clinical characteristics of patients who were screened for lung cancer at an Academic Medical Center (AMC) in Alabama and a Safety Net Hospital (SNH) in Georgia., Methods: A retrospective cohort study of screen-eligible patients was constructed using electronic health records between 2015 and 2020 seen at an Academic Medical Center (AMC) and a Safety Net Hospital (SNH) separately. Chi-square tests and Student t tests were used to compare screening uptake across patient demographic and clinical variables. Bivariate and multivariate logistic regressions determined significant predictors of lung cancer screening uptake., Results: At the AMC, 67,355 were identified as eligible for LCS and 1,129 were screened. In bivariate analyses, there were several differences between those who were screened and those who were not screened. Screening status in the site at Alabama-those with active tobacco use are significantly more likely to be screened than former smokers (OR: 3.208, p < 0.01). For every 10-unit increase in distance, the odds of screening decreased by about 15% (OR: 0.848, p < 0.01). For every 10-year increase in age, the odds of screening decrease by about 30% (OR: 0.704, p < 0.01). Each additional comorbidity increases the odds of screening by about 7.5% (OR: 1.075, p < 0.01). Those with both private and public insurance have much higher odds of screening compared to those with only private insurance (OR: 5.403, p < 0.01). However, those with only public insurance have lower odds of screening compared to those with private insurance (OR: 0.393, p < 0.01). At the SNH-each additional comorbidity increased the odds of screening by about 11.9% (OR: 1.119, p = 0.01). Notably, those with public insurance have significantly higher odds of being screened compared to those with private insurance (OR: 2.566, p < 0.01)., Conclusion: The study provides evidence that LCS has not reached all subgroups and that additional targeted efforts are needed to increase lung cancer screening uptake. Furthermore, disparity was noticed between adults living closer to screening institutions and those who lived farther., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests. Ethical approval: This study was approved by both University of Alabama at Birmingham and Morehouse School of Medicine. Transformative: I confirm that I understand journal Cancer Causes & Control is a transformative journal. When research is accepted for publication, there is a choice to publish using either immediate gold open access or the traditional publishing route. Dual publication: The results/data/figures in this manuscript have not been published elsewhere nor are they under consideration by another publisher. Authorship: I have read the Nature Portfolio journal policies on author responsibilities and submit this manuscript in accordance with those policies. Third party material: All of the material is owned by the authors and/or no permissions are required., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Almost half of individuals born with Down syndrome (DS) have congenital heart defects (CHDs). Yet, little is known about the health and healthcare needs of adults with CHDs and DS. Therefore, we examined comorbidities and healthcare utilization of this population., Methods: Data were from the 2016-2019 Congenital Heart Survey to Recognize Outcomes, Needs, and well-beinG (CH STRONG), a survey of 19-38-year-olds with CHDs identified through birth defects registries in Arkansas, Arizona, and Atlanta. Outcome estimates were standardized to the CH STRONG eligible population. Multivariable Poisson regression generated adjusted prevalence ratios (aPRs) for associations between DS and each outcome, adjusting for covariates, including CHD severity., Results: Among 1500 respondents, 9.1% had DS. Compared to those without DS, respondents with DS were more commonly male (55.5% vs. 45.0%), < 25 years old (51.8% vs. 42.7%), non-Hispanic White (72.3% vs. 69.3%), and publicly insured (77.4% vs. 22.8%; all p < 0.05). Of adults with CHDs and DS, 5.5% had cardiac comorbidities, 19.3% had emergency room (ER) visits, 6.2% had hospital admissions, and 1.2% had cost-related delays in care in the last year; 0.1 to 0.6 times lower than adults with CHDs without DS. Additionally, 26.7% had non-cardiac comorbidities (aPR = 1.25 [0.92-1.72]), most commonly sleep apnea (13.7% vs. 3.2%, aPR = 3.67 [2.02-6.67]). Receipt of cardiology care in the last 2 years was similarly low (52.7% vs. 44.7%)., Conclusions: Adults with CHDs and DS comprise a substantial percentage of adults with CHDs and have unique health and healthcare needs. Half of adults with CHDs and DS are not receiving recommended routine cardiac care., (Published 2025. This article is a U.S. Government work and is in the public domain in the USA.)

Background: The COVID-19 pandemic was an unprecedented global health crisis. Vulnerable populations with preexisting mental illness have been disproportionately burdened and may experience adverse mental health outcomes related to the COVID-19 pandemic., Objectives: Our objective was to evaluate the association between COVID-19 diagnosis, known exposure to COVID-19, sheltering in place, symptom severity, psychological distress, and depression severity among adults with severe mental illness (SMI)., Methods: In a cross-sectional study, participants were recruited among patients with SMI who visited an urban community health center in Georgia between February 1, 2019, and March 11, 2021. Measures included COVID-19 impacts on the symptoms of schizophrenia and other psychotic disorders, and severe mood disorders with psychotic features, depression symptoms, self-reported psychological distress, and social connectedness., Results: Adults diagnosed with COVID-19 experienced more severe psychological distress (odds ratio [OR] = 2.48, 95% CI, 1.02-6.28) compared to those not diagnosed with COVID-19. After adjusting for sex and age, adults with SMI who sheltered in place during the lockdown experienced higher psychological distress than those who did not (adjusted odds ratio [aOR] = 2.52, 95% CI, 1.02-6.48). Women experienced significantly higher SMI severity (Brief Psychiatric Rating Scale scores [ x̄ ., ± SD] for women =56.7 ±24.4 vs men = 48.5± 19.1; [ P = .039]) and higher odds of depression (OR = 2.74, 95% CI, 1.22-6.13) during the pandemic than men. Furthermore, adults with SMI with high social support experienced higher psychological distress than those with low social support (aOR = 4.60, 95% CI, 1.82-11.8)., Conclusions: The findings of this study emphasized the need to incorporate infectious disease responses with mental health interventions during a public health crisis., (© Copyright 2025 Physicians Postgraduate Press, Inc.)

The US faces substantial demographic and geographic disparities in both HIV burden and access to pre-exposure prophylaxis (PrEP), an effective strategy to prevent HIV acquisition. Long-acting cabotegravir (CAB) is a novel, injectable PrEP option which demonstrated superior reduction in risk of HIV acquisition compared to daily-oral PrEP in the HPTN083 trial. We modelled the impact of increased PrEP initiations and the introduction of long-acting CAB on HIV incidence among men who have sex with men (MSM) in Atlanta, Georgia, a population with a high burden of HIV. The Georgia Department of Public Health has set an ambitious 25% HIV incidence reduction target, which could be reached with a daily-oral PrEP coverage of 42.2%. However, the target could be achieved at lower levels of PrEP coverage (34.6%) if a mix of PrEP modalities was used, such as an equal split of long-acting CAB PrEP and daily-oral PrEP. Our results clearly demonstrate that broadening access to new PrEP options has the potential to facilitate the achievement of public health HIV incidence reduction goals at plausible levels of PrEP coverage., Competing Interests: The study was funded by ViiV Healthcare. Medical writing and editorial assistance with the preparation of this manuscript was provided by Karolina Badora, PhD, of Maple Health Group, and funded by ViiV Healthcare. The study sponsor had a role in the study design, data collection and analysis, and preparation of the manuscript. The decision to publish was made by the authors. I have read the journal’s policy and the authors of this manuscript have the following competing interests: JF and SS are employees of ViiV Healthcare and own stock in GSK; JF owns stock in Gilead Sciences. SJA is an employee of and owns stock in GSK. FA is an employee of Incremental Action Consulting, Lda, and owns stock in Gilead Sciences. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare., (Copyright: © 2025 Fraysse 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.)

Objective: Black people in the USA have a higher incidence and severity of SLE and worse outcomes, yet they are significantly under-represented in SLE clinical trials. We assessed racial differences in clinical trial perceptions among a large cohort of predominantly Black people with SLE., Methods: Georgians Organised Against Lupus (GOAL) is a population-based, prospective cohort of people with a validated diagnosis of SLE living in Atlanta. The 2021-2022 GOAL survey included questions assessing knowledge, perceptions and experiences of lupus clinical trials involving drug therapy. Self-reported race was categorised as Black or non-Black. Survey responses by race were compared using χ 2 analyses. Among Black respondents, factors associated with willingness to participate in clinical trials were examined using univariable logistic regression., Results: A total of 767 individuals responded to the 2021-2022 GOAL survey, of whom 80% were Black. There were 720 female respondents and 47 male respondents. There was no significant difference in willingness to participate in clinical trials between Black and non-Black respondents (28% vs 31%, p=0.071). Black respondents were less likely to correctly identify the definition of a clinical trial (34% vs 70%, p<0.001). Male gender, unemployed or disabled status, governmental health insurance and higher disease activity were associated with willingness to participate in clinical trials among Black respondents., Conclusions: We found that only 28% of respondents were willing to participate in lupus clinical trials, with no difference by race. Efforts must continue to engage those resistant to trial participation, regardless of race. Our findings also indicate that further research is warranted to assess whether strategies such as clinical trial education and diversification of study staff may be helpful to increase Black patient recruitment. Sociodemographic factors (gender, work status, insurance status) and disease-related factors (lupus activity) may also play important roles in clinical trial participation among Black people., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: Exposure to trauma across the life course may be associated with cardio-metabolic dysfunction during pregnancy; however, previous research has been inconsistent, particularly in highly exposed populations., Objectives: To estimate associations between types and timing (first occurrence) of trauma exposure and hypertension experienced during pregnancy in a safety-net hospital in Atlanta, Georgia, 2011-2022., Methods: Participants completed a 14-item trauma screener. We linked that information to data from the medical record on hypertension (including chronic hypertension, gestational hypertension or preeclampsia). We fit logistic regression models and used the estimates to calculate risk ratios for each trauma type and each critical window (0-9 years, 10-19 and 20+). We fit unadjusted models and adjusted for age, parity and education., Results: We included 704 individuals with a delivery within 12 months following screening. The majority (94%, 661) reported at least one traumatic event, most commonly witnessing violence (79.4%). Overall, 18% experienced gestational hypertension, 10.8% chronic hypertension and 11.9% preeclampsia. Among individuals who reported trauma, 31.5% screened positive for probable posttraumatic stress disorder and 30.9% for probable depression, compared to 0 and 2.3% among those without reported trauma. No trauma type (violence, witnessing violence, non-interpersonal or sexual assault) was associated with increased hypertensive risk, regardless of timing., Conclusions: In this sample with a high trauma and hypertension burden, trauma was not associated with an elevated risk of hypertension during pregnancy, despite a high burden of PTSD and depressive symptoms among people with trauma exposure., (© 2024 John Wiley & Sons Ltd.)

Introduction: There are limited data regarding the associations between public transportation reliance, availability, and diabetic foot ulcer (DFU)-related amputations., Research Design and Methods: We used visit-level data from the Georgia 2016-2019 Healthcare Cost and Utilization Project database and obtained transportation variables from open sources. Using Bayesian spatial-temporal models, we assessed the associations between transportation and DFU-related amputations within each quartile of poverty status indicators at the ZIP code tabulation area (ZCTA) level. We used the proportion of adults who use public transportation to commute, distance to nearest transit stop, and per capita expense on public transportation as proxies for public transportation reliance, availability, and both, respectively., Results: Of 114 606 DFUs, 21 388 (19%) were associated with a major or minor amputation. Among ZCTAs at the highest income quartile, reduced amputation risk was associated with the proportion of adults who use public transportation to commute to work (relative risk (RR)=0.29, 95% CI 0.09 to 0.97 per IQR increase of 1.13%) and per capita expense on public transportation (RR=0.78, 95% CI 0.63 to 0.78 per IQR increase of 6 cents). In metropolitan Georgia, a 1 IQR (261 m) increase in distance to the nearest transit stop was associated with lower amputation risk among ZCTAs at the lowest income quartile (RR=0.47, 95% CI 0.26 to 0.85)., Conclusion: In Georgia, public transportation reliance and availability are protective against DFU-related amputations in high-income but not among low-income ZCTAs. Reducing disparities in DFU-related amputations requires interventions to mitigate transportation barriers to care., Competing Interests: Competing interests: LW received book royalties from John Wiley and Sons, Ltd., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Management of wildlife populations is most effective with a thorough understanding of the interplay among vital rates, population growth, and density-dependent feedback; however, measuring all relevant vital rates and assessing density-dependence can prove challenging. Integrated population models have been proposed as a method to address these issues, as they allow for direct modeling of density-dependent pathways and inference on parameters without direct data. We developed integrated population models from a 25-year demography dataset of Northern Bobwhites ( Colinus virginianus ) from southern Georgia, USA, to assess the demographic drivers of population growth rates and to estimate the strength of multiple density-dependent processes simultaneously. Furthermore, we utilize a novel approach combining breeding productivity and post-breeding abundance and age-and-sex ratio data to infer juvenile survival. Population abundance was relatively stable for the first 14 years of the study but began growing after 2012, showing that bobwhite populations may be stable or exhibit positive population growth in areas of intensive management. Variation in breeding and non-breeding survival drove changes in population growth in a few years; however, population growth rates were most affected by productivity across the entire study duration. A similar pattern was observed for density-dependence, with relatively stronger negative effects of density on productivity than on survival. Our novel modeling approach required an informative prior but was successful at updating the prior distribution for juvenile survival. Our results show that integrated population models provide an attractive and flexible method for directly modeling all relevant density-dependent processes and for combining breeding and post-breeding data to estimate juvenile survival in the absence of direct data., Competing Interests: The authors declare that they have no competing interests., (© 2024 Lewis et al.)

A nationwide serosurvey among adults in 2021 showed a 2.7% (95% confidence interval [CI]: 2.3%-3.4%) prevalence of hepatitis B. Our analysis evaluates knowledge, attitudes and practices (KAP) for hepatitis B virus (HBV) infection among primary healthcare physicians (PHPs) in Georgia. We randomly selected 550 PHPs from medical facilities in Georgia's six largest cities. Using bivariate ordinal regression, we assessed the association of socio-demographic factors with an ordinal knowledge score (low/middle/high). Multivariable logistic regression was performed to calculate adjusted odds ratios (aOR) and 95% CI to determine associations between HBV knowledge score and practices. Of 550 selected PHPs, 506 (92.0%) agreed to participate. Among them, 62.8% scored in the medium or high knowledge tertiles, 72.7% were confident in diagnosing HBV infection, 37.3% were confident in managing patients with hepatitis B; 47.4% reported being screened for and 26.2% reported being vaccinated against HBV infection. Compared to those with low knowledge scores, PHPs with a high score were less likely to recommend activities not supported by evidence, such as: the use of 'hepatoprotective' medications (aOR 0.43, 95% CI 0.25-0.73), caesarean sections (aOR 0.47, 95% CI 0.27-0.82) and withholding breastfeeding (aOR 0.57, 95% CI 0.34-0.96) to prevent HBV transmission. The majority of PHPs were confident in diagnosing HBV infection, but only one in three were confident in managing patients with hepatitis B. PHPs with higher HBV knowledge were less likely to provide inaccurate instructions to their patients. These findings will help to develop awareness and education campaigns supporting HBV elimination in Georgia., (© 2024 The Author(s). Journal of Viral Hepatitis published by John Wiley & Sons Ltd.)

Background: Residential greenness is linked to birth outcomes. However, the role of greenspace morphology remains poorly understood. Additionally, evidence is lacking regarding whether these relationships vary by subpopulation., Objective: We examined the association between preterm birth and residential greenspace morphology, including percentage, shape, connectedness, aggregation, closeness, and fragmentation., Methods: We analyzed 2,063,444 singleton live births between 2001 to 2016 in Georgia, USA. Thirty-meter resolution landcover data from National Land Cover Databased (2001-2016) were obtained to calculate greenspace morphology metrics for 1,953 census tracts in Georgia. A two-stage logistic regression examined associations between each greenspace morphology metric and preterm birth at individual level. Stratified analysis was conducted by maternal race, ethnicity, education, urbanicity, poverty rate, and greenspace percentage., Results: Higher greenspace percentage, aggregation, closeness, shape complexity, connectedness, and lower fragmentation were linked to a lower risk of preterm birth. After adjusting for poverty rate, associations with morphology attenuated, except for fragmentation [odds ratio (OR) = 1.014; 95% confidence interval (CI): 1.0001, 1.026] across the entire population. Strongest associations were found among black mothers and in high-poverty areas. Specifically, the odds of preterm birth in the highest quartile of greenspace percentage were 0.962 (95% CI: 0.933, 0.991) times the odds in the lowest quartile. Additionally, a lower risk of preterm birth was associated with higher greenspace aggregation (OR = 0.969; 95% CI: 0.947, 0.992), and a higher risk of preterm birth was associated with higher fragmentation (OR = 1.028; 95% CI: 1.009, 1.047), both in the black mothers group. In tracts with a high poverty rate, a lower risk of preterm birth associate with higher greenspace percentage (OR = 0.953; 95% CI: 0.910, 0.999), aggregation (OR = 0.976; 95% CI: 0.955, 0.997), and lower fragmentation (OR = 0.976; 95% CI: 0.958, 0.994). The association with greenspace morphology was most pronounced in census tracts with a medium level of greenspace percentage., Discussion: Our study complements other studies by showing the importance and protective effects of greenspace morphology. The observed effects are particularly prominent in census tracts characterized by a moderate level of greenspace percentage, high poverty rates, and among black women. Our findings suggest the need for tailored greenspace planning strategies based on varying levels of greenness in different areas. For locations with low greenness, increasing the greenspace percentage may be prioritized. In areas with a medium level of greenness, strategic enhancement of greenspace morphology is recommended. For areas with high greenness, the focus should be on improving spatial closeness of greenspace. https://doi.org/10.1289/EHP14571.

Objective: This study aims to predict the number of undiagnosed HIV cases at the ZIP Code-level in Atlanta, Georgia, based on publicly available information., Study Design: Statistical modeling., Methods: We fitted a Bayesian hierarchical Binomial model to county-level estimates of the passive-surveillance-system. The denominator was the true total HIV cases arising from a Negative Binomial distribution. The trial probability, known as ascertainment probability, depended on socio-economic determinants of HIV, retained via feature-selection algorithms. Data were obtained from CDC's HIV report for End of the HIV Epidemic and the American Community Survey. The prediction model was assessed out-of-sample in Georgia counties. We combined socio-economic data with the posterior predictive distribution of the coefficients to predict the mean ascertainment probability and total HIV cases at the ZIP Code-level. These estimates were spatially smoothed and aggregated at the county-level for secondary validations., Results: The county-level model showed good mixing properties and predictive accuracy. The mean ascertainment probability calibrated to the ZIP Code-level varied from 78.4% (95% credible interval: 24.4%-99.3%) to 93.8% (95%CI: 80.6%-99.8%). Further, the predicted undiagnosed HIV cases ranged between 12 (95%CI: 6-19; ZIP Code 30322) to 1603 (95%CI 1209-1968; ZIP Code 30318)., Conclusions: Our findings provide a more complete picture of the relative burden of HIV across ZIP codes. Such information can be used by Local Health Departments to identify underserved areas and allocate resources accordingly. Furthermore, our methodological approach can be applied to complement the information obtained from passive surveillance, especially when more resource-intensive approaches are not available or are unfeasible to employ., (Copyright © 2024 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: Posttraumatic stress disorder (PTSD) is associated with maladaptive dysregulation of stress response systems, which could lead to an increased risk of heart failure. We investigated whether PTSD was independently associated with first and recurrent heart failure hospitalizations in the setting of coronary artery disease., Methods: Individuals with stable coronary artery disease and without heart failure at baseline were enrolled in 2 parallel prospective cohort studies in metropolitan Atlanta, GA. Participants underwent a structured clinical interview to assess their lifetime history of PTSD. Current PTSD symptoms were assessed using the PTSD symptom checklist. Participants were followed up for a median time of 4.9 years. The primary end point was first or recurrent hospitalization for heart failure. Secondary end points included cardiovascular death and nonfatal myocardial infarction with and without hospitalization for heart failure. Survival analysis for repeated events was used to assess the association of PTSD with adverse events., Results: We studied 736 individuals with a mean age of 60±10 years; 36% were Black, and 35% were women. In total, 69 (9.4%) patients met the criteria for PTSD. Having a PTSD diagnosis was associated with the primary end point of first or recurrent heart failure hospitalizations, with a hazard ratio of 4.4 (95% CI, 2.6-7.3). The results were minimally attenuated after adjusting for demographic and clinical factors (hazard ratio, 3.7 [95% CI, 2.1-6.3]). Similarly, a 10-point increase in the PTSD symptom checklist score was associated with a 30% (95% CI, 10%-50%) increase in heart failure hospitalizations. PTSD was not associated with an end point of cardiovascular death or nonfatal myocardial infarction, which excluded hospitalizations due to heart failure., Conclusions: Among patients with coronary artery disease, PTSD is associated with incident and recurrent heart failure hospitalizations. Future research is needed to investigate whether PTSD management can reduce the risk of heart failure., Competing Interests: None.

Avian pathogenic Escherichia coli (APEC) is a significant cause of morbidity, mortality, and production loss to the poultry industry worldwide. Here, we characterized 569 E. coli isolates from avian-diagnosed colibacillosis cases from the state of Georgia, USA. In total, 339 isolates were assigned into 32 serogroups with the majority classifying as O78, O2, O25, O8, O1, O86, O18, and O15. Serogroup O25 was found to link with broilers, while broiler breeders were more often associated with serogroup O1 and pet/ hobby birds with serogroup O8. In addition, some serogroups (O1) were more prevalent in the summer and fall. Analysis for virulence-associated genes (VAGs) found 23.20% of isolates did not harbour any genes linked with the APEC pathotype, while ColV plasmid-associated genes ( iroN , ompT , hlyF , iss , and aerJ ) were frequently detected among most isolates (with 80-96% prevalence) and some of these genes were linked with serogroup. Phylogenetic analysis, classified isolates into phylogenetic groups B2 (34%), F (19%), A (15%), and G (9%). The phylogenetic group B2 isolates also harboured the highest number of VAGs. This study highlights that the current APEC-causing disease in birds in the State of Georgia has identified several emerging serogroups possessing several VAGs that could potentially lead to challenges in colibacillosis control. RESEARCH HIGHLIGHTS Several emerging APEC serogroups were observed in Georgia poultry populations.An association between APEC serogroups and bird type was observed.The prevalence of different APEC serogroups was influenced by season.A multiplex PCR assay targeting common serogroups of APEC in Georgia poultry was developed.

Background: Annual influenza epidemics lead to a substantial public health burden, and pregnant people are vulnerable to severe outcomes. Influenza during pregnancy is hypothesized to increase the risk of adverse birth outcomes, but population-based epidemiologic evidence remains limited and inconsistent., Methods: We conducted a time-series analysis to estimate short-term associations between community-level seasonal influenza activity and daily counts of preterm births in Atlanta, United States from October 17, 2010 to July 10, 2017. We defined weekly influenza exposures four ways: (1) percent test-positive from virologic surveillance, (2) percent of patients with symptoms of influenza-like illness (ILI) in outpatient settings, (3) a composite measure of percent test-positive and ILI, and (4) influenza hospitalization rates. We used Poisson log-linear models to estimate associations, adjusting for time-varying confounders and ongoing at-risk pregnancies. We further examined associations by influenza type and exposure lags and effect modification by maternal characteristics., Results: We studied a total of 316,253 births. We found consistent positive associations between influenza activity and preterm birth across different exposure measures and exposure lags. An interquartile range increase in a composite measure of ILI activity and percent test-positive was associated with a 1.014 (95% confidence interval: 1.001-1.027) increase in preterm birth during the same week. In stratified analyses, associations were more pronounced among married, non-Black, and Hispanic pregnant people., Conclusion: Periods of high influenza activity were associated with an increased risk of preterm birth., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The association between extreme ambient heat exposures during pregnancy and neural tube defects (NTDs) in offspring remains unclear. This study sought to estimate the association between exposure to extreme ambient heat during periconception and NTDs., Methods: This population-based case-control study in Georgia, USA (1994-2017) included 825 isolated NTD cases (473 anencephaly, 352 spina bifida) and 3,300 controls matched 1:4 on county of residence and time period of delivery. Daily ambient temperature data were linked to fetal death and birth records by county of residence. Extreme ambient heat exposure was defined as the number of consecutive days the daily apparent temperature exceeded the county-specific 95th percentile (derived over 1980-2010) during an eight-week periconception period. We calculated adjusted odds ratios (aORs) and 95% confidence intervals (CI) using conditional logistic regression models adjusted for maternal age, education, and ethnicity and month and year of last menstrual period., Results: The aORs for NTDs were 1.09 (95% CI 1.01, 1.17), 1.18 (95% CI 1.03, 1.36), and 1.29 (95% CI 1.04, 1.58) for exposure to 1-2, 3-5, and 6 or more consecutive days with apparent ambient temperatures exceeding the county-specific 95th percentile during periconception, respectively, compared to no days of extreme ambient heat exposure. Weekly analysis of extreme heat exposure indicated consistently elevated odds of offspring NTDs during periconception. These results were largely driven by spina bifida cases., Conclusions: Our results highlight potential health threats posed by increasing global average temperatures for pregnant people with implications for increased risk of neural tube defects in their offspring., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Howard H. Chang reports financial support was provided by National Institute of Environmental Health Sciences. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Racial disparities in sexually transmitted infections (STIs) in the United States have been linked to social inequities. Gentrification instigates population-level shifts in housing markets and neighborhood racial/ethnic composition in ways that may impact the spatial distribution of STIs. This study assessed overlap in clusters of STIs, gentrification, social and economic disadvantage, and rental cost burden in Atlanta, Georgia, between 2005 and 2018. Overlap between gentrification and STIs among Black people was greater than that observed for the overlap between gentrification and STIs among White people. Overlap of STIs with social disadvantage and rental cost burden was more prominent among White people than Black people over time. Additional investigation into the factors behind the spatial dynamics observed in this study, and explanations for their variation by race, are necessary to inform where place-based efforts are targeted to reduce racial disparities in STI transmission in gentrifying cities., Competing Interests: Declaration of competing interest The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Limited data exist on mortality rates after tuberculosis (TB) treatment in the United States. We analyzed mortality rates for all adults in Georgia, USA, who had a TB diagnosis and finished treatment during January 1, 2008-December 31, 2019. We obtained posttreatment mortality rate data from the National Death Index and calculated standardized mortality ratios (SMRs) for TB treatment survivors and the general Georgia population. Among 3,182 TB treatment survivors, 233 (7.3%) had died as of December 31, 2019. The overall TB cohort age- and sex-adjusted SMR was 0.89 (95% CI 0.73-1.05). The SMR among US-born TB treatment survivors was 1.56 (95% CI 1.36-1.77). In the TB cohort, US-born status, HIV co-infection, excess alcohol use, diabetes mellitus, and end-stage renal disease were associated with increased risk for death after TB treatment. TB treatment survivors could benefit from improved linkage to primary and HIV comprehensive care to prevent posttreatment death.

Objective:  To compare the risk of severe maternal morbidity (SMM) from the delivery admission to 42 days' postdischarge among persons with sickle cell disease (SCD) to those without SCD., Study Design:  This retrospective cohort study included deliveries ≥20 weeks' gestation at an urban safety net hospital in Atlanta, GA from 2011 to 2019. The exposure was SCD diagnosis. The outcome was a composite of SMM from the delivery admission to 42 days' postdischarge. SMM indicators as defined by the Centers for Disease Control and Prevention were identified using the International Classification of Diseases, Ninth and Tenth Revisions (ICD-9/10) codes; transfusion of blood products and sickle cell crisis were excluded., Results:  Of N  = 17,354 delivery admissions, n  = 92 (0.53%) had SCD. Persons with SCD versus without SCD had an increased risk of composite SMM (15.22 vs. 2.29%, p  < 0.001), acute renal failure (6.52 vs. 0.71%, p  < 0.001), acute respiratory distress syndrome (4.35 vs. 0.17%, p  < 0.001), puerperal cerebrovascular disorders (3.26 vs. 0.10%, p  < 0.001), sepsis (4.35 vs. 0.42%, p  < 0.01), air and thrombotic embolism (5.43 vs. 0.10%, p  < 0.001), and ventilation (2.17 vs. 0.09%, p  < 0.01). Ultimately, those with SCD had an approximately 6-fold higher incidence risk ratio of SMM, which remained after adjustment for confounders (adjusted incidence risk ratio [aIRR]: 5.96, 95% confidence interval [CI]: 3.4-9.19, p  < 0.001). Persons with SCD in active vaso-occlusive crisis at the delivery admission had an approximately 9-fold higher risk of SMM up to 42 days' postdischarge compared with those with SCD not in crisis at the delivery admission (incidence: 25.71 vs. 8.77%, p  < 0.05; aIRR: 8.92, 95% CI: 4.5-10.04, p  < 0.05). Among those with SCD, SMM at the delivery admission was primarily related to renal and cerebrovascular events, whereas most postpartum SMM was related to respiratory events or sepsis., Conclusion:  SCD is significantly associated with an increased risk of SMM during the delivery admission and through 42 days' postdischarge. Active crisis at delivery further increases the risk of SMM., Key Points: · Sickle cell disease was associated with an approximately 6-fold increased risk of SMM.. · Active vaso-occlusive crisis at delivery was associated with an approximately 9-fold increased risk of SMM.. · 48% of SMM events in persons with SCD occurred postpartum and were respiratory- or sepsis-related.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Traffic-related air pollutants have been associated with a variety of adverse human health impacts, including cancers. In the United States, numerous studies have documented racial inequities in neighborhood exposures to traffic-related air pollution. Emerging evidence suggests that structural racism may influence neighborhood exposures to air pollutants. However, existing research has largely focused on residential racial segregation, one indicator of structural racism. This study developed a multidimensional measure of structural racism to examine the relationship between structural racism and estimated cancer risk from air pollutants in Georgia., Methods: Carcinogenic air toxics data were obtained from the US Environmental Protection Agency's 2019 Air Toxics Screening Assessment and sociodemographic data from the American Community Survey. Guided by stakeholder input, county-level data on residential segregation, education, employment, incarceration, economic status, political participation, and homeownership were used to create a multidimensional county-level structural racism index. Relative risks (RRs) were estimated for associations between structural racism and elevated (top 10% in Georgia) estimated cancer risk from air toxics., Results: Multilevel analyses revealed a significant association between multidimensional structural racism and exposure to carcinogenic traffic-related air pollutants. Neighborhoods in the highest quartile of structural racism exhibited an elevated cancer risk from traffic-related air pollutants (RR, 7.84; 95% CI, 5.11-12.05) compared to neighborhoods with lower levels of structural racism., Conclusions: Multidimensional structural racism was associated with estimated cancer risk from traffic-related air pollution in Georgia. Findings can inform future studies and policy interventions that address racial inequalities in exposure to traffic-related air pollution., (© 2024 American Cancer Society.)

Introduction: People with HIV (PWH) have nearly twice the risk of emphysema than people without HIV. This risk, which has been associated with HIV-mediated changes in the lung immune environment and more extensive radiographic emphysema, may result in different patterns of airflow limitation on pulmonary function testing (PFT) than those traditionally used in people without HIV., Methods: In this prospective cohort of PWH in Atlanta, Georgia, we analyzed PFT and chest computed tomography data from July 2013 through June 2018. After comparing the prevalence of PFT measures of airflow limitation for those with and without radiographic emphysema, we used binary recursive partitioning to identify PFT measures that differentiated between PWH with and without radiographic emphysema., Results: Among 167 PWH who had both PFT and computed tomography data during the study period, 89 (53%) had radiographic emphysema. Those with radiographic emphysema were more likely to have airflow limitations on PFTs. Recursive partitioning identified partitions at a forced expiratory volume in 1 second to forced vital capacity ratio (FEV1/FVC) of 0.78 and a residual volume of 116% predicted. These partitions enabled the identification of 84 (94%) PWH with radiographic emphysema, in contrast to the traditional diagnostic criteria of an FEV1/FVC ratio of 0.7, which only identified 49 (55%) of those with radiographic emphysema., Conclusions: Emphysema in PWH may have different patterns of airflow limitation on PFTs that are not adequately captured by traditional diagnostic criteria. Future studies can seek to validate these findings and determine optimal thresholds for diagnosing HIV-associated emphysema., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Childhood cancer constitutes a major cause of death in children. In a recent study of the Georgia Cancer Registry, joint exposures to environmental and social/behavioral stressors were associated with spatial clustering of lymphomas and reticuloendothelial neoplasms among the 159 counties in Georgia, USA. The present study aims to further investigate these associations on a more granular level. Bayesian Poisson and zero-inflated Poisson regression models with spatial and non-spatial variance structures were utilized to investigate whether county-specific cancer patterns may be explained by single or combinations of social stressors and ambient air pollution while adjusting for confounding and accounting for overfitting using differences in expected log predictive densities. While we did not find associations between lymphoma rates and social variables, air pollution, or their interactions, our proposed analysis workflow can serve as a blueprint for future studies investigating dependencies in regression models that feature combinations of unobserved and observed dependency structures., Competing Interests: Declaration of competing interest The authors have declared no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected Black and Latinx communities. Ecologic analyses have shown that counties with a higher percentage of Latinx and Black people have worse COVID-19 outcome rates. Few ecologic analyses have been published at the neighborhood (census tract) level. We sought to determine whether certain sociodemographic neighborhood ecologies were associated with COVID-19 case and death rates in metropolitan Atlanta, Georgia., Methods: We used census data and principal-component analysis to identify unique neighborhood ecologies. We then estimated correlation coefficients to determine whether the neighborhood profiles produced by a principal-component analysis were correlated with COVID-19 case and death rates. We conducted geographically weighted regression models to assess how correlation coefficients varied spatially for neighborhood ecologies and COVID-19 outcomes., Results: We identified two unique neighborhood profiles: (1) high percentage of residents, Hispanic ethnicity, without a high school diploma, without health insurance, living in crowded households, and lower percentage older than 65 years; and (2) high percentage of residents, Black race, living in poverty, unemployed, and households receiving Supplemental Nutrition Assistance Program benefits. Profile 1 was associated with COVID-19 case rate (Pearson r = 0.462, P < 0.001) and profile 2 was associated with COVID-19 death rate (Spearman r = 0.279, P < 0.001). Correlations between neighborhood profiles and COVID-19 outcomes varied spatially., Conclusions: Neighborhoods were differentially at risk of COVID-19 cases or deaths depending on their sociodemographic ecology at the beginning of the COVID-19 pandemic. Prevention methods and interventions may need to consider different social determinants of health when addressing potential cases and deaths during future emergent epidemics.

Background: A wide range of household secondary infection rates has been reported, and the role of children in population transmission dynamics for SARS-CoV-2 remains ill-defined. We sought to better understand household infection early in the pandemic., Methodology: A cross-sectional study of 17 households in the Atlanta metropolitan area with at least one child and one case of COVID-19 in the prior 1-4 months were recruited between December 2020 and April 2021. Self-collected saliva samples were tested on a multiplexed platform to detect IgG antibodies that bind to SARS-CoV-2 antigens. Secondary infection rates (SIR) were calculated and compared., Results: We report results on 17 families, including 66 individuals. We found an average SIR of 0.58; children and adults were similarly infected (62% children vs. 75% adults) ( p  = 0.2). Two out of 17 households had a pediatric index per our definition. Number of pediatric infections per household ( p  = 0.18), isolation ( p  = 0.34), and mask wearing ( p  = 0.80) did not differ significantly among households with an SIR above the mean vs. those with SIR below the mean. Households with higher SIR also had a higher number of symptomatic cases ( p  < 0.001)., Discussion: We demonstrated high household SIRs at the early stages of the pandemic in late 2020 to early 2021 with similar impact on children and adults. The ease of collecting saliva and the detection of asymptomatic infections highlight the advantages of this strategy and potential for scale-up., Competing Interests: EJA has consulted for Pfizer, Sanofi Pasteur, Janssen, and Medscape, and his institution receives funds to conduct clinical research unrelated to this manuscript from MedImmune, Regeneron, PaxVax, Pfizer, GSK, Merck, Sanofi-Pasteur, Janssen, and Micron. He also serves on a safety monitoring board for Kentucky BioProcessing, Inc. and Sanofi Pasteur. His institution has also received funding from NIH to conduct clinical trials of Moderna and Janssen COVID-19 vaccines. 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 © 2024 Nowak, Lane, Mbanya, Carter, Binion, Espinoza, Collins, Heaney, Pisanic, Kruczynski, Spicer, Rivera, Glover, Ojo-Akosile, Breiman, Anderson, Lobelo and Fairley.)

Introduction: Understanding the pneumococcal serotypes causing community-acquired pneumonia (CAP) is essential for evaluating the impact of pneumococcal vaccines., Methods: We conducted a prospective surveillance study of adults aged ≥18 years hospitalized with CAP at 3 hospitals in Tennessee and Georgia between 1 September 2018 and 31 October 2022. We assessed for pneumococcal etiology with cultures, the BinaxNOW urinary antigen detection test, and serotype-specific urinary antigen detection assays that detect 30 pneumococcal serotypes contained in the investigational pneumococcal conjugate vaccine V116, as well as licensed vaccines PCV15 and PCV20 (except serotype 15B). The distribution of pneumococcal serotypes was calculated based on serotype-specific urinary antigen detection results., Results: Among 2917 hospitalized adults enrolled with CAP, 352 (12.1%) patients had Streptococcus pneumoniae detected, including 51 (1.7%) patients with invasive pneumococcal pneumonia. The 8 most commonly detected serotypes were: 3, 22F, 19A, 35B, 9N, 19F, 23A, and 11A. Among 2917 adults with CAP, 272 (9.3%) had a serotype detected that is contained in V116, compared to 196 (6.7%) patients with a serotype contained in PCV20 (P < .001), and 168 (5.8%) patients with a serotype contained in PCV15 (P < .001). A serotype contained in V116 but not PCV15 or PCV20 was detected in 120 (4.1%) patients, representing 38.0% of serotype detections., Conclusions: Approximately 12% of adults hospitalized with CAP had S. pneumoniae detected, and approximately one-third of the detected pneumococcal serotypes were not contained in PCV15 or PCV20. Development of new pneumococcal vaccines with expanded serotype coverage has the potential to prevent a substantial burden of disease., Competing Interests: Potential conflicts of interest . This study was funded by Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc. Additionally, the following authors made the following disclosures. K. D. J. reports being an employee and shareholder with stock options of Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc. C. G. G. reports consulting fees from Merck & Co., Inc and research funding outside the submitted work from NIH, CDC, AHRQ, FDA, and Campbell Alliance/Syneos Health. C. A. R. reports research funding outside the submitted work from BioFire, GSK, MedImmune, Micron, Merck, Novavx, PaxVax, Regeneron, Pfizer, Sanofi-Pasteur, Janssen, Moderna, NIH, and CDC, reports royalties from Meissa Vaccines, and reports 2 planned patents for RSV vaccines. I. Y. reports research funding outside the submitted work from Merck, and consulting fees from Sanofi Pasteur and Merck. T. W. reports being an employee and shareholder with stock options of Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc. C. R. reports being an employee and shareholder with stock options of Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc. N. R. reports research funding outside the submitted work from Merck, Sanofi, Pfizer, Vaccine Company, Immorna, Quidel and Lilly, reports consulting fees from Krog, reports honoraria from Virology Education and Medscape, reports support for attending a meeting from Sanofi and Moderna, reports participation in advisory boards for Moderna, Sanofi, Seqirus, Pfizer, EMMES, ICON, and Micron, and reports leadership roles with ARLG, TMRC, CDC-Pertussis challenge, and Clinical Infectious Diseases. The other authors reported no conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Little is known regarding the relationship between common comorbidities in persons with tuberculosis (TB) (including human immunodeficiency virus [HIV], diabetes, and hepatitis C virus [HCV]) and post-TB mortality. We conducted a retrospective cohort study among persons who initiated treatment for rifampicin-resistant or multi/extensively drug-resistant (RR or M/XDR) TB reported to the country of Georgia's TB surveillance during 2009-2017. Exposures included HIV serologic status, diabetes, and HCV status. Our outcome was all-cause post-TB mortality determined by cross-validating vital status with Georgia's death registry through November 2019. We estimated adjusted hazard rate ratios (aHR) and 95% confidence intervals (CI) of post-TB mortality among participants with and without comorbidities using cause-specific hazard regressions. Among 1032 eligible participants, 34 (3.3%) died during treatment and 87 (8.7%) died post-TB treatment. The median time to post-TB death was 21 months (interquartile range 7-39) after TB treatment. After adjusting for confounders, the hazard rates of post-TB mortality were higher among participants with HIV co-infection (aHR = 3.74, 95%CI 1.77-7.91) compared to those without HIV co-infection. In our cohort, post-TB mortality occurred most commonly in the first 3 years post-TB treatment. Linkage to care for common TB comorbidities post-treatment may reduce post-TB mortality rates., (© 2024. The Author(s).)

People with sickle cell disease (SCD) often have emergency department (ED) revisits. The characteristics of people with SCD with ED revisits were assessed in this study using Medicaid administrative claims data from California and Georgia, representing 2794 and 3641 individuals with SCD, respectively. In both states, those with 6+ primary care provider (PCP) encounters had the highest percentage of ED revisits. In California, those with 6+ hematology encounters had the lowest percentage of individuals with an ED revisit; in Georgia, those with 1-2 hematology encounters. Increasing access to hematologic care may reduce ED revisits among people with SCD., (© The Author(s). Pediatric Blood & Cancer published by Wiley Periodicals LLC.)

Background: The aim of this study was to evaluate the impact of hepatitis C virus (HCV) infection and treatment status on coronavirus disease 2019 (COVID-19)-related hospitalizations in Georgia., Methods: We analyzed 2020-2021 Georgian health registry data for COVID-19-positive individuals and categorized the data by HCV infection and treatment status. Logistic regression was used to assess the strengths of the associations., Results: Treated individuals with HCV had lower odds of COVID-19-related hospitalization compared to anti-HCV-negative individuals, while untreated HCV-viremic and anti-HCV-positive nonviremic individuals had higher odds., Conclusions: HCV treatment prior to COVID-19 infection was associated with lower odds of COVID-19-related hospitalization, highlighting the benefits of HCV management in the context of the pandemic., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

At the beginning of the COVID-19 pandemic, the Georgia Institute of Technology made the decision to keep the university doors open for on-campus attendance. To manage COVID-19 infection rates, internal resources were applied to develop and implement a mass asymptomatic surveillance program. The objective was to identify infections early for proper follow-on verification testing, contact tracing, and quarantine/isolation as needed. Program success depended on frequent and voluntary sample collection from over 40,000 students, faculty, and staff personnel. At that time, the nasopharyngeal (NP) swab, not saliva, was the main accepted sample type for COVID-19 testing. However, due to collection discomfort and the inability to be self-collected, the NP swab was not feasible for voluntary and frequent self-collection. Therefore, saliva was selected as the clinical sample type and validated. A saliva collection kit and a sample processing and analysis workflow were developed. The results of a clinical sample-type comparison study between co-collected and matched NP swabs and saliva samples showed 96.7% positive agreement and 100% negative agreement. During the Fall 2020 and Spring 2021 semesters, 319,988 samples were collected and tested. The program resulted in maintaining a low overall mean positivity rate of 0.78% and 0.54% for the Fall 2020 and Spring 2021 semesters, respectively. For this high-throughput asymptomatic COVID-19 screening application, saliva was an exceptionally good sample type.

Competing Interests: The authors declare no conflict of interests.

Objectives: Rural patients have poor cancer outcomes and clinical trial (CT) enrollment compared to urban patients due to attitudinal, awareness, and healthcare access differential. Knowledge of cancer survival disparities and CT enrollment is important for designing interventions and innovative approaches to address the stated barriers. The study explores the potential disparities in cancer survival rates and clinical trial enrollments in rural and urban breast and lung cancer patients. Our hypotheses are that for both cancer types, urban cancer patients will have longer 5-year survival rates and higher enrollment rates in clinical trials than those in rural counties., Methods: We compared breast and lung cancer patients' survival rates and enrollment ratios in clinical trials between rural (RUCC 4-9) and urban counties in Georgia at a Comprehensive Cancer Center (CCC). To assess these differences, we carried out a series of independent samples t -tests and Chi-Square tests., Results: The outcomes indicate comparable 5-year survival rates across rural and urban counties for breast and lung cancer patients, failing to substantiate our hypothesis. While clinical trial enrollment rates demonstrated a significant difference between breast and lung cancer patients at CCC, no significant variation was observed based on rural or urban classification., Conclusion: These findings underscore the need for further research into the representation of rural patients with diverse cancer types at CCC and other cancer centers. Further, the findings have considerable implications for the initiation of positive social change to improve CT participation and reduce cancer survival disparities., Competing Interests: The authors declare that they have no conflicts of interest to report regarding the present study., (© 2024 The Authors.)

This study aims to quantify the effectiveness of lockdown as a non-pharmacological solution for managing the COVID-19 pandemic. Daily COVID-19 death counts were collected for four states: California, Georgia, New Jersey, and South Carolina. The effectiveness of the lockdown was studied and the number of people saved during 7 days was evaluated. Five neural network models (MLP, FFNN, CFNN, ENN, and NARX) were implemented, and the results indicate that FFNN is the best prediction model. Based on this model, the total number of survivors over a 7-day period is 211, 270, 989, and 60 in California, Georgia, New Jersey, and South Carolina, respectively. The coefficients and weights of the FFNN for each state differ due to various factors, including socio-demographic conditions and the behavior of citizens towards lockdown laws. New Jersey and South Carolina have the most lockdowns and the least., (© 2024. The Author(s).)

Background: Human immunodeficiency virus (HIV) and syphilis disproportionately impact communities with low access to primary care, who often utilize urgent care centers (UCCs) for sexual health care. UCC visits represent an opportunity for identification and treatment of syphilis and linkage to HIV testing and prevention services. We describe a universal, opt-out syphilis screening program pilot at an Atlanta UCC., Methods: A chart review was performed on patients 18 years and older who were offered opt-out syphilis screening and had a rapid plasma reagin (RPR) test collected from September 1, 2021 to December 31, 2021. Demographic data, syphilis stage and treatment, and HIV testing and serostatus were abstracted from the electronic health record. Patients with reactive RPRs were contacted by a study physician for syphilis staging and treatment, counseling, and referral for HIV preexposure prophylaxis (PrEP) or treatment., Results: From September 1, 2021 to December 31, 2021, 5794 patients were triaged and 1381 underwent RPR screening (23.8%). Eighty (5.8%) had reactive RPRs, and 42 (52.5%) had active syphilis. Of those with active syphilis, 39 (92.9%) received any treatment, and 35 (83.3%) completed treatment. Patients with late syphilis were less likely to complete syphilis treatment (adjusted odds ratio, 0.03; P = 0.009; 95% confidence interval, 0.002-0.42). Among 955 offered PrEP, 41 (4.3%) expressed interest in PrEP, and 7 (0.7%) completed PrEP clinic intake. Univariate analysis did not identify any factors associated with interest in PrEP., Conclusions: In a UCC setting, routine, opt-out syphilis testing resulted in increased syphilis identification and treatment. It also provided an opportunity for PrEP counseling and referral, although few patients completed PrEP clinic intake., Competing Interests: Conflict of Interest and Sources of Funding: The authors report no financial or nonfinancial conflicts of interest. Some of the material in this manuscript has been previously presented as an abstract at the Infectious Disease Week (ID Week) 2023 conference. This work was supported by internal departmental funding., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Objective: To study the relationship between neighborhood deprivation index (NDI) and markers of ovarian reserve and outcomes of controlled ovarian stimulation among young, healthy oocyte donors., Design: Retrospective cohort study., Patients: A total of 547 oocyte donors who underwent 905 oocyte retrieval cycles (2008-2020) at a private fertility center in Sandy Springs, Georgia, United States., Interventions: Neighborhood deprivation index was calculated using principal component analysis applied to census-level measures of poverty, employment, household composition, and public assistance, which was then standardized and linked to donor information on the basis of donor residence., Main Outcome Measures: Markers of ovarian reserve, including antral follicle count (AFC) and antimüllerian hormone (AMH) levels, and outcomes of controlled ovarian stimulation including number of total and mature oocytes retrieved and ovarian sensitivity index (OSI) (defined as the number of oocytes retrieved/total gonadotropin dose × 1,000). Multivariable generalized estimating equations with Poisson and normal distribution were used to model the relationship between NDI and outcome measures adjusting for age, body mass index, and year of retrieval., Results: The mean (SD) age of donors was 25.0 (2.8) years and 29% of the donors were racial or ethnic minorities. There were no associations between donor NDI and ovarian reserve markers. For every interquartile range increase in NDI, there was a reduction of -1.5% (95% confidence interval: -5.3% to 2.4%) in total oocytes retrieved although the effect estimate was imprecise. Associations of NDI with a number of mature oocytes retrieved and OSI were in a similar direction. We observed evidence for effect modification of the NDI and OSI association by donor race. There was a suggestive positive association between NDI and OSI in Black donors but no association in White donors., Conclusion: In this cohort of young, healthy, racially diverse oocyte donors, we found little evidence of associations between NDI and markers of ovarian reserve or outcomes of ovarian stimulation., Competing Interests: Declaration of Interests T.S. has nothing to disclose. S.L.P. has nothing to disclose. J.C.L. has nothing to disclose. Z.P.N. has nothing to disclose. D.B.S. has nothing to disclose. M.R.K. has nothing to disclose. H.S.H. has nothing to disclose. A.J.G. reports funding from R01 ES032446 from the National Institute of Environmental Health Sciences (NIEHS) for the submitted work; funding from NIEHS R21ES034130, NICHD R01HD096033, and an ASRM Research Grant; and stock options in Doveras Fertility Inc. outside the submitted work., (Copyright © 2024 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: We investigated the role of serum 25(OH)D (25-hydroxyvitamin D) in COVID-related health outcomes., Methods: We conducted a retrospective cross-sectional study using data of the National Center of Disease Control and Public Health, Georgia. We extracted patient data including length of hospital stay, transfer to the intensive care unit, requirement for oxygen therapy, treatment with glucocorticoids, and symptoms. After obtaining written informed consent, 384 individuals were enrolled. We divided participants into three groups according to 25(OH)D levels: group 1 = 25(OH)D <12 ng/mL (n = 83), group 2 = 25(OH)D 12-20 ng/mL (n = 141), and group 3 = 25(OH)D >20 ng/mL (n = 160)., Results: The odds ratio (OR) for hospitalization in group 1 versus group 2 was 8.7 (95% confidence interval [CI] 3.6-21.3) and 5.6 for group 1 versus 3 (95% CI 2.7-11.9). Regarding oxygen therapy, OR = 28.41 for group 1 versus 2 (95% CI 3.7-220.5) and OR = 5.2 for group 1 versus 3 (95% CI 1.9-14.1). Regarding treatment with glucocorticoids, OR = 3.7 for group 1 versus 2 (95% CI 1.1-12.5) and OR = 8.4 for group 1 versus 3 (95% CI 1.8-40.7)., Conclusion: COVID-19-related morbidity was associated with decreased serum 25(OH)D levels. Future studies should investigate the potential role of vitamin D sufficiency in preventing SARS-CoV-2 infection and mortality., Competing Interests: Declaration of conflicting interestThe authors declare that there is no conflict of interest.

Background: To examine the impact of county-level colorectal cancer (CRC) screening rates on stage at diagnosis of CRC and identify factors associated with stage at diagnosis across different levels of screening rates in rural Georgia., Methods: We performed a retrospective analysis utilizing data from 2004 to 2010 Surveillance, Epidemiology, and End Results Program. The 2013 United States Department of Agriculture rural-urban continuum codes were used to identify rural Georgia counties. The 2004-2010 National Cancer Institute small area estimates for screening behaviors were applied to link county-level CRC screening rates. Descriptive statistics and multinominal logistic regressions were performed., Results: Among 4,839 CRC patients, most patients diagnosed with localized CRC lived in low screening areas; however, many diagnosed with regionalized and distant CRC lived in high screening areas (p-value = 0.009). In multivariable analysis, rural patients living in high screening areas were 1.2-fold more likely to be diagnosed at a regionalized and distant stage of CRC (both p-value < 0.05). When examining the factors associated with stage at presentation, Black patients who lived in low screening areas were 36% more likely to be diagnosed with distant diseases compared to White patients (95% CI, 1.08-1.71). Among those living in high screening areas, patients with right-sided CRC were 38% more likely to have regionalized disease (95% CI, 1.09-1.74)., Conclusion: Patients living in high screening areas were more likely to have a later stage of CRC in rural Georgia., Impact: Allocating CRC screening/treatment resources and improving CRC risk awareness should be prioritized for rural patients in Georgia., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Introduction: Military trainees are at increased risk for infectious disease outbreaks because of the unique circumstances of the training environment (e.g., close proximity areas and physiologic/psychologic stress). Standard medical countermeasures in military training settings include routine immunization (e.g., influenza and adenovirus) as well as chemoprophylaxis [e.g., benzathine penicillin G (Bicillin) for the prevention of group A streptococcal disease] for pathogens associated with outbreaks in these settings. In a population of U.S. Army Infantry trainees, we evaluated changes in the oral microbiome during a 14-week military training cycle., Materials and Methods: Trainees were enrolled in an observational cohort study in 2015-2016. In 2015, Bicillin was administered to trainees to ameliorate the risk of group A Streptococcus outbreaks, whereas in 2016, trainees did not receive a Bicillin inoculation. Oropharyngeal swabs were collected from participants at days 0, 7, 14, 28, 56, and 90 of training. Swabs were collected, flash frozen, and stored. DNA was extracted from swabs, and amplicon sequencing of the 16s rRNA gene was performed. Microbiome dynamics were evaluated using the QIIME 2 workflow along with DADA2, SINA with SILVA, and an additional processing in R., Results: We observed that microbiome samples from the baseline (day 0) visit were distinct from one another, whereas samples collected on day 14 exhibited significant microbiome convergence. Day 14 convergence was coincident with an increase in DNA sequences associated with Streptococcus, though there was not a significant difference between Streptococcus abundance over time between 2015 and 2016 (P = .07), suggesting that Bicillin prophylaxis did not significantly impact overall Streptococcus abundance., Conclusions: The temporary convergence of microbiomes is coincident with a rise in communicable infections in this population. The dynamic response of microbiomes during initial military training supports similar observations in the literature of transient convergence of the human microbiome under cohabitation in the time frame including in this experiment. This population and the associated longitudinal studies allow for controlled studies of human microbiome under diverse conditions., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Improving the delivery of existing evidence-based interventions to prevent and diagnose HIV is key to Ending the HIV Epidemic in the United States. Structural barriers in the access and delivery of related health services require municipal or state-level policy changes; however, suboptimal implementation can be addressed directly through interventions designed to improve the reach, effectiveness, adoption or maintenance of available interventions. Our objective was to estimate the cost-effectiveness and potential epidemiological impact of six real-world implementation interventions designed to address these barriers and increase the scale of delivery of interventions for HIV testing and pre-exposure prophylaxis (PrEP) in three US metropolitan areas., Methods: We used a dynamic HIV transmission model calibrated to replicate HIV microepidemics in Atlanta, Los Angeles (LA) and Miami. We identified six implementation interventions designed to improve HIV testing uptake ("Academic detailing for HIV testing," "CyBER/testing," "All About Me") and PrEP uptake/persistence ("Project SLIP," "PrEPmate," "PrEP patient navigation"). Our comparator scenario reflected a scale-up of interventions with no additional efforts to mitigate implementation and structural barriers. We accounted for potential heterogeneity in population-level effectiveness across jurisdictions. We sustained implementation interventions over a 10-year period and evaluated HIV acquisitions averted, costs, quality-adjusted life years and incremental cost-effectiveness ratios over a 20-year time horizon (2023-2042)., Results: Across jurisdictions, implementation interventions to improve the scale of HIV testing were most cost-effective in Atlanta and LA (CyBER/testing cost-saving and All About Me cost-effective), while interventions for PrEP were most cost-effective in Miami (two of three were cost-saving). We estimated that the most impactful HIV testing intervention, CyBER/testing, was projected to avert 111 (95% credible interval: 110-111), 230 (228-233) and 101 (101-103) acquisitions over 20 years in Atlanta, LA and Miami, respectively. The most impactful implementation intervention to improve PrEP engagement, PrEPmate, averted an estimated 936 (929-943), 860 (853-867) and 2152 (2127-2178) acquisitions over 20 years, in Atlanta, LA and Miami, respectively., Conclusions: Our results highlight the potential impact of interventions to enhance the implementation of existing evidence-based interventions for the prevention and diagnosis of HIV., (© 2024 The Author(s). Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS Society.)

Context: Stroke remains a major public health concern in the state of Georgia with high mortality, disproportionately affecting rural and socioeconomically disadvantaged communities. Georgia's age-standardized stroke death rate is 10.8% higher than the national average, and related comorbidities remain elevated in adult Georgians, contributing to higher stroke prevalence., Program: The Georgia Department of Public Health piloted a Community Paramedicine (CP) program in 2 rural counties to improve stroke management, readmissions, and mortality. Various supportive interventions to address barriers to chronic disease management were provided by a local emergency medical service agency for 90 days. This study aims to evaluate the effectiveness of the CP care delivery model in improving stroke outcomes among high-risk individuals., Implementation: CP leverages emergency medical service infrastructure to provide community health services such as home visits, telemedicine, care coordination, education, and access to social support services. The Georgia Hospital Discharge data and Georgia death records were used to measure stroke rehospitalization and deaths at 30, 60, and 90 days post-discharge for stroke. We compared the health outcomes of high-risk individuals who participated in the CP program to those who did not., Evaluation: Multivariable analysis suggested a reduction in stroke mortality rates among the intervention groups in both counties., Discussion: The CP program demonstrated effectiveness in assisting patients with managing risk factors through medication adherence for conditions such as hypertension, hypercholesterolemia, and diabetes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc.)

Introduction: The US opioid epidemic continues to escalate, with overdose deaths being the most-used metric to quantify its burden. There is significant geographic variation in opioid-related outcomes. Rural areas experience unique challenges, yet many studies oversimplify rurality characterizations. Contextual factors, such as area deprivation, are also important to consider when understanding a community's need for treatment services and prevention programming. This study aims to provide a geospatial snapshot of the opioid epidemic in Georgia using several metrics of opioid-related morbidity and mortality and explore differences by rurality across counties., Methods: This was a spatial ecologic study. Negative binominal regression was used to model the relationship of county rurality with four opioid-related outcomes - overdose mortality, emergency department visits, inpatient hospitalizations, and overdose reversals - adjusting for county-level sex, racial/ethnic, and age distributions. Area Deprivation Index was also included., Results: There was significant geographic variation across the state for all four opioid-related outcomes. Counts remained highest among the metro areas. For rates, counties in the top quartile of rates varied by outcome and were often rural areas. In the final models, rurality designation was largely unrelated to opioid outcomes, with the exception of medium metro areas (inversely related to hospitalizations and overdose reversals) and non-core areas (inversely related to hospitalizations), as compared to large central metro areas. Higher deprivation was significantly related to increased ED visits and hospitalizations, but not overdose mortality and reversals., Conclusions: When quantifying the burden of the opioid epidemic in a community, it is essential to consider multiple outcomes of morbidity and mortality. Understanding what outcomes are problematic for specific communities, in combination with their demographic and socioeconomic context, can provide insight into gaps in the treatment continuum and potential areas for intervention. Additionally, compared to demographic and socioeconomic factors, rurality may no longer be a salient predictor of the severity of the opioid epidemic in an area., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To assess the relationship between the Child Opportunity Index (COI), a comprehensive measurement of social determinants of health, and specific COI domains on patient-specific outcomes following congenital cardiac surgery in the metropolitan region of Atlanta, Georgia., Study Design: In this retrospective chart review, we included patients who underwent an index operation for congenital heart disease between 2010 and 2020 in a single pediatric health care system. Patients' addresses were geocoded and mapped to census tracts. Descriptive statistics, univariable analysis, and multivariable regression models were employed to assess associations between variables and outcomes., Results: Of the 7460 index surgeries, 3798 (51%) met eligibility criteria. Presence of an adverse outcome, defined as either mortality or 1 of several other major postoperative morbidities, was significantly associated with COI in the univariable model (P = .008), but not the multivariable regression model (P = .39). Postoperative hospital length of stay was significantly associated with COI (P < .001) in univariable and multivariable regression models. There was no significant association between COI and readmission within 30 days of hospital discharge in univariable (P < .094) and multivariable (P = .49) models., Conclusion: COI is associated with postoperative hospital length of stay but not all outcomes in patients after congenital heart surgery. By understanding the role of COI in outcomes related to cardiac surgery, targeted interventions can be developed to improve health equity., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Published by Elsevier Inc.)

Spatial count data with an abundance of zeros arise commonly in disease mapping studies. Typically, these data are analyzed using zero-inflated models, which comprise a mixture of a point mass at zero and an ordinary count distribution, such as the Poisson or negative binomial. However, due to their mixture representation, conventional zero-inflated models are challenging to explain in practice because the parameter estimates have conditional latent-class interpretations. As an alternative, several authors have proposed marginalized zero-inflated models that simultaneously model the excess zeros and the marginal mean, leading to a parameterization that more closely aligns with ordinary count models. Motivated by a study examining predictors of COVID-19 death rates, we develop a spatiotemporal marginalized zero-inflated negative binomial model that directly models the marginal mean, thus extending marginalized zero-inflated models to the spatial setting. To capture the spatiotemporal heterogeneity in the data, we introduce region-level covariates, smooth temporal effects, and spatially correlated random effects to model both the excess zeros and the marginal mean. For estimation, we adopt a Bayesian approach that combines full-conditional Gibbs sampling and Metropolis-Hastings steps. We investigate features of the model and use the model to identify key predictors of COVID-19 deaths in the US state of Georgia during the 2021 calendar year., (© 2024 Wiley‐VCH GmbH.)

Objective: If untreated, hepatitis C virus (HCV) leads to poor health outcomes, including liver disease and death, particularly among people with HIV (PWH). We describe trends over time in incidence rates of HCV diagnoses among PWH in the state of Georgia., Methods: We constructed a retrospective cohort of PWH in Georgia by using matched HIV and HCV case surveillance data from people diagnosed with HCV infection from January 1, 2014, through December 31, 2019. We calculated annual incidence rates per 1000 person-years and estimated trends over time in HCV diagnoses among the cohort of PWH by demographic characteristics and HIV care outcomes using Poisson regression analysis, with α = .05 considered significant., Results: From 2014 through 2019, among 49 530 PWH in Georgia, 1945 (3.9%) were diagnosed with HCV infection. During this period, overall incidence per 1000 person-years of newly diagnosed HCV infection among PWH decreased from 8.7 to 4.5 ( P for trend < .001). However, from 2014 through 2019, the annual incidence rates of PWH who were newly diagnosed with HCV infection increased from 4.6 to 7.1 ( P for trend = .003) among people born from 1980 through 1989 and from 3.3 to 12.8 ( P for trend < .001) among people born in 1990 or later., Conclusion: Strategies are needed to increase prevention, diagnosis, and treatment of HIV/HCV coinfection, particularly among PWH born in 1980 and later. Routine linkage of state surveillance data can inform prioritization of PWH at highest risk of HCV infection., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Georgia has a higher rate of severe maternal morbidity and mortality when compared with the rest of the United States. Evidence gained from the Georgia Maternal Mortality Review Committee identified areas of focus for high-yield clinical initiatives for improvement in maternal health outcomes. Cardiovascular disease, including cardiomyopathy, coronary conditions, and preeclampsia with or without eclampsia, is the most common cause of pregnancy-related death in non-Hispanic Black women in Georgia. The development of a cardio-obstetrics program is an initiative to advance health equity by decreasing cardiovascular morbidity and mortality. This report describes the following: (1) state-level advocacy for improving maternal health outcomes with funding gained through the legislative process and partnership with a governmental agency; (2) cardio-obstetrics program development based on evidence gained from the maternal mortality review process; and (3) implementation of a cardio-obstetrics service, beginning with a focused approach for capacity building and understanding barriers to care., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Four counties within the Atlanta, Georgia 20-county eligible metropolitan area (EMA) are currently prioritized by the US "Ending the HIV Epidemic" (EHE) initiative which aims for a 90% reduction in HIV incidence by 2030. Disparities driving Atlanta's HIV epidemic warrant an examination of local service availability, unmet needs and organizational capacity to reach EHE targets. We conducted a mixed-methods evaluation of the Atlanta EMA to examine geographic HIV epidemiology and distribution of services, service needs and organization infrastructure for each pillar of the EHE initiative., Methods: We collected 2021 county-level data (during June 2022), from multiple sources including: AIDSVu (HIV prevalence and new diagnoses), the Centers for Disease Control and Prevention web-based tools (HIV testing and pre-exposure prophylaxis [PrEP] locations) and the Georgia Department of Public Health (HIV testing, PrEP screenings, viral suppression and partner service interviews). We additionally distributed an online survey to key local stakeholders working at major HIV care agencies across the EMA to assess the availability of services, unmet needs and organization infrastructure (June-December 2022). The Organizational Readiness for Implementing Change questionnaire assessed the organization climate for services in need of scale-up or implementation., Results: We found racial/ethnic and geographic disparities in HIV disease burden and service availability across the EMA-particularly for HIV testing and PrEP in the EMA's southern counties. Five counties not currently prioritized by EHE (Clayton, Douglas, Henry, Newton and Rockdale) accounted for 16% of the EMA's new diagnoses, but <9% of its 177 testing sites and <7% of its 130 PrEP sites. Survey respondents (N = 48; 42% health agency managers/directors) reported high unmet need for HIV self-testing kits, mobile clinic testing, HIV case management, peer outreach and navigation, integrated care, housing support and transportation services. Respondents highlighted insufficient existing staffing and infrastructure to facilitate the necessary expansion of services, and the need to reduce inequities and address intersectional stigma., Conclusions: Service delivery across all EHE pillars must substantially expand to reach national goals and address HIV disparities in metro Atlanta. High-resolution geographic data on HIV epidemiology and service delivery with community input can provide targeted guidance to support local EHE efforts., (© 2024 The Author(s). Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS Society.)

Importance: Neighborhood deprivation has been associated with increased breast cancer mortality among White women, but findings are inconsistent among Black women, who experience different neighborhood contexts. Accounting for interactions among neighborhood deprivation, race, and other neighborhood characteristics may enhance understanding of the association., Objective: To investigate whether neighborhood deprivation is associated with breast cancer mortality among Black and White women and whether interactions with rurality, residential mobility, and racial composition, which are markers of access, social cohesion, and segregation, respectively, modify the association., Design, Setting, and Participants: This population-based cohort study used Georgia Cancer Registry (GCR) data on women with breast cancer diagnosed in 2010 to 2017 and followed-up until December 31, 2022. Data were analyzed between January 2023 and October 2023. The study included non-Hispanic Black and White women with invasive early-stage (I-IIIA) breast cancer diagnosed between 2010 and 2017 and identified through the GCR., Exposures: The Neighborhood Deprivation Index (NDI), assessed in quintiles, was derived through principal component analysis of 2011 to 2015 block group-level American Community Survey (ACS) data. Rurality, neighborhood residential mobility, and racial composition were measured using Georgia Public Health Department or ACS data., Main Outcomes and Measures: The primary outcome was breast cancer-specific mortality identified by the GCR through linkage to the Georgia vital statistics registry and National Death Index. Cox proportional hazards regression was used to estimate age-adjusted and multivariable-adjusted hazard ratios (HRs) and 95% CIs for the association between neighborhood deprivation and breast cancer mortality., Results: Among the 36 795 patients with breast cancer (mean [SD] age at diagnosis, 60.3 [13.1] years), 11 044 (30.0%) were non-Hispanic Black, and 25 751 (70.0%) were non-Hispanic White. During follow-up, 2942 breast cancer deaths occurred (1214 [41.3%] non-Hispanic Black women; 1728 [58.7%] non-Hispanic White women). NDI was associated with an increase in breast cancer mortality (quintile 5 vs 1, HR, 1.36; 95% CI, 1.19-1.55) in Cox proportional hazards models. The association was present only among non-Hispanic White women (quintile 5 vs 1, HR, 1.47; 95% CI, 1.21-1.79). Similar race-specific patterns were observed in jointly stratified analyses, such that NDI was associated with increased breast cancer mortality among non-Hispanic White women, but not non-Hispanic Black women, irrespective of the additional neighborhood characteristics considered., Conclusions and Relevance: In this cohort study, neighborhood deprivation was associated with increased breast cancer mortality among non-Hispanic White women. Neighborhood racial composition, residential mobility, and rurality did not explain the lack of association among non-Hispanic Black women, suggesting that factors beyond those explored here may contribute to breast cancer mortality in this racial group.

Background: In custodial settings such as jails and prisons, infectious disease transmission is heightened by factors such as overcrowding and limited healthcare access. Specific features of social contact networks within these settings have not been sufficiently characterized, especially in the context of a large-scale respiratory infectious disease outbreak. The study aims to quantify contact network dynamics within the Fulton County Jail in Atlanta, Georgia., Methods: Jail roster data were utilized to construct social contact networks. Rosters included resident details, cell locations, and demographic information. This analysis involved 6702 male residents over 140,901 person days. Network statistics, including degree, mixing, and dissolution (movement within and out of the jail) rates, were assessed. We compared outcomes for two distinct periods (January 2022 and April 2022) to understand potential responses in network structures during and after the SARS-CoV-2 Omicron variant peak., Results: We found high cross-sectional network degree at both cell and block levels. While mean degree increased with age, older residents exhibited lower degree during the Omicron peak. Block-level networks demonstrated higher mean degrees than cell-level networks. Cumulative degree distributions increased from January to April, indicating heightened contacts after the outbreak. Assortative age mixing was strong, especially for younger residents. Dynamic network statistics illustrated increased degrees over time, emphasizing the potential for disease spread., Conclusions: Despite some reduction in network characteristics during the Omicron peak, the contact networks within the Fulton County Jail presented ideal conditions for infectious disease transmission. Age-specific mixing patterns suggested unintentional age segregation, potentially limiting disease spread to older residents. This study underscores the necessity for ongoing monitoring of contact networks in carceral settings and provides valuable insights for epidemic modeling and intervention strategies, including quarantine, depopulation, and vaccination, laying a foundation for understanding disease dynamics in such environments.Top of Form., Competing Interests: Declaration of Competing Interest The authors of this paper have no conflicts of interest to declare., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Adolescents and young adults (AYAs) living with HIV have high rates of co-sexually transmitted infections (STIs). During the coronavirus disease (COVID) pandemic, STI prevention strategies, including access to testing/treatment facilities, availability of health care workers, and condom availability, may have decreased. This study aimed to determine if differences in STI incidence for first infection and reinfection existed between the pre-COVID and COVID eras in a cohort of AYAs living with HIV in Atlanta, GA. Retrospective chart review was conducted for all patients between ages 13 and 24 at the Grady Ponce Clinic. Two eras were identified: a pre-COVID era (January 1, 2009-December31, 2019) and a COVID era (January 1, 2020-June 30, 2021). STIs recorded included gonorrhea, chlamydia, human papillomavirus, syphilis, trichomonas, herpes simplex virus, lymphogranuloma venereum, hepatitis C, bacterial vaginosis, and chancroid. First and recurrent incidence rates for any STIs were reported. Our sample included 766 sexually active AYAs with HIV. A total of 721 patients were included in the pre-COVID era and 583 (80.9%) had at least one STI. A total of 337 patients were included in the COVID era, and 158 had at least one STI (46.9%). The overall first STI incidence rate increased from 42.47 to 58.67 per 100 person-years (PY) and the recurrent STI incidence rate increased from 121.50 to 169.85 per 100 PY from the pre-COVID to the COVID era ( p < 0.001). Our study demonstrated significantly higher incidence rates of first and recurrent STIs in AYAs living with HIV in the COVID era. We urge continuation of existing STI prevention programs to avoid secondary clinical and economic adverse effects of increased infections.

Purpose: The majority of breast cancer patients are diagnosed with early-stage estrogen receptor (ER) positive disease. Despite effective treatments for these cancers, Black women have higher mortality than White women. We investigated demographic and clinical factors associated with receipt of chemotherapy among those with a discretionary indication who are at risk for overtreatment., Methods: Using Georgia Cancer Registry data, we identified females diagnosed with ER positive breast cancer who had a discretionary indication for chemotherapy (2010-2017). We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) associating patient demographic and clinical characteristics with chemotherapy initiation overall, and comparing non-Hispanic Black (NHB) with non-Hispanic White (NHW) women within strata of patient factors., Results: We identified 11,993 ER positive breast cancer patients with a discretionary indication for chemotherapy. NHB patients were more likely to initiate chemotherapy compared with NHW women (OR = 1.41, 95% CI: 1.28, 1.56). Race differences in chemotherapy initiation were pronounced among those who did not receive Oncotype DX testing (OR = 1.47, 95% CI: 1.31, 1.65) and among those residing in high socioeconomic status neighborhoods (OR = 2.48, 95% CI: 1.70, 3.61). However, we observed equitable chemotherapy receipt among patients who received Oncotype DX testing (OR = 0.90, 95% CI: 0.71, 1.14), were diagnosed with grade 1 disease (OR = 1.00, 95% CI: 0.74, 1.37), and those resided in rural areas (OR = 1.01, 95% CI: 0.76, 1.36)., Conclusion: We observed racial disparities in the initiation of chemotherapy overall and by sociodemographic and clinical factors, and more equitable outcomes when clinical guidelines were followed., (© 2024. The Author(s).)

Background: Per- and polyfluoroalkyl substances (PFAS) are man-made chemicals that are slow to break down in the environment and widely detected in humans. Epidemiological evidence suggests that prenatal exposure to perfluorooctanoic acid (PFOA), a legacy PFAS, is linked to gestational hypertension and preeclampsia. However, the relationship between other PFAS, which are structurally similar, and these outcomes remains largely understudied, despite biologic plausibility. Here, we examined associations between serum PFAS mixtures in relation to hypertensive disorders of pregnancy within a birth cohort of African Americans., Methods: Participants in the present study were enrolled in the Atlanta African American Maternal-Child cohort between 2014 and 2020 (n = 513). Serum samples collected between 8 and 14 weeks gestation were analyzed for four PFAS. Logistic regression was used to assess associations between individual natural log transformed PFAS and specific hypertensive disorders of pregnancy (preeclampsia, gestational hypertension), while quantile g-computation was used to estimate mixture effects. Preeclampsia and gestational hypertension were treated as separate outcomes in individual models. All models were adjusted for maternal education, maternal age, early pregnancy body mass index, parity, and any alcohol, tobacco, or marijuana use., Results: The geometric mean of PFOS and PFHxS was slightly lower among those with preeclampsia relative to those without a hypertensive disorder (e.g., geometric mean for PFOS was 1.89 and 1.94, respectively). Serum concentrations of PFAS were not strongly associated with gestational hypertension or preeclampsia in single pollutant or mixture models. For example, using quantile g-computation, a simultaneous one quartile increase in all PFAS was not associated with odds of gestational hypertension (odds ratio = 0.86, 95% CI = 0.60, 1.23), relative to those without a hypertensive disorder of pregnancy., Conclusions: In this birth cohort of African Americans, there was no association between serum PFAS measured in early pregnancy and hypertensive disorders of pregnancy, which may be reflective of the fairly low PFAS levels in our study population., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)