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22, 2.94), 1.36 (95% CI, 1.15, 1.61) and 1.90 (95% CI, 1.22, 2.94), respectively. The OR for diabetes was 0.86 (95% CI 0.73, 1.02), and use of sunglasses, contact lens, allergic conjunctivitis, side sleep position and prone sleep position was 0.40 (95% CI, 0.16, 0.99), 1.68 (0.70, 4.00), 2.24 (95% CI, 0.68, 7.36), 3.81 (95% CI, 0.31, 46.23), 12.76 (95% CI, 0.27, 598.58), respectively. Twenty studies were considered to be of high quality, nine to be moderate and one to be low. Environmental risk factors have been identified to play a role in the susceptibility of keratoconus. However, further large-scale longitudinal studies are needed to understand the mechanisms between environmental risk factors and keratoconus.Advanced practice providers comprise an increasing percentage of the health care and primary care workforce. This paper evaluates the weighted contribution of advanced practice providers to the primary care workforce in well-served and underserved counties across North Carolina using age- and sex-adjusted population measures of access.Clinical care makes a modest contribution to well-being, but adequate access to high-quality care is a necessary, if insufficient, condition for health. This issue of the North Carolina Medical Journal focuses on the Healthy North Carolina 2030 clinical indicators, the impact of health disparities, and the COVID-19 pandemic.North Carolina's uninsured rate is higher than the national average. This issue's guest editor, Adam Zolotor, MD, DrPH, sits down with North Carolina Senator Joyce Krawiec to talk about solutions to the state's uninsurance problem, including a General Assembly study committee evaluating Medicaid expansion.Transgender youth face health disparities in suicidality, which have been exacerbated by the COVID-19 pandemic. Health care providers should advocate for upstream interventions to reduce suicide disparities, including Medicaid expansion, family acceptance therapy, improved access to name and gender marker changes, continuation of telehealth, and creation of trauma-informed schools.BACKGROUND Excessive drinking, including binge and heavy drinking, is a leading cause of morbidity and mortality in North Carolina. In 2010, excessive drinking cost North Carolina $7.03 billion, and this analysis aimed to update this figure for 2017.METHODS Following the methods of Sacks, et al. (2015), we obtained proxies for the 2010 and 2017 incidence and price for 26 alcohol-attributable cost components. We then multiplied each component's 2010 cost by the incidence trend (2017 incidence/2010 incidence) and price trend (2017 price/2010 price) to estimate the 2017 cost. Finally, we summed these cost components to calculate the total cost and allocated them by payer and county.RESULTS Excessive drinking cost $9.72 billion in North Carolina in 2017, which equals approximately $2.09 per standard drink. Government paid $4.43 billion (45.6%), drinkers paid $3.76 billion (38.7%), and persons other than the drinker paid $1.53 billion (15.7%).LIMITATIONS These methods relied on alcohol-attributable fractions, which were calculated using scientific literature and national data. If consumption patterns differ between the United States and North Carolina, these fractions may not generalize. Scaling processes may over- or underestimate individual cost components, so total state costs should be interpreted as estimates.CONCLUSIONS The societal costs from excessive drinking are high but spread across public sectors. This can make it difficult to attribute this burden to alcohol. While drinkers paid less than half of the costs of excessive drinking, a broad range of stakeholders bore the burden. Evidence-based strategies to reduce excessive drinking may decrease these costs.Despite documentation spanning decades, health care disparities across North Carolina have remained persistent for populations of color, especially for Black patients. This commentary reviews recent studies that used system-based interventions to reduce disparities and improve outcomes for everyone, and outlines how clinicians, partnering with NC AHEC, can apply results to practice.BACKGROUND Evidence suggests that those who have sustained a traumatic brain injury (TBI) are at increased risk of adverse behaviors and health indicators, such as certain chronic physical and mental health conditions. However, little is known about the prevalence of these behaviors and health indicators among these individuals, information that could help decrease their risk of developing such conditions.METHODS Data (N = 4733) from the 2018 North Carolina Behavioral Risk Factor Surveillance System (BRFSS) were analyzed to determine the prevalence of behaviors and health indicators among individuals who report having a lifetime history of TBI with loss of consciousness (LOC).RESULTS North Carolinians who report a lifetime history of TBI with LOC were at increased risk of reporting a range of 3 negative health behaviors less than always seatbelt use (adjusted odds ratio [AOR] = 1.7; 95% confidence interval [CI] = 1.2-2.4), HIV risk behaviors (AOR = 1.7; 95% CI = 1.1-2.6), and reporting less than 7 hours of slng positive and negative behaviors and health indicators can help identify and tailor evidence-based interventions for those who have a history of TBI.North Carolina is a leader in family medicine, but a growing health care chasm exists between the state's urban centers and rural areas. Training family medicine residents in rural communities can address disparities in health care access and improve rural population health metrics for all subsets of the population, goals that align well with renewed state and national strategies.The following is a review of current policy and proposed legislation related to clinical care indicators in North Carolina. It is not an endorsement of any policy or bill; it is meant to serve as a resource for policy makers, health care stakeholders, and other readers of the NCMJ.North Carolina implemented a rapid statewide COVID-19 vaccine strategy that focused on vaccinating people quickly and equitably. We describe the sociodemographic factors associated with COVID-19 vaccine uptake in North Carolina and how these factors were considered in communication as well as community and health care provider engagement in the COVID-19 response.In North Carolina, rural health care-especially the primary care safety net-is a remarkable but under-resourced vital support system. COVID-19 stressed that already precarious system. While the acute COVID-19 crisis may be receding, we are concerned about the long-term effects of the pandemic on both individuals and the rural primary care safety net.BACKGROUND The average lifetime risk of breast cancer for an American woman is 12.5%, but individual risks vary significantly. Risk modeling is a standard of care for breast cancer screening and prevention with recommended tools to stratify individual risks based on age, family history, breast density, and a host of other known risk factors. Because of a lack of resources rurally, we have not consistently met this standard of care within all of North Carolina.METHODS We implemented a quality improvement project to assess the risk for breast cancer by gathering data on community risks. We implemented an evidence-based tool (Tyrer-Cuzick) for quantifying risk within a mostly rural population of Eastern North Carolina and developed customized services for women meeting elevated-risk definition. These services included additional imaging for elevated-risk women and a risk-reduction program. We also assessed genetic risks for hereditary breast and ovarian cancer in our at-risk population using National Comprehensi score. Using a model of targeted intervention within a population with elevated risks can be helpful in improving outcomes.LIMITATIONS This population within Eastern North Carolina is mostly rural and represents a potentially biased population, as it involves older women undergoing annual mammography. It may not be broadly applicable to the entire population based on age, geography, and other risks.CONCLUSIONS This model for improving cancer risk assessment and testing at a small community hospital in Eastern North Carolina was successful and addressed a community need. selleck chemical We discovered a high rate of increased-risk women who can benefit from individualized risk management, and a higher percentage of women who potentially benefit from genetic testing. These higher cumulative risks may in part explain some of the disparities seen for breast-cancer-specific outcomes in some parts of the state.Virtually all of the Healthy North Carolina 2030 goals rely on access to affordable health care. This commentary provides an overview of how North Carolina's coverage gap impacts the state's health status and how expanding Medicaid could improve the odds of reaching Healthy NC 2030 goals.

Depression is a serious problem in the United States. It not only impacts chronic illness and healthcare utilization, but it can also result in death, intentional or unintentional.Despite the seriousness associated with depression, it continues to be underdiagnosed and undertreated. The primary care setting provides an ideal location to screen and initiate treatment for depression in individuals who would otherwise not be screened.

The objective of this evidence-based practice project was to improve the diagnosis and treatment of depression in an adult primary care office.

An intervention consisting of a HealthWatcher reminder for depression screening, the administration of the PHQ-9 instrument, and a treatment algorithm was incorporated into the office workflow. The charts of a pre-intervention random sample were compared to a post-intervention random sample to test for significant differences in depression screening and treatment rates.

Using the chi-squared test, the post-intervention sample screening rate was significantly higher than pre-intervention sample rate (90% vs 23.3%; χ

= 54.3,

= 1,

< .000).

It is feasible to improve the diagnosis and treatment of depression for adult primary care patients by modifying office protocols and using the PHQ-9 screening instrument and a treatment algorithm.

It is feasible to improve the diagnosis and treatment of depression for adult primary care patients by modifying office protocols and using the PHQ-9 screening instrument and a treatment algorithm.Acute-onset amnesia is a dramatic neurological presentation that can cause considerable concern to both patient and clinician. The patient typically presents with an inability not only to retain new memories but also to access previously acquired memories, suggesting disturbance of hippocampal function. Transient global amnesia (TGA) is the most common cause of acute-onset amnesia, and is characterised by a profound anterograde and retrograde amnesia that typically lasts for up to 24 hours. Although TGA has a strikingly stereotypical presentation, it can be challenging to distinguish from other causes of acute-onset amnesia, including posterior circulation strokes, transient epileptic amnesia, psychogenic amnesia, post-traumatic amnesia, and toxic/drug-related amnesia. Here, we describe the general approach to the patient with acute amnesia; summarise the clinical and neuropsychological differences between the potential causes; and, provide practical recommendations to aid diagnosis and management of acute amnesia.