Undertriage of firearm-related injuries was much more prevalent than expected. Although the likelihood of dying during hospitalization was greater among patients treated in designated trauma centers, these patients were substantially in worse condition across all measures of injury severity. A smaller proportion of patients treated in designated trauma centers died during the first 24 hours of hospitalization. This study highlights the need for better regional coordination, especially with interhospital transfers, as well as the importance of assessing the distribution of emergency medical services resources to make the trauma care system more effective and equitable.

Among the inpatient cases, PC assistance was associated with lower total charges only among the most expensive to treat. However, this outlier group is very important when discussing medical costs. It has been repeatedly shown that the majority of treatment costs are attributable to a small fraction of patients as seen in this study.

Aims/Introduction Caloric excess and physical inactivity fail to fully account for the rise of diabetes prevalence. Individual environmental pollutants can disrupt glucose homeostasis and promote metabolic dysfunction. However, the impact of cumulative exposures on diabetes risk is unknown. Materials and Methods The Environmental Quality Index, a county‐level index composed of five domains, was developed to capture the multifactorial ambient environmental exposures. The Environmental Quality Index was linked to county‐level annual age‐adjusted population‐based estimates of diabetes prevalence rates. Prevalence differences (PD, annual difference per 100,000 persons) and 95% confidence intervals (CI) were estimated using random intercept mixed effects linear regression models. Associations were assessed for overall environmental quality and domain‐specific indices, and all analyses were stratified by four rural‐urban strata. Results Comparing counties in the highest quintile/poorest environmental quality to those in the lowest quintile/best environmental quality, counties with poor environmental quality demonstrated lower total diabetes prevalence rates. Associations varied by rural–urban strata; overall better environmental quality was associated with lower total diabetes prevalence rates in the less urbanized and thinly populated strata. When considering all counties, good sociodemographic environments were associated with lower total diabetes prevalence rates (prevalence difference 2.77, 95% confidence interval 2.71–2.83), suggesting that counties with poor sociodemographic environments have an annual prevalence rate 2.77 per 100,000 persons higher than counties with good sociodemographic environments. Conclusions Increasing attention has focused on environmental exposures as contributors to diabetes pathogenesis, and the present findings suggest that comprehensive approaches to diabetes prevention must include interventions to improve environmental quality.

BackgroundCauses of most birth defects are largely unknown. Genetics, maternal factors (e.g., age, smoking) and environmental exposures have all been linked to some birth defects, including neural tube, oral cleft, limb reduction, and gastroschisis; however, the contribution of cumulative exposures across several environmental domains in association with these defects is not well understood.MethodsThe Environmental Quality Index (EQI) and its domains (air, water, land, sociodemographic, built) were used to estimate county‐level cumulative environmental exposures from 2006–2010 and matched to birth defects identified from Texas Birth Defects Registry and live birth records from births in years 2007–2010 (N = 1,610,709). Poisson regression models estimated prevalence ratios (PR) and 95% confidence intervals (CI) for associations between 10 birth defects and the EQI.ResultsWe observed some positive associations between worst environmental quality and neural tube, anencephaly, spina bifida, oral cleft, cleft palate, cleft lip with and without cleft palate, and gastroschisis [PR range: 1.12–1.55], but near null associations with limb reduction defects. Among domain specific results, we observed the strongest positive associations with the sociodemographic domain across birth defects but varied positive associations among the air and water domains, and negative or null associations with the land and built domains. Overall, few exposure‐response patterns were evident.ConclusionsOur results highlight the complexities of cumulative, simultaneous environmental exposures in the prevalence rates of 10 selected birth defects. We were able to explore the impact of overall and domain specific environmental quality on birth defects and identify potential domain specific drivers of these associations.