LGBTQ+ health education for medical students in the United States: a narrative literature review

INTRODUCTION

People who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, and other sexual/gender minorities (LGBTQ+) may experience discrimination when seeking healthcare. Medical students should be trained in inclusive and affirming care for LGBTQ+ patients. This narrative literature review explores the landscape of interventions and evaluations related to LGBTQ+ health content taught in medical schools in the USA and suggests strategies for further curriculum development.

METHODS

PubMed, ERIC, and Education Research Complete databases were systematically searched for peer-reviewed articles on LGBTQ+ health in medical student education in the USA published between 1 January 2011-6 February 2023. Articles were screened for eligibility and data was abstracted from all eligible articles. Data abstraction included the type of intervention or evaluation, sample population and size, and key outcomes.

RESULTS

One hundred thirty-four articles met inclusion criteria and were reviewed. This includes 6 (4.5%) that evaluate existing curriculum, 77 (57.5%) study the impact of curriculum components and interventions, 36 (26.9%) evaluate student knowledge and learning experiences, and 15 (11.2%) describe the development of broad learning objectives and curriculum. Eight studies identified student knowledge gaps related to gender identity and affirming care and these topics were covered in 34 curriculum interventions.

CONCLUSION

Medical student education is important to address health disparities faced by the LGBTQ+ community, and has been an increasingly studied topic in the USA. A variety of curriculum interventions at single institutions show promise in enhancing student knowledge and training in LGBTQ+ health. Despite this, multiple studies indicate that students report inadequate education on certain topics with limitations in their knowledge and preparedness to care for LGBTQ+ patients, particularly transgender and gender diverse patients. Additional integration of LGBTQ+ curriculum content in areas of perceived deficits could help better prepare future physicians to care for LGBTQ+ patients and populations.

Impact of the COVID-19 pandemic on social media utilization, influences related to parental vaccine decision making, and opinions on trustworthy social media vaccination campaigns: A qualitative analysis

There is a continued need for research to better understand the influence social media has on parental vaccination attitudes and behaviors, especially research capturing the effects of the COVID-19 pandemic. The goal of this study was to explore parents' perspectives related to the impact the pandemic had on 1) social media engagement, 2) vaccine messaging on social media, and 3) factors to guide future intervention development. Between February and March 2022, 6 online, synchronous, text-based focus groups were conducted with parents of adolescents aged 11 to 17 years. Participants who all utilized social media were recruited from across the United States. Qualitative data were analyzed using content analysis. A total of 64 parents participated. Average age was 47 years, and participants were predominantly White (71.9%), female (84.3%), and engaged with social media multiple times per day (51.6%). Participants (95.3%) viewed obtaining all recommended vaccines as important or very important; however, overall vaccination rates for their adolescents were varied (50% ≥1 dose HPV; 59.4% MenACWY; 78.1% Tdap; 65.6% Flu; 81.3% COVID-19). Three themes emerged highlighting the pandemic's impact on parent's (1) general patterns of social media use, (2) engagement about vaccines on social media and off-line behaviors related to vaccination, and (3) perspectives for developing a credible and trustworthy social media intervention about vaccination. Participants reported fatigue from contentious vaccine-related content on social media and desired future messaging to be from recognizable health institutions/associations with links to reputable resources. Plus, providers should continue to provide strong vaccine recommendations in clinic.

Medical student non-modifiable risk factors and USMLE Step 1 exam score

For diversity to exist in the medical graduate workforce, students from all backgrounds should have equitable opportunities of employment. Specialties have utilized a minimal threshold for USMLE Step 1 score when screening applicants for residency interviews. The OHSU SOM class of 2021 completed a 14-question voluntary survey on their Step 1 score and the following non-modifiable risk factors: Adverse Childhood Experience score (ACEs), sex, gender, Underrepresented in Medicine status (URiM), family income during adolescence, highest degree held by a guardian, discrimination experience during medical school, federal/state assistance use, and rural versus urban primary home. Descriptive statistics and unadjusted risk ratios were applied to study the relation between Step 1 score and non-modifiable risk factors as well as certain non-modifiable risk factors and ACEs ≥ 3. The mean Step 1 score was 230 (213, 247). Of the students, 28.2% identified ACEs ≥ 3, 13.6% were considered URiM, and 65.4% were female. URiM were 2.34 (1.30, 4.23),females were 2.77 (1.06-7.29), and those who experienced discrimination in medical school were 4.25 (1.85, 9.77) times more likely to have ACEs ≥ 3. Students who had ACEs ≥ 3 were 3.58 (1.75, 7.29) times less likely to meet a minimal threshold for residency interviews of 220. These are the first results to demonstrate a relationship between Step 1 score and ACEs. Those who identified as URiM, females, and those who experienced discrimination in medical school were at a higher risk of ACEs of ≥ 3. Step 1 transitioned to pass/fail in January 2022. However, the first application cycle that residencies will see pass/fail scoring is 2023-2024, and fellowships will continue to see scored Step 1 until, at the earliest, the 2026-2027 application cycle. These data contribute to a foundation of research that could apply to Step 2CK testing scores, and help to inform decisions about the diversity and equity of the residency interview process.

Community based participatory research as a promising practice for addressing vaccine hesitancy, rebuilding trust and addressing health disparities among racial and ethnic minority communities

The COVID-19 pandemic disproportionately affected racial and ethnic minority communities across the United States (U.S.). Despite the disproportionate burden of COVID-19 faced by communities of color, Black and Hispanic communities are less likely to be fully vaccinated than White non-Hispanic Persons. Health inequity and vaccine hesitancy are complex phenomena that require multilevel responses tailored to the unique needs of each community, a process that inherently necessitates a high level of community engagement in order to develop the most effective health interventions. Building on the principles of community based participatory research (CBPR) and with the support of the National Institutes of Health (NIH), Project 2VIDA! was born. A multidisciplinary collaborative of academic researchers, community members, and clinicians whose aim is to foster sustainable partnerships to reduce the burden of COVID-19 in Hispanic and Black communities across Southern California. Our model was designed to meet our community members where they were - whether on their lunch break or picking their children from school. This CBPR model has been well received by community members. Future health interventions focused on reducing health disparities should prioritize the role of the community, leverage the voices of key community partners, and be grounded in equitable power sharing.

Racial and ethnic disparities in human papillomavirus (HPV) vaccine uptake among United States adults, aged 27-45 years

In 2018, the Food and Drug Administration expanded the age of eligibility for the human papillomavirus (HPV) vaccine to 27 to 45 years. However, it is unclear if there are racial/ethnic disparities in HPV vaccine uptake for this age-group following this expanded recommendation. We aimed to identify any disparities in HPV vaccine in 27 to 45 year-olds based on sociodemographic factors. We analyzed nationally representative, cross-sectional data from the 2019 National Health Interview Survey (n = 9440). Logistic regression models estimated the odds of vaccine uptake (receipt of ≥1 vaccine dose) based on sociodemographic factors. Participants were mostly Non-Hispanic Whites (60.7%) and females (50.9%). In adjusted models, females had over three times greater odds of vaccine uptake compared to males (aOR = 3.58; 95% CI 3.03, 4.23). Also, compared to Non-Hispanic Whites, Non-Hispanic Blacks were 36% more likely (aOR = 1.36; 95% CI 1.09, 1.70), and Hispanics were 27% less likely (aOR = 0.73; 95% CI 0.58, 0.92) to receive the vaccine. Additionally, individuals without a usual place of care had lower odds of vaccine uptake (aOR = 0.72; 95% CI 0.57, 0.93), as were those with lower educational levels (aORhigh school = 0.62; 95% CI 0.50, 0.78; aORsome college = 0.83; 95% CI 0.70, 0.98). There are disparities in HPV vaccine uptake among 27 to 45 year-olds, and adult Hispanics have lower odds of receiving the vaccine. Given the vaccine's importance in cancer prevention, it is critical that these disparities are addressed and mitigated.

Exploration of the integration of microbiology and immunology emerging topics into undergraduate medical education

PURPOSE

Medical school educators face challenges determining which new and emerging topics to incorporate into medical school curricula, and how to do so. A study was conducted to gain a better understanding of the integration of emerging topics related to microbiology and immunology in the undergraduate medical curriculum (UME).

METHODS

An anonymous survey with 17 questions was emailed to medical school faculty who teach immunology and/or microbiology through the DR-Ed listserv, the American Society for Microbiology (ASM) Connect listserv, and attendees of the Association of Medical School Microbiology and Immunology Chairs (AMSMIC) Educational Strategies Workshop. Participants were asked about experiences, perceptions, and the decision-making process regarding integrating emerging topics into UME.

RESULTS

The top emerging topics that were added to the curriculum or considered for addition in the last 10 years included COVID-19, Zika virus, mRNA vaccines, and Mpox (formerly known as monkeypox). Most respondents reported lectures and active learning as the major methods for topic delivery, with most faculty indicating that formative assessment was the best way to assess emerging topics. Content experts and course directors were the most cited individuals making these decisions. Top reasons for incorporating emerging topics into curricula included preparing students for clinical treatment of cases, followed by demonstrating the importance of basic science, and opportunities to integrate basic science into other disciplines. Challenges for incorporating these topics included making room in an already crowded curriculum, followed by content overload for students.

CONCLUSIONS

This study describes the rationale for integrating emerging topics related to microbiology and immunology into UME, and identifies the current new and emerging topics, as well as the main methods of integration and assessment. These results may be used by medical educators to inform curricular decisions at their institutions. Future studies will include developing innovative learning modules that overcome barriers to integration.

Exploring the GMO narrative through labeling: strategies, products, and politics

Labels are influential signals in the marketplace intended to inform and to eliminate buyer confusion. Despite this, food labels continue to be the subject of debate. None more so than non-GMO (genetically modified organisms) labels. This manuscript provides a timeline of the evolution of GMO labels beginning with the early history of the anti-GMO movement to the current National Bioengineered Food Disclosure Standard in the United States. Using media and market intelligence data collected through Buzzsumo™ and Mintel™, public discourse of GMOs is analyzed in relation to sociopolitical events and the number of new food products with anti-GMO labels, respectively. Policy document and publication data is collected with Overton™ to illustrate the policy landscape for the GMO topic and how it has changed over time. Analysis of the collective data illustrates that while social media and policy engagement around the topic of GMOs has diminished over time, the number of new products with a GMO-free designation continues to grow. While discourse peaked at one point, and has since declined, our results suggest that the legacy of an anti-GMO narrative remains firmly embedded in the social psyche, evidenced by the continuing rise of products with GMO-free designation. Campaigns for GMO food labels to satisfy consumers' right to know were successful and the perceived need for this information now appears to be self-sustaining.

Real-world effectiveness of recombinant zoster vaccine in self-identified Chinese individuals aged ≥50 years in the United States

We evaluated the vaccine effectiveness (VE) of two doses of recombinant zoster vaccine (RZV) against herpes zoster (HZ) and postherpetic neuralgia (PHN) in Chinese adults at Kaiser Permanente Southern California (KPSC). Chinese KPSC members were identified based on self-reported ethnicity or self-reported preferred spoken/written language. Those aged ≥50 years who received two doses of RZV 4 weeks to ≤ 6 months apart were matched 1:4 to RZV unvaccinated Chinese members and followed through June 2022; second doses were accrued 6/1/2018-12/31/2020. We estimated incidence and adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) comparing outcomes (HZ and PHN). Adjusted VE (%) was calculated as (1-aHR)×100. 3978 RZV vaccinated Chinese members were matched to 15,912 RZV unvaccinated Chinese members. The incidence per 1000 person-years (95% CI) of HZ in the vaccinated group was 1.5 (0.9-2.5) and 10.9 (9.8-12.1) in the unvaccinated group; aHR (95% CI) was 0.12 (0.07-0.21). Adjusted VE (95% CI) was 87.6% (78.9-92.7) against HZ. We identified 0 PHN cases in the vaccinated group and 19 in the unvaccinated group. Among Chinese adults aged ≥50 years, two doses of RZV provided substantial protection against HZ and PHN supporting the real-world effectiveness of the vaccine in this population.

Perceptions of dengue risk and acceptability of a dengue vaccine in residents of Puerto Rico

Dengvaxia is the first dengue vaccine recommended in the United States (U.S.). It is recommended for children aged 9-16 y with laboratory-confirmed previous dengue infection and living in areas where dengue is endemic. We conducted focus groups with parents and in-depth interviews with key informants (i.e. practicing pediatricians, physicians from immunization clinics, university researchers, and school officials) in Puerto Rico (P.R.) to examine acceptability, barriers, and motivators to vaccinate with Dengvaxia. We also carried out informal meetings and semi-structured interviews to evaluate key messages and educational materials with pediatricians and parents. Barriers to vaccination included lack of information, distrust toward new vaccines, vaccine side effects and risks, and high cost of/lack of insurance coverage for laboratory tests and vaccines. Motivators included clear information about the vaccine, a desire to prevent future dengue infections, the experience of a previous dengue infection or awareness of dengue fatality, vaccine and laboratory tests covered by health insurance, availability of rapid test results and vaccine appointments. School officials and parents agreed parents would pay a deductible of $5-20 for Dengvaxia. For vaccine information dissemination, parents preferred an educational campaign through traditional media and social media, and one-on-one counseling of parents by healthcare providers. Education about this vaccine to healthcare providers will help them answer parents' questions. Dengvaxia acceptability in P.R. will increase by addressing motivators and barriers to vaccination and by disseminating vaccine information in plain language through spokespersons from health institutions in P.R.

Performance evaluation on vaccination rates monitoring report system of Shenzhen, China

To evaluate the performance of "Vaccination Rates Monitoring Report System" implemented by Shenzhen CDC, we conducted an analysis of the data quality and identify key areas for system improvement. Following evaluation guidelines provided by WHO and United States CDC, we established six evaluation attributes: representativeness, simplicity, acceptability, data reliability, stability and timeliness. In eastern, central and western regions of Shenzhen, we selected one district from each region, of which the local CDC and ten CHSCs under jurisdiction were chosen for evaluation. On-site inspections, questionnaires survey and interviews were utilized for data collection, while the Likert scale method was used for attributes rating evaluation. A total of 70 participants were surveyed, consisting of 60 CHSCs and 10 CDCs staff. The gender ratio was 1:2.5 (males to females), with the majority falling within the 25-34 age range (46%). Most participants held full-time positions (80%) and had more than 5 years of work experience (62%). The system achieved 100% coverage of all CHSCs and CDCs (100%). The cumulative percentage scores for the overall favorable options of simplicity, acceptability, data reliability, stability, and timeliness were 79%, 85%, 73%, 50%, and 71% respectively. The system operates normally with strong representativeness. Acceptability was rated as "good." Simplicity, data reliability, and system timeliness were rated as "average," while system stability was rated as "poor." Based on these survey results, developers should urgently investigate reasons for poor stability, particularly addressing concerns from CHSCs users. Additionally, the issues and shortcomings identified in other attributes should also be gradually improved.

Understanding healthcare providers' preferred attributes of pediatric pneumococcal conjugate vaccines in the United States

As higher-valent pneumococcal conjugate vaccines (PCVs) become available for pediatric populations in the US, it is important to understand healthcare provider (HCP) preferences for and acceptability of PCVs. US HCPs (pediatricians, family medicine physicians and advanced practitioners) completed an online, cross-sectional survey between March and April 2023. HCPs were eligible if they recommended or prescribed vaccines to children age <24 months, spent ≥25% of their time in direct patient care, and had ≥2 y of experience in their profession. The survey included a discrete choice experiment (DCE) in which HCPs selected preferred options from different hypothetical vaccine profiles with systematic variation in the levels of five attributes. Relative attribute importance was quantified. Among 548 HCP respondents, the median age was 43.2 y, and the majority were male (57.9%) and practiced in urban areas (69.7%). DCE results showed that attributes with the greatest impact on HCP decision-making were 1) immune response for the shared serotypes covered by PCV13 (31.4%), 2) percent of invasive pneumococcal disease (IPD) covered by vaccine serotypes (21.3%), 3) acute otitis media (AOM) label indication (20.3%), 4) effectiveness against serotype 3 (17.6%), and 5) number of serotypes in the vaccine (9.5%). Among US HCPs, the most important attribute of PCVs was comparability of immune response for PCV13 shared serotypes, while the number of serotypes was least important. Findings suggest new PCVs eliciting high immune responses for serotypes that contribute substantially to IPD burden and maintaining immunogenicity against serotypes in existing PCVs are preferred by HCPs.

Outpatient management of essential hypertension: a review based on the latest clinical guidelines

Background: Essential hypertension, a prevalent cardiovascular condition, poses a significant health burden worldwide. Based on the latest American clinical guidelines, half of adults in the United States have hypertension. Of these, only about a half are treated and about a quarter are adequately controlled for hypertension. Given its impact on morbidity and mortality, ensuring effective management of high blood pressure is crucial to reduce associated risks and improve patient outcomes.Objective: This review aims to provide a comprehensive and up-to-date summary of the latest cardiology guidelines and evidence-based research on essential hypertension, with a focus on guiding outpatient clinical practice.Methods: The review evaluates both non-pharmacological approaches and pharmacological interventions to offer clinicians practical insights. Notably, it emphasizes the importance of individualized treatment plans tailored to patients' specific risk profiles and comorbidities.Results: By consolidating the latest advancements in hypertension management, this review provides clinicians with an up-to-date reference, offering a nuanced understanding of treatment goals and strategies.Conclusion: Through the incorporation of evidence-based recommendations, healthcare practitioners can optimize patient care, mitigate potential complications, and improve overall outcomes in essential hypertension.

Student views on the culture of STEM research laboratories: Results from an interview study

In this article, we present the results of 30 ethnographic interviews in which we asked STEM graduate and undergraduate students at a Midwest university in the United States about topics related to the culture of their research group, how group members communicate and interact, and their experience with ethical issues that arise within the laboratory. Here we focus on the culture of research laboratories and describe the key categories that emerged through analysis, including communication, community structure, governance, and collaboration that influence and shape lab culture. We also consider the critical role of the principal investigator (PI) to influence conditions in the lab that facilitate or inhibit lab culture and the subsequent effects on student feelings and behaviors, interpersonal communication, collaboration, work output, and ethics. Our findings suggest that the quality of research and the wellbeing of the lab members depend not only on purely scientific factors and routine research practices but are also dependent on the culture of the lab as it manifests in interpersonal relationships. The interviews reveal the critical role students ascribe to the PI in shaping the lab culture. Based on this study, we suggest how ethical lab cultures might be encouraged.

Programs supporting incarcerated and previously incarcerated indigenous peoples: a scoping review protocol

The overincarceration of Indigenous peoples and its impacts on individual and community health is a growing concern across Canada and the United States. Federally run Healing Lodges in Canada are an example of support services for incarcerated and previously incarcerated Indigenous peoples to reintegrate into community and support their healing journey. However, there is a need to synthesise research which investigates these programmes. We report a protocol for a scoping review that is guided by the following research question: What is known about culturally informed programmes and services available to incarcerated and previously incarcerated Indigenous peoples in Canada and the US? This scoping review will follow guidelines published by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. This review will only identify programmes that are guided by Indigenous ways of being and knowing in order to best serve Indigenous communities and our community partners. The results of this review will support the development of programmes that are necessary for understanding and addressing the diverse needs of incarcerated and previously incarcerated Indigenous peoples.

Effects of Social Determinants and Pharmacogenetic Medication Interactions on 90-Day Hospital Readmissions

Context: The present study builds on our prior work that demonstrated an association between pharmacogenetic interactions and 90-day readmission. Objective: Evaluate aggregate contribution of social determinants, comorbidity, and gene-x-drug interactions to moderate 90-day hospital readmission. Study Design and Analysis: Non-concurrent cohort study; Multivariable logistic regression Setting: Hospital/integrated healthcare delivery system in northern Illinois Population Studied: 19,999 adults tracked from 2010 through 2020 who underwent testing with a 13-gene pharmacogenetic panel Outcome Measure: 90-day hospital readmission (primary outcome) Results: Univariate logistic regression analyses demonstrated that strongest associations with 90 day hospital readmissions were the number of medications prescribed within 30 days of a first hospital admission that had Clinical Pharmacogenomics Implementation Consortium (CPIC) guidance (CPIC medications) (5+ CPIC medications, odds ratio (OR) = 7.66, 95% confidence interval 5.45-10.77) (p < 0.0001), major comorbidities (5+ comorbidities, OR 3.36, 2.61-4.32) (p < 0.0001), age (65 + years, OR = 2.35, 1.77-3.12) (p < 0.0001), unemployment (OR = 2.19, 1.88-2.64) (p < 0.0001), Black/African-American race (OR 2.12, 1.47-3.07) (p < 0.0001), median household income (OR = 1.63, 1.03-2.58) (p = 0.035), male gender (OR = 1.47, 1.21-1.80) (p = 0.0001), and one or more gene-x-drug interaction (defined as a prescribed CPIC medication for a patient with a corresponding actionable pharmacogenetic variant) (OR = 1.41, 1.18-1.70). Health insurance was not associated with risk of 90-day readmission. Race, income, employment status, and gene-x-drug interactions were robust in a multivariable logistic regression model. The odds of 90-day readmission for patients with one or more identified gene-x-drug interactions after adjustment for these covariates was attenuated by 10% (OR = 1.31, 1.08-1.59) (p = 0.006). Although the interaction between race and gene-x-drug interactions was not statistically significant, White patients were more likely to have a gene-x-drug interaction (35.2%) than Black/African-American patients (25.9%) who were not readmitted (p < 0.0001). Conclusions: These results highlight the major contribution of social determinants and medical complexity to risk for hospital readmission, and that these determinants may modify the effect of gene-x-drug interactions on rehospitalization risk.

Factors affecting Family Physician follow-up 30 days post-discharge from a Canadian Academic Emergency Department

Close outpatient follow-up of patients discharged from the emergency department (ED) has been associated with improved antimicrobial stewardship, medication compliance, and decreased mortality. Despite these clear benefits, studies have shown most patients do not receive follow-up from specialists or Family Physicians (FP). While age, race and insurance status may be factors in Australia and the United States, there remains a paucity of Canadian studies investigating potential factors that influence follow-up. This retrospective cohort study aimed to elucidate factors associated with Family Physician follow up within 30 days at two urban, academic Family Medicine clinics. Our study included patients aged 18 or older who have an academic Family Physician and visited a London Health Sciences Centre ED between January 1, 2021 and June 1, 2021. A binary logistic regression was used to determine if a specific patient or provider factor was associated with follow-up. Of the 367 cases that met criteria, 220 (60%) patients received Family Physician follow-up within 30 days. Additionally, 51 patients (23%) received specialist follow-up within 30 days. A higher number of medications (OR 1.12 p=0.003) and a Family Physician appointment within the 90 days preceding the ED visit (OR 2.51, p<0.001) were significantly predictive of Family Physician follow-up. The use of a Family Physician referral form, documented discharge instructions, and increasing comorbidity (as documented by the Charlson Comorbidity Index) were not associated with a higher odds of follow-up. These data suggest that patients on numerous medications may require close follow-up for monitoring, dose adjustments, and reassessment. Additionally, those patients with recent Family Physician visits may have stronger relationships with their provider, increasing their likelihood of follow-up. Based on this study, there is insufficient evidence to suggest that documented discharge instructions nor the use of a FP referral form impact the rate of follow-up. Future work should focus on an optimal mechanism to ensure Family Physician follow-up, when required, in urban centres. The impact of mental health and substance use disorders on the rate of follow-up should also be evaluated.

Neurofibroma: Case Series with Clinical Features and Recommendations

Neurofibroma is an autosomal benign disorder. It can be localized, diffuse or invasive like plexiform neurofibroma that involves the nerves, muscle, tissues, skeleton. It represents itself as a destructive variant of neurofibroma, mostly present as orbital or periorbital neurofibroma or may be associated with autosomal dominant disease. Clinical diagnosis of neurofibromatosis (NF) according to National Institutes of Health (NIH) criteria should have more than two of the seven features including lisch nodules, cafe'- au-lait spots, plexiform neurofibroma, optic glioma, freckling, first degree relative with NF or dysplasia of cortical bones. However, proper early diagnosis is still crucial due to its various presentation such as cheek mass, painless swelling on skin, chalazion, intratracheal tumor, genital swelling or ptosis. It is reported that neurofibroma often represents as ocular or facial swelling. Here we are presenting features of neurofibroma of eight cases of patients from Civil Hospital, Karachi. These cases had main complain of overhanging skin mass mainly on orbital or periorbital region that damage the area and with poor daily activities. Multiple nodules on face and body along with them Cafe'-au-lait spots and lisch nodules were main signs. While, other signs i.e. ptosis, pterygium, telecanthus and muddy discoloration of conjunctiva need further evaluation for correlation with neurofibromatosis. Debulking surgery was planned for most of the cases but the huge disfigurement caused by overhanging skin mass and nodules made it a challenge for plastic surgeons to provide good outcomes with minimum damage. Keywords: neurofibroma; lisch nodules; ptosis; Cafe'-au-lait spot; periorbital; overhanging skin.

A Bibliometric Analysis of the Research on Social Attitudes Towards LGBT Community (2002-2022)

A bibliometric analysis was conducted to map out trends in publications on attitudes toward the LGBT community based on the 470 documents retrieved from the SCOPUS database for 2002-2022. The results revealed that the United States is the leading country contributing to the publications on attitudes toward the LGBT community and has a strong impact in the field (64.68%). The authorship analysis revealed that Flores, Woodford, and Worthen from the United States are the leading researchers in this field. Analysis of publication sources showed that the Journal of Homosexuality is the top publisher of findings on the LGBT community whereas the Journal of Interpersonal Violence and Sexuality and Culture have gained more traction among researchers in recent years. The analysis of the co-occurrence of author's keywords indicated that transgender is the gender group that is the most researched compared to other sexual identities. Negative attitudes such as homophobia, discrimination and being heterosexist toward one's sexuality or same-sex marriage are the current research foci. Religion and culture are seen as important predictors of attitudes about homosexuality and same-sex marriage policy. The study addresses the gaps in the literature by recommending future researchers to investigate attitudes toward other gender identities as a result of the revolution in sexual identities.

Greater upper limb muscle mass associated with reduced cardiovascular mortality compared with other muscle groups in diabetics

OBJECTIVES

Although muscle mass and its distribution have been shown to affect prognosis, the association between regional muscle mass and cardiovascular mortality risk in diabetic patients remains unclear.

METHODS

This prospective cohort study analyzed data from 2166 individuals with diabetes who participated in the National Health and Nutrition Survey conducted in the United States between 2003 to 2006 and 2011 to 2018, linked to the National Death Index. Weighted Kaplan-Meier analysis and multivariable Cox proportional hazards models were used to explore the association between different regional lean mass and cardiovascular mortality.

RESULTS

The weighted Kaplan-Meier analysis revealed statistically significant differences in survival probabilities across lean upper limbs, lean lower limbs, lean gynoid, and lean trunk mass levels in diabetic participants (P < 0.05). In the multivariate adjusted Cox proportional hazards models, higher levels of upper limb lean mass were found to be associated with decreased cardiovascular mortality (hazard ratio, 0.589; 95% confidence interval, 0.332-0.976; P = 0.041). Notably, this correlation was more significant in men (hazard ratio, 0.378; 95% confidence interval, 0.171-0.834; P = 0.016), which was indicated by the results of the Cox regression and nonlinear regression analysis.

CONCLUSIONS

Higher upper limb lean mass is associated with lower cardiovascular mortality compared with other regional lean mass in patients with diabetes, especially for men. Further research is needed to elucidate the mechanisms involved in muscle metabolic differentiation.

Communicating medical device recalls: A rapid review of the literature

OBJECTIVES

The U.S. Food and Drug Administration (FDA) currently regulates more than 190,000 different medical devices. Like all products, these devices may be subject to manufacturing problems, flawed designs, or new and unexpected risks, which in some cases require devices to be recalled. In 2021, the FDA's Patient Engagement Advisory Committee (PEAC) recommended that the FDA consider changes to the communication approach used for medical device recalls to make them more patient-focused, timely, and action-oriented.

METHODS

To support this recommendation, we conducted a rapid review of literature published from 2008-2022 to capture and examine information on risk communication approaches, methods, and best practices for recall-related communications about medical products.

RESULTS

We identified 23 articles to include in our review.

CONCLUSION

Our review found a lack of research-based studies as well as gaps in understanding about consumer perspectives, comprehension, and communication preferences related to recalls. Despite these limitations, we identified current communication approaches, numerous challenges, and recommendations for communicating medical products recall information to consumers.

PRACTICE IMPLICATIONS

Further research is needed to assess consumer attitudes, understanding, and preferences and to reach consensus on best practices for effectively communicating recall information to consumers of medical products.

Access to, Experience with, and Attitudes towards Take Home Naloxone: An Online Survey

The opioid public health crisis continues to burden individuals, communities, and economies. Public health opinion has emphasized the need for increased access to harm reduction services, but there is a dearth of information on the views and experiences of people who use opioids. Our study aimed to investigate the prevalence of naloxone use, attitudes, and experiences with naloxone among an online community of people who use drugs. We performed a cross-sectional survey looking at experiences with and attitudes towards take-home naloxone. Data is presented descriptively, with analysis of the differences between people who do and do not use opioids using the χ2 and Fisher's exact tests. There were 1,143 respondents, of whom 70% were from the United States. Only 38% of participants who use opioids had received naloxone training, but 56% of these individuals said that they felt comfortable using a naloxone kit. Nearly all respondents (95%) said they would be willing to use naloxone on someone who had overdosed and approximately 90% would want naloxone used on them in case of an overdose. Regarding harm reduction, 24% of respondents said they had access to safe use programs, and 33% said they had access to clean needle exchange programs. A majority of the participants who use opioids were in favor of having naloxone with them when using drugs and believed naloxone should be freely available. This study demonstrates the receptiveness of take-home naloxone and highlights the need for better implementation of naloxone within communities that use opioids.

Survey of anesthesia department chairs about the environmental sustainability initiatives of their programs

BACKGROUND

Anesthesia departments can reduce their environmental impact. Barriers exist to the promotion of individual anesthesiologists' roles in environmentally sustainable practices. We hypothesized that accountability of departmental leadership is associated with reports of practices that can encourage and sustain environmentally favorable practices.

METHODS

Invitations to complete a six-question survey were sent to academic anesthesia department chairs in the United States and Canada. Questions were presented in random sequence. We assessed the association between the sum of the answers to five questions about department- and hospital-related sustainability activities (e.g., more than one "educational session dedicated to environmental sustainability … for anesthesiology residents or other trainees?") and the sixth question ("In the past 12 months, did review of the anesthesia department chair or review of your department include" more than one "item related to promotion of environmental sustainability?").

RESULTS

Of the 138 departments receiving invitation and reminder emails, 63 departments (46%) responded to our requests. The median (interquartile range) was 1 (0,3) sustainability activity for "No" items evaluating the department chair or department (N = 43) versus 4 (2, 4.5) activities for "Yes" evaluation of department chair or department (N = 20) (Wilcoxon-Mann-Whitney test, P = 0.0021; median regression, P = 0.0002). Results were similar for sensitivity analyses (excluding one question about hospital leadership, excluding the four responding Canadian departments, controlling for time to complete the survey, and controlling for the date of completion of the survey).

CONCLUSIONS

Anesthesia department chairs and departments with annual performance evaluations that included items related to environmental sustainability reported more activities to promote sustainability. The result suggests that leadership-sponsored initiatives directed toward environmental sustainability are associated with environmental sustainability activities in anesthesia departments.

Racial and ethnic disparities in regional anesthesia in the United States: A narrative review

BACKGROUND

Racial and ethnic disparities exist in the delivery of regional anesthesia in the United States. Anesthesiologists have ethical and economic obligations to address existing disparities in regional anesthesia care.

OBJECTIVES

Current evidence of racial and ethnic disparities in regional anesthesia utilization in adult patients in the United States is presented. Potential contributors and solutions to racial disparities are also discussed.

EVIDENCE REVIEW

Literature search was performed for studies examining racial and ethnic disparities in utilization of regional anesthesia, including neuraxial anesthesia and/or peripheral nerve blocks.

FINDINGS

While minoritized patients are generally less likely to receive regional anesthesia than white patients, the pattern of disparities for different racial/ethnic groups and for types of regional anesthetics can be complex and varied. Contributors to racial/ethnic disparities in regional anesthesia span hospital, provider, and patient-level factors. Potential solutions include standardization of regional anesthetic practices via Enhanced Recovery After Surgery (ERAS) pathways, increasing patient education, health literacy, language translation services, and improving diversity and cultural competency in the anesthesiology workforce.

CONCLUSION

Racial and ethnic disparities in regional anesthesia exist. Contributors and solutions to these disparities are multifaceted. Much work remains within the subspecialty of regional anesthesia to identify and address such disparities.

Meta Data Analysis of Sex Distribution of Study Samples Reported in Summer Biomechanics, Bioengineering, and Biotransport Annual Conference Abstracts

The biased use of male subjects in biomedical research has created limitations, underscoring the importance of including women to enhance the outcomes of evidence-based medicine and to promote human health. While federal policies (e.g., the 1993 Revitalization Act and the 2016 Sex as a Biological Variable Act) have aimed to improve sex balance in studies funded by the National Institutes of Health (NIH), data on sex inclusivity in non-NIH funded research remain limited. The objective of this study was to analyze the trend of sex inclusion in abstracts submitted to the Summer Biomechanics, Bioengineering, & Biotransport Conference (SB3C) over 7 years. We scored every abstract accepted to SB3C, and the findings revealed that approximately 20% of total abstracts included sex-related information, and this trend remained stable. Surprisingly, there was no significant increase in abstracts, including both sexes and those with balanced female and male samples. The proportion of abstracts with balanced sexes was notably lower than those including both sexes. Additionally, we examined whether the exclusion of one sex from the corresponding studies was justified by the research questions. Female-only studies had a 50% justification rate, while male-only studies had only 2% justification. Disparity in sex inclusion in SB3C abstracts was apparent, prompting us to encourage scientists to be more mindful of the sex of the research samples. Addressing sex inclusivity in biomechanics and mechanobiology research is essential for advancing medical knowledge and for promoting better healthcare outcomes for everyone.

Tribal Perspectives on Patient Navigation for Rural Native Veterans Using Veteran Health Administration Services

American Indian and Alaska Native (Native) Veterans enrolled in the U.S. Department of Veterans Affairs (VA) benefits program are far less likely to access health care compared to other racial/ethnic groups, in part driven by challenges posed by often distant, complex, and culturally unresponsive health care that does not easily interface with the Indian Health Service (IHS) and local Tribal Health Care. To address this disparity, in 2020 the Veteran's Health Administration's (VHA) Office of Rural Health (ORH) initiated the development of a patient navigation program designed specifically for rural Native Veterans. There are no navigation programs for rural Native Veterans to guide development of such a program. Hence, the project team sought perspectives from rural Native Veterans, their families, and community advocates, (n = 34), via video and phone interviews about the role and functions of a Veteran patient navigator and personal characteristics best be suited for such a position. Participants believed a navigator program would be useful in assisting rural Native Veterans to access VHA care. They emphasized the importance of empathy, support, knowledge of local culture, and of Veteran experience within tribal communities, adeptness with VHA systems, and personnel consistency. These insights are critical to create a program capable of increasing rural Native Veteran access to VHA services.

Range and climate niche shifts in European and North American breeding birds

Species respond dynamically to climate change and exhibit time lags. Consequently, species may not occupy their full climatic niche during range shifting. Here, we assessed climate niche tracking during recent range shifts of European and United States (US) birds. Using data from two European bird atlases and from the North American Breeding Bird Survey between the 1980s and 2010s, we analysed range overlap and climate niche overlap based on kernel density estimation. Phylogenetic multiple regression was used to assess the effect of species morphological, ecological and biogeographic traits on range and niche metrics. European birds shifted their ranges north and north-eastwards, US birds westwards. Range unfilling was lower than expected by null models, and niche expansion was more common than niche unfilling. Also, climate niche tracking was generally lower in US birds and poorly explained by species traits. Overall, our results suggest that dispersal limitations were minor in range shifting birds in Europe and the USA while delayed extinctions from unfavourable areas seem more important. Regional differences could be related to differences in land use history and monitoring schemes. Comparative analyses of range and niche shifts provide a useful screening approach for identifying the importance of transient dynamics and time-lagged responses to climate change. This article is part of the theme issue 'Ecological novelty and planetary stewardship: biodiversity dynamics in a transforming biosphere'.

Exploring Teen Suicide Rates through the Lens of Macro Risk Factors

As the second leading cause of death in teenagers, suicide has been a consistent public health issue for the past decade. Our goal is to understand the relationship between increasing teen suicide rates by state policies. We explore links between macro-level risk factors and state suicide rates. Risk factors explored include state behavioral health spending, child access policies for firearms, insurance coverage, tax revenue from tobacco and alcohol, school spending per pupil, pupil support services funding, and teacher spending. This research shows a relationship between pupil support spending, any child access law, required legislation, and lower teen suicide rates. The results from this study can aid in the understanding of macro-level influences on teen suicide; empowering advocates, lawmakers, and researchers to develop informed interventions and policies. Increasing multi-level understanding around suicide can provide an opportunity to slow or stop suicide rates.

Disparities in Teleneurology Use in Medicaid Beneficiaries With Epilepsy by Practice Setting: Promoting Health Equity in Academic Centers

BACKGROUND AND OBJECTIVES

Medicaid beneficiaries in many American academic medical centers can receive care in a separate facility than those not covered by Medicaid. We aimed to identify possible disparities in care by evaluating the association between facility type (integrated faculty practice or Medicaid-only outpatient clinic) and telehealth utilization in people with epilepsy.

METHODS

We performed retrospective analyses using structured data from the Mount Sinai Health System electronic medical record data from January 2003 to August 2021. We identified people of all ages with epilepsy who were followed by an epileptologist after January 3, 2018, using a validated ICD-9-CM/10-CM coded case definition. We evaluated associations between practice setting and telehealth utilization, an outcome measure that captures the evolving delivery of neurologic care in a post-coronavirus disease 2019 era, using multivariable logistic regression.

RESULTS

We identified 4,586 people with epilepsy seen by an epileptologist, including Medicaid beneficiaries in the Medicaid outpatient clinic (N = 387), Medicaid beneficiaries in the faculty practice after integration (N = 723), and non-Medicaid beneficiaries (N = 3,476). Patients not insured by Medicaid were significantly older (average age 40 years vs 29 in persons seen in Medicaid-only outpatient clinic and 28.5 in persons insured with Medicaid seen in faculty practice [p < 0.0001]). Medicaid beneficiaries were more likely to have drug-resistant epilepsy (DRE), with 51.94% of people seen in Medicaid-only outpatient clinic, 41.63% of Medicaid beneficiaries seen in faculty practice, and 37.2% of non-Medicaid beneficiaries having DRE (p < 0.0001). Medicaid outpatient clinic patients were less likely to have telehealth visits (phone or video); 81.65% of patients in the Medicaid outpatient clinic having no telehealth visits vs 71.78% of Medicaid beneficiaries in the faculty practice and 70.89% of non-Medicaid beneficiaries (p < 0.0001). In an adjusted logistic regression analysis, Medicaid beneficiaries had lower odds (0.61; 95% CI 0.46-0.81) of using teleneurology compared with all patients seen in faculty practice (p = 0.0005).

DISCUSSION

Compared with the Medicaid-only outpatient clinic, we found higher telehealth utilization in the integrated faculty practice with no difference by insurance status (Medicaid vs other). Integrated care may be associated with better health care delivery in people with epilepsy; thus, future research should examine its impact on other epilepsy-related outcomes.

Proportion of Community-Dwelling Individuals Older Than 70 Years Eligible for Lecanemab Initiation: The Gothenburg H70 Birth Cohort Study

OBJECTIVES

To determine the prevalence of individuals with Alzheimer disease (AD) eligible for treatment with the recently FDA-approved lecanemab based on data from a population-based sample of 70-year-olds and extrapolate an estimation of individuals eligible in Europe and the United States.

METHODS

Participants from the Gothenburg H70 Birth Cohort Study with clinical data, CSF-amyloid beta 42, and brain MRI analysis were evaluated for eligibility to receive lecanemab treatment according to FDA-approved recommendations, noting factors requiring special consideration. Results were used to extrapolate the number of eligible individuals in Europe and the United States using public demographic data.

RESULTS

Thirty (10.3%) of 290 participants met the indication for treatment of whom 18 (6.2%) were eligible and did not present factors requiring special consideration. Our estimate that 6.2% of all 70-year-olds in the full cohort are eligible for treatment extrapolates to an approximation that around 5.9 million Europeans and 2.2 million US residents could be eligible.

DISCUSSION

Information on proportion of individuals eligible for AD treatment with lecanemab in the general public is limited. We provide information on 70-year-olds in Sweden and extrapolate these data to Europe and the United States. This study opens for larger studies on this proportion and implementation of lecanemab treatment.

Challenges in Arranging to Waive Parental Consent in HIV Prevention Studies of Adolescent Men Who have Sex with Men: The Case of HPTN 078

Including adolescent men who have sex with men (AMSM) in HIV prevention and treatment studies without parental permission is vital, but has often faced barriers. We examine the case of recent Institutional Review Boards (IRB) reviews of an HIV treatment and prevention study that requested waiving parental permission at four United States sites, but received different responses from each institution. IRBs varied in whether and how they weighed parental rights against AMSMs' rights and individual and social benefits, and potential harms (e.g., if a parent disapproves of the adolescents' sexual behavior). One IRB "tabled" the decision to receive advice from the university Office of General Counsel (OGC), despite state laws allowing minors to consent to HIV testing and treatment without parental permission. Another IRB consulted the university's Chief Compliance Officer (CCO), which thought the waiver was inconsistent with state law, which discusses "venereal disease," but not HIV. University attorneys may have competing priorities, however, and thus interpret relevant laws differently. This case raises critical concerns, highlighting needs for advocates for AMSM, researchers, IRBs and others at institutional, governmental, and community levels to educate policymakers, public health departments, IRB chairs, members, and staff, OGCs and CCOs about these issues.

"God Loves All Equally and Infinitely": A Mixed Methods Analysis of LGBTQ+ Ally Development Within Religious/Spiritual Contexts

Within the United States, conservative theological perspectives have exerted influential sociocultural influences toward LGBTQ+ communities, with profound implications toward ally development. Ally development can present its challenges, especially for those in non-affirming religious and/or spiritual (R/S) contexts. We employed a mixed methods approach, utilizing both Enhanced Critical Incident Technique and chi-square tests of independence, focusing on the self-identified incidents that influenced the internal negotiation process of 315 LGBTQ+ allies within R/S contexts. Participants described critical R/S incidents that impacted their ally development, and these incidents fell into four main categories: (1) the influence of religious organizations, leaderships, and congregants, (2) the impact of meaningful relationships, (3) the experience of spiritual or divine shifting events, and (4) meaning making. Additionally, participants identified wish list items represented by four main themes: (1) fostering ally development, (2) taking action, (3) nothing should have changed, and (4) wishing for support broadly. Chi-square tests of independence revealed that R/S incidences were related to specific wish list items.

The National Wastewater Surveillance System (NWSS): From inception to widespread coverage, 2020-2022, United States

Wastewater surveillance is a valuable tool that can be used to track infectious diseases in a community. In September 2020, the Centers for Disease Control and Prevention (CDC) established the National Wastewater Surveillance System (NWSS) to coordinate and build the nation's capacity to detect and quantify concentrations of SARS-CoV-2 RNA in U.S. wastewater. This is the first surveillance summary of NWSS, covering September 1, 2020 to December 31, 2022. Through partnerships with state, tribal, local, and territorial health departments, NWSS became a national surveillance platform that can be readily expanded and adapted to meet changing public health needs. Beginning with 209 sampling sites in September 2020, NWSS rapidly expanded to >1500 sites by December 2022, covering ≈47 % of the U.S. population. As of December 2022, >152,000 unique wastewater samples have been collected by NWSS partners, primarily from wastewater treatment plants (WWTPs). WWTPs participating in NWSS tend to be larger than the average U.S. WWTP and serve more populated communities. In December 2022, ≈8 % of the nearly 16,000 U.S. WWTPs were participating in NWSS. NWSS partners used a variety of methods for sampling and testing wastewater samples; however, progress is being made to standardize these methods. In July 2021, NWSS partners started submitting SARS-CoV-2 genome sequencing data to NWSS. In October 2022, NWSS expanded to monkeypox virus testing, with plans to include additional infectious disease targets in the future. Through the rapid implementation and expansion of NWSS, important lessons have been learned. Wastewater surveillance programs should consider both surge and long-term capacities when developing an implementation plan, and early standardization of sampling and testing methods is important to facilitate data comparisons across sites. NWSS has proven to be a flexible and sustainable surveillance system that will continue to be a useful complement to case-based surveillance for guiding public health action.

Contamination of aquatic ecosystems by persistent organic pollutants (POPs) originating from landfills in Canada and the United States: A rapid scoping review

Persistent organic pollutants (POPs) are organic chemical substances that threaten human health and the planet's ecosystems due to their toxicity and their ability to remain intact for a long time, wide distribution throughout the environment, and accumulation and magnification in living organisms through the food chain. Discarded products from landfills and dumpsites are potential sources of POPs due to their persistence for several decades and constant release to surrounding environment. POPs in aquatic systems signal input predominantly from landfills, wastewater treatment plants, sewage, and urban runoff, suggesting a research gap to guide policies to address these unabated releases. This scoping review aims to rapidly identify the key concepts underpinning the containment, translation, and migration of POPs in Canadian and US landfill leachate. The review targeted multidisciplinary perspectives on the topic and spanned forensic biology, environmental sciences, chemistry, and geology. Contaminated municipal solid waste (MSW) landfill characteristics, as reported by government agencies in Canada and the US, were synthesized and harmonized to illustrate the geographical scope of MSW landfills releasing POPs into the surrounding environment. The knowledge and data gaps summarized in this study highlight the need to address the inadvertent release of POPs from Canadian and US landfills, particularly in consideration of dated and degrading landfill infrastructure, the proximity of marginalized people, and the implications of climate change on the countries' more vulnerable landscapes. This review is applicable to the development of future studies that aim to guide environmental protective policies.

Research on aquatic microcosm: Bibliometric analysis, toxicity comparison and model prediction

Recently, aquatic microcosms have attracted considerable attention because they can be used to simulate natural aquatic ecosystems. First, to evaluate the development of trends, hotspots, and national cooperation networks in the field, bibliometric analysis was performed based on 1841 articles on aquatic microcosm (1962-2022). The results of the bibliometric analysis can be categorized as follows: (1) Aquatic microcosm research can be summarized in two sections, with the first part focusing on the ecological processes and services of aquatic ecosystems, and the second focusing on the toxicity and degradation of pollutants. (2) The United States (number of publications: 541, proportion: 29.5%) and China (248, 13.5%) are the two most active countries. Second, to determine whether there is a difference between single-species and microcosm tests, that is, to perform different-tier assessments, the recommended aquatic safety thresholds in risk assessment [i.e., the community-level no effect concentration (NOECcommunity), hazardous concentrations for 5% of species (HC5) and predicted no effect concentration (PNEC)] were compared based on these tests. There was a significant difference between the NOECcommunity and HC5 (P < 0.05). Moreover, regression models predicting microcosm toxicity values were constructed to provide a reference for ecological systemic risk assessments based on aquatic microcosms.

Building Back Better: Going Big with Emancipatory Sciences

This commentary argues that precarity and inequity across the life course and aging has accelerated via the COVID-19 pandemic. President Biden's vaccination efforts, $1.9 trillion American Rescue Plan Act, and Build Back Better framework reflect a paradigm shift to restore faith and trust in government that boldly confronts entrenched austerity ideologues. We offer emancipatory sciences as a conceptual framework to analyze and promote social structural change and epic theory development. Emancipatory sciences aim to advance knowledge and the realization of dignity, access, equity, respect, healing, social justice, and social change through individual and collective agency and social institutions. Epic theory development moves beyond isolated incidents as single events and, instead, grasps and advances theory through attempts to change the world itself by demanding attention to inequality, power, and action. Gerontology with an emancipatory science lens offers a framework and vocabulary to understand the individual and collective consequences of the institutional and policy forces that shape aging and generations within and across the life course. It locates an ethical and moral philosophy engaged in the Biden Administration's approach, which proposes redistributing - from bottom-up - material and symbolic resources via family, public, community, and environmental benefits.

Are Wealthy Older Adults who use Medicaid Opportunistically Accessing the Program?

Medicaid is the largest payer of long-term services and supports (LTSS) and millions of older Americans rely on this means-tested program, especially during late life. There has been longstanding concern that wealthy older adults may be accessing the program by opportunistically divesting assets in order to qualify for coverage rather than by having high medical or LTSS expenses on which they spend down their resources to eligibility levels. Few current studies analyze this question longitudinally. Thus, questions remain about whether states need to tighten asset eligibility rules to prevent opportunistic asset divestiture. This analysis explores robust longitudinal data to determine the extent to which older, wealthier Americans accessing Medicaid do so by engaging in opportunistic asset transfer. Our findings demonstrate that this may occur among a relatively small proportion of wealthy people, and that tightening Medicaid eligibility criteria would likely have only a very modest impact on program expenditures.

Chronic Disease, Functional Limitations, and Workforce Participation Among Medicaid Enrollees Over 50: The Potential Impact of Medicaid Work Requirements Post-COVID-19

From 2018-2020, 19 states enacted Medicaid work requirements as a strategy for reducing program enrollment and overall cost. While these requirements were later rescinded, strategies to reduce Medicaid costs are likely to reemerge as states attempt to recover economically from the COVID-19 pandemic. Here, we evaluated the impact of Medicaid work requirements on adults aged > 50, a group that likely faces significant age-related chronic disease burden. Using 2016 Health and Retirement Study data, we evaluated the chronic disease burden of adult Medicaid beneficiaries aged 51-64 years (n = 1460) who would be at risk of losing their Medicaid coverage due to work requirements. We compared Medicaid beneficiaries working <20 hours per week (i.e. those at risk of coverage loss) to those working at least 20 hours per week on eight chronic health conditions, adjusting for demographic characteristics. Among those with chronic health conditions, we also evaluated differences in disease severity based on hours worked per week. Among those working fewer than 20 hours per week, odds of disease were greater for seven of eight chronic conditions, including history of stroke (OR: 5.66; 95% CI: 2.22-14.43) and lung disease (OR: 3.79; 95% CI: 2.10-6.85). Further, those with greater disease severity were likely to work fewer hours. Thus, the introduction of Medicaid work requirements would likely result in coverage loss and lower access to care among older Medicaid beneficiaries with multiple chronic health conditions.

Does diversity foster individualism? The relation of racial-ethnic diversity to individualism-collectivism across the 50 American States

Recent longitudinal research by others analyzing the relation between racial-ethnic diversity and individualism-collectivism in the 50 American states over the period 2000-2018 suggests that racial-ethnic diversity promotes individualism. The present study used a cross-sectional approach based on 2013 data to determine whether a relation mirroring the longitudinal pattern exists between racial-ethnic diversity and individualism-collectivism across the 50 states. Two measures of state racial-ethnic diversity were related to four measures of state individualism-collectivism using Pearson correlation and partial correlation controlling for state socioeconomic status. All correlations between diversity and individualism were negative and all those between diversity and collectivism were positive. The absolute magnitudes ranged from .43 to .68 for the Pearson correlations and from .43 to .67 for the partial correlations. Contrary to the earlier longitudinal findings, the current results show that states with higher racial-ethnic diversity are less individualistic and more collectivistic.

Leveraging the Contribution of Volunteers: The Critical Role and Economic Value of Volunteers in Older Americans Act Programs

The United States is facing a surge in the aging population, which will increase the demand for services and supports that allow older adults to age independently. This study assessed the size and value of the volunteer labor force in two home- and community-based programs funded under the Older Americans Act (OAA). Using publicly available program data for fiscal years 2015-2019, we calculated the annual contribution of volunteers, based on the total number of volunteer hours and share of labor effort, and estimated the economic value of volunteers in these OAA programs. In fiscal year 2019, volunteers contributed a total value of $1.7 billion in the OAA Title III program and $14.0 million in the Title VII long-term care ombudsman program. These results highlight the value of volunteers in OAA programs and the need for policies to support volunteers in the aging services network.

How Medicaid Financial Eligibility Rules Exclude Financially and Medically Vulnerable Older Adults

Millions of older Americans rely on Medicaid because it is the largest payer of long-term services and supports. To qualify for the program, low-income individuals age 65 and over must meet income standards based on the dated Federal Poverty Level as well as asset tests that are often viewed as quite stringent. There has long been concern that current eligibility standards exclude many adults with significant health and financial vulnerabilities. We use updated household socio-demographic and financial information to simulate the impacts of five alternative financial eligibility standards on the number and profile of older adults that would gain Medicaid coverage. The study clearly demonstrates that a large number of financially- and health-vulnerable older adults are excluded from the Medicaid program under current policy. The study highlights the implications for policymakers of updating Medicaid financial eligibility standards to assure that Medicaid benefits are targeted to vulnerable older adults who need them.

Pet collars containing tetrachlorvinphos (TCVP): evaluation of the results of torsion and on-animal release studies and implications for post-application consumer exposure and risk analysis

Tetrachlorvinphos (TCVP) is the pesticidal active ingredient found in some flea and tick collars for dogs and cats. Recent studies sponsored by The Hartz Mountain Corporation, confirm the safety of TCVP as an active ingredient in pet collars. Based upon data from these new studies and results previously relied upon by the U.S. Environmental Protection Agency, the following conclusions have been made: Torsion study data clearly indicate that approximately 93% of released formulation from TCVP containing pet collars is in a liquid phase immediately following activation.Further, even more relevant to human health risk analysis associated with post-application exposures, in vivo data from dogs wearing TCVP pet collars definitively document that TCVP dust released from the collar is rapidly absorbed into the sebum. The maximum ratio of dust to liquid was 0.023% dust to 99.977% liquid.In vivo fur data provide scientific evidence confirming that the mechanism of dissemination of TCVP from pet collars is as a liquid suspended or dissolved in the animal's sebum, even though it may be released from the collar as a solid. Thus, potential post-application exposure to TCVP, including immediately following collar placement, is almost entirely to a liquid phase.Based upon EPA's refined and conservative "untrimmed" collar risk assessment, post-application incidental oral hand-to-mouth activity by children aged 1 to <2 years of age results in margins of exposure significantly greater than the level of concern of 1000, and therefore do not present unreasonable health risk.

Evaluating the Feasibility of a Novel Firearm Injury Prevention Program for Pre-adolescent Children Through Health Care and Community-Based Partnerships: The Future Healers Program Pilot Study

BACKGROUND

Firearm violence is an American public health crisis that negatively impacts children and disproportionately affects Black youth. Few firearm injury prevention programs have been described in pre-adolescent children. The Future Healers Program is a novel collaboration constructed via partnership between the medical school, trauma center, academic surgery department, and local non-profit community organization. Our study sought to evaluate if (1) partnering with community organizations facilitated recruitment of children with prior exposure to firearm violence and (2) the health care community was a potential trusted partner appropriate for program delivery.

METHODS

Children aged 4-13 were recruited to join the program via news outlets and social media and in partnership with a local non-profit organization. Of the children and parents participating in the program, 48% (44/92) and 59% (38/64), respectively, completed an IRB-approved survey study. Pearson's chi-square, percentages, and 95% confidence intervals evaluated differences between children and caregivers on sociodemographic characteristics, firearm exposure (FE), firearm violence exposure (FVE), and perception of health care. Participant's residence was geocoded in relationship to incidents of firearm injury (2008-2021) in the same region.

RESULTS

Caregivers (95%) and children (84%) reported substantial exposure to firearm violence and resided in areas with frequent firearm injury incidents. Notably, 82% of caregivers and 66% of children reported having a family member injured by gunfire. A high percentage of caregivers (79%) and children (91%) self-reported trust in the health care system.

CONCLUSION

Partnerships between community organizations and health care systems can develop prevention programs that effectively recruit and engage pre-adolescent children impacted by firearm violence.

Is it safe to learn about vital pulp capping from YouTube™ videos? A content and quality analysis

AIM

To evaluate YouTube videos on vital pulp capping (VPC) for content, quality, source, usefulness, and reliability.

MATERIALS AND METHODS

This study assessed 249 English-language videos on vital pulp therapy using the Total Content Score (TCS), Video Information and Quality Index (VIQI), Global Quality Scale (GQS), Journal of the American Medical Association (JAMA) score and modified DISCERN score. Videos were categorized based on communication quality, duration, likes and dislikes, views, source, and video type. Of the videos analyzed, 22.1% met the inclusion criteria. Data were analyzed using Shapiro-Wilk, Kruskal-Wallis, and post hoc Bonferroni tests. Sperman's correlation, Kendal tau tests for correlations, and Fisher's exact test were used to assess associations between categorical variables.

RESULTS

The study identified significant correlations between various parameters. A higher TCS was correlated with increased VIQI (p = 0.005) and GQS scores (r = 0.685, p < 0.05). A moderate positive correlation was found between GQS scores and TCSs (r = 0.577, p < 0.05). VIQI scores were significantly and positively correlated with TCS (r = 0.573, p < 0.05) and comment count (r = 0.306, p < 0.05). JAMA scores were positively correlated with upload time (r = 0.304, p < 0.05), comment count (r = 0.337, p < 0.05), and likes (r = 0.301, p = 0.05).

CONCLUSIONS

YouTube videos provided low-to-average quality VPC information and tended to be inaccurate. Therefore, public videos may be incorrect, incomplete, and low-quality. Clinicians and patients should seek reliable information from specialists.

Digital surveillance: The interest in mouthwash-related information

BACKGROUND

The comprehension of the interests of Internet users regarding their health-related searches may reveal the community's demands about oral health. The study aimed to characterize the interests of Google users related to mouthwash in Australia, Brazil, Chile, Japan, Mexico, Russia, the United Kingdom, the United States, Saudi Arabia and South Africa applying the Google Trends.

METHODS

This longitudinal retrospective study analysed the mouthwash-related interest of Google users from January 2004 to December 2020. The monthly variation of relative search volume (RSV) and the main queries related were determined using Google Trends. Autoregressive integrated moving average (ARIMA) forecasting models were built to establish the predictive RSV values for mouthwash for additional 12 months. Auto-correlation plots and a general additive model (GAM) were used to diagnose trends and seasonality in RSV curves. In addition, the influence of social isolation related to the outbreak of COVID-19 were analysed.

RESULTS

The RSVs curves showed a considerable increase in searches related to mouthwash to AUS, BRA, JAP, MEX, GBR and USA (RSV > 25), while the growth was slight to CHI, KSA, RSA and RUS (RSV < 25) over the years, without influence of monthly seasonality. All countries showed a significant increase in mouthwash interest after the outbreak of COVID-19, except for KSA and RUS. The mouthwash-related searches were associated to specific brands or chemical compositions, treatments, whitening agents, homemade mouthwash and indications for the 'best mouthwash'.

CONCLUSIONS

In general, there was an increasing interest of Google users in mouthwash-related topics between 2004 and 2020. In addition, in most countries, there was an expansion in searches during the social isolation of the COVID-19 pandemics.

Experiences from a cluster-randomized trial (ParaNASPP) exploring triage and diagnostic accuracy in paramedic-suspected stroke: a qualitative interview study

BACKGROUND AND PURPOSE

Timely prehospital stroke recognition was explored in the Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) by implementation of stroke education for paramedics and use of the National Institutes of Health Stroke Scale (NIHSS) through a mobile application. The study tested triage and facilitated communication between paramedics and stroke physicians. To complement the quantitative results of the clinical trial, a qualitative approach was used to identify factors that influence triage decisions and diagnostic accuracy in prehospital stroke recognition experienced by paramedics and stroke physicians.

METHOD

Semi-structured qualitative individual interviews were performed following an interview guide. Informants were recruited from the enrolled paramedics and stroke physicians who participated in the ParaNASPP trial from Oslo University Hospital. Interviews were audio recorded, transcribed verbatim and approached inductively using the principles of thematic analysis.

RESULTS

Fourteen interviews were conducted, with seven paramedics and seven stroke physicians. Across both groups two overarching themes were identified related to triage decisions and diagnostic accuracy in prehospital stroke recognition: prehospital NIHSS reliably improves clinical assessment and communication quality; overtriage is widely accepted whilst undertriage is not.

CONCLUSION

Paramedics and stroke physicians described how prehospital NIHSS improved communication quality and reliably improved prehospital clinical assessment. The qualitative results support a rationale of an application algorithm to decide which NIHSS items should prompt immediate prenotification rather than a complete NIHSS as default.

Type 2 diabetes and health-related quality of life among older Medicare beneficiaries: The mediating role of sleep

OBJECTIVE

To examine mediating effects of sleep quality and duration on the association between T2D and QoL among Medicare beneficiaries 65+.

METHODS

Data from the Medicare Health Outcome Survey (2015-2020) were used. The outcome was QoL (physical and mental health component-summary scores [PCS and MCS]) measured by the Veterans-Rand-12. The main predictor was diagnosed T2D. Mediators were sleep duration and sleep quality. The effect modifier was race/ethnicity. Structural Equation Modeling was used to estimate moderated-mediating effects of sleep quality and duration across race/ethnicity.

RESULTS

Of the 746,400 Medicare beneficiaries, 26.7% had T2D, and mean age was 76 years (SD ± 6.9). Mean PCS score was 40 (SD ± 12.2), and mean MCS score was 54.0 (SD ± 10.2). Associations of T2D with PCS and MCS were negative and significant. For all racial/ethnic groups, those with T2D reported lower PCS. For White, Black, Asian, and Hispanic beneficiaries only, those with T2D reported lower MCS. The negative impact of T2D on PCS and MCS was mediated through sleep quality, especially very bad sleep quality.

CONCLUSION

Improving sleep may lead to improvement in QoL in elderly adults with T2D.

Development and Pilot Testing of a Programmatic System for Competency Assessment in US Anesthesiology Residency Training

BACKGROUND

In 2018, a set of entrustable professional activities (EPAs) and procedural skills assessments were developed for anesthesiology training, but they did not assess all the Accreditation Council for Graduate Medical Education (ACGME) milestones. The aims of this study were to (1) remap the 2018 EPA and procedural skills assessments to the revised ACGME Anesthesiology Milestones 2.0, (2) develop new assessments that combined with the original assessments to create a system of assessment that addresses all level 1 to 4 milestones, and (3) provide evidence for the validity of the assessments.

METHODS

Using a modified Delphi process, a panel of anesthesiology education experts remapped the original assessments developed in 2018 to the Anesthesiology Milestones 2.0 and developed new assessments to create a system that assessed all level 1 through 4 milestones. Following a 24-month pilot at 7 institutions, the number of EPA and procedural skill assessments and mean scores were computed at the end of the academic year. Milestone achievement and subcompetency data for assessments from a single institution were compared to scores assigned by the institution's clinical competency committee (CCC).

RESULTS

New assessment development, 2 months of testing and feedback, and revisions resulted in 5 new EPAs, 11 nontechnical skills assessments (NTSAs), and 6 objective structured clinical examinations (OSCEs). Combined with the original 20 EPAs and procedural skills assessments, the new system of assessment addresses 99% of level 1 to 4 Anesthesiology Milestones 2.0. During the 24-month pilot, aggregate mean EPA and procedural skill scores significantly increased with year in training. System subcompetency scores correlated significantly with 15 of 23 (65.2%) corresponding CCC scores at a single institution, but 8 correlations (36.4%) were <30.0, illustrating poor correlation.

CONCLUSIONS

A panel of experts developed a set of EPAs, procedural skill assessment, NTSAs, and OSCEs to form a programmatic system of assessment for anesthesiology residency training in the United States. The method used to develop and pilot test the assessments, the progression of assessment scores with time in training, and the correlation of assessment scores with CCC scoring of milestone achievement provide evidence for the validity of the assessments.