A Resident-Led Initiative to Advance Diversity, Equity, Inclusion, and Antiracism in a Pediatrics Residency Program

A racially and ethnically diverse physician workforce is critical to meeting the needs of the United States' increasingly diverse patient population. Unfortunately, Black, Latinx, American Indian, and Alaska Native communities remain underrepresented in medicine. The disproportionate impact of the COVID-19 pandemic by race/ethnicity and increased public attention to anti-Black and anti-Asian racism have inspired a growing national discourse on addressing systemic racism. Within academic medicine, there has been a call for the fundamental incorporation of antiracism into medical training and professional competency. From the perspective of a group primarily led by residents who are women of color, we describe our 6 years of experience leading a Diversity Committee that catalyzed sustained and systemic efforts to advance diversity, equity, inclusion (DEI), and antiracism at a large urban pediatrics residency program. We outline the implementation and key outcomes of the Diversity Committee's ongoing initiatives to increase resident diversity, foster an inclusive learning environment, develop a resident curriculum on DEI and antiracism, and center the needs and wisdom of the communities that our institution serves. Finally, we highlight challenges and lessons learned to inform other institutions striving to advance DEI and antiracism in academic medicine.

Excess pregnancy weight gain in latinas: Impact on infant's adiposity and growth hormones at birth

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Immigrant Latinas with overweight and obesity have excessive gestational gain.

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Excessive gestational weight gain is associated with high birthweight percentiles.

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Higher IGF-1 and lower PYY in cord blood in context of excessive gestational gain.

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Gestational weight counseling in pregnancy may help prevent childhood obesity.

Excess maternal weight gain during pregnancy has been associated with childhood overweight and obesity both in mothers with and without obesity. Latinx children are at higher risk for earlier obesity compared with other population groups. A cohort of 82 self-identified pregnant Latina women were recruited at the prenatal clinics of Zuckerberg San Francisco General Hospital (ZSFG) prior to delivery during the second and third trimesters of pregnancy in 2011 and 2012. Maternal pre-pregnancy weight and weight prior to delivery were collected by self-report to calculate maternal pre-pregnancy body mass index (BMI) and weight gain in pregnancy. At delivery, anthropometric measurements of infants were obtained and cord blood and maternal finger stick blood samples were collected for hormonal assays. Fifty-three point seven percent of women had excessive weight gain in pregnancy. A high percentage of the cohort was overweight and obese prior to pregnancy (67.1%) with mean pre-pregnancy BMI 27.4 ± 4.5 kg/m² and greater pre-pregnancy weight was independently associated with weight gain during pregnancy (OR 1.05, 95%CI 1.002–1.09). Mean infant birthweight was 3377.2 ± 481.5 g and excessive weight gain in pregnancy was independently associated with birthweight percentile (OR 13.46, 95%CI 2.43–34.50). Excessive gestational gain was positively associated with cord blood insulin-like growth factor-1 (IGF-1) and negatively with Peptide YY (PYY) levels. Latina women with pre-pregnancy overweight and obesity have a high rate of excessive gestational gain in pregnancy and could benefit from early counseling about appropriate gain in pregnancy. Excessive gestational weight impacts the intrauterine environment in high-risk infants impacting fetal growth and development.

Cord blood telomere length in Latino infants: relation with maternal education and infant sex

OBJECTIVE

Telomere length (TL) has important consequences for early disease and lifelong health. However, few studies have examined determinants of TL at birth.

STUDY DESIGN

Here we test associations between cord blood TL and parental and birth factors associated with exposure to stress and indicative of healthy intrauterine life in Latino infants. We tested associations that were significant in bivariate analysis in a multivariate regression model to identify independent predictors for shorter TL at birth.

RESULT

Two novel and independent predictors emerged in our analysis of 54 infants. Female gender was associated with longer TL by ~350 base pairs (adjusted β-coefficient for male gender=-369.57, (95% confidence interval, -718.21 to (-)20.92), P=0.02); rho=-0.26, P=0.057). Increased maternal high-school education, as indicated by a high-school diploma or additional education beyond high school, was also associated with longer TL, by ~500 base pairs (adjusted β-coefficient for high-school diploma or greater=505.68 (95% confidence interval, 151.69 to 859.68), P<0.01); rho=0.36, P<0.01). Increasing head circumference trended towards statistical significance in association with longer TL (adjusted β-coefficient = 7.33; 95% confidence interval -0.52 to 15.18; P=0.07). When we removed all infants who had been exposed to high oxidative stress in pregnancy including those exposed to maternal hypertension, preeclampsia, gestational diabetes, and those who were low birth weight or preterm birth (n=7), increasing birth weight percentile was associated with longer TL (adjusted β-coefficient=8.04 (95% confidence interval 0.07 to 16.00), P=0.048).

CONCLUSION

Shorter TL at birth is associated with being male, low maternal education (less than a high school degree), and a trend towards lower birth weight and head circumference. Given the critical role of long TL in predicting health and disease, these findings contribute to the growing literature attempting to understand determinants of TL.

Estimating the sensitivity and specificity of Kato-Katz stool examination technique for detection of hookworms, Ascaris lumbricoides and Trichuris trichiura infections in humans in the absence of a 'gold standard'

The accuracy of the Kato-Katz technique in identifying individuals with soil-transmitted helminth (STH) infections is limited by day-to-day variation in helminth egg excretion, confusion with other parasites and the laboratory technicians' experience. We aimed to estimate the sensitivity and specificity of the Kato-Katz technique to detect infection with Ascaris lumbricoides, hookworm and Trichuris trichiura using a Bayesian approach in the absence of a 'gold standard'. Data were obtained from a longitudinal study conducted between January 2004 and December 2005 in Samar Province, the Philippines. Each participant provided between one and three stool samples over consecutive days. Stool samples were examined using the Kato-Katz technique and reported as positive or negative for STHs. In the presence of measurement error, the true status of each individual is considered as latent data. Using a Bayesian method, we calculated marginal posterior densities of sensitivity and specificity parameters from the product of the likelihood function of observed and latent data. A uniform prior distribution was used (beta distribution: alpha=1, beta=1). A total of 5624 individuals provided at least one stool sample. One, two and three stool samples were provided by 1582, 1893 and 2149 individuals, respectively. All STHs showed variation in test results from day to day. Sensitivity estimates of the Kato-Katz technique for one stool sample were 96.9% (95% Bayesian Credible Interval [BCI]: 96.1%, 97.6%), 65.2% (60.0%, 69.8%) and 91.4% (90.5%, 92.3%), for A. lumbricoides, hookworm and T. trichiura, respectively. Specificity estimates for one stool sample were 96.1% (95.5%, 96.7%), 93.8% (92.4%, 95.4%) and 94.4% (93.2%, 95.5%), for A. lumbricoides, hookworm and T. trichiura, respectively. Our results show that the Kato-Katz technique can perform with reasonable accuracy with one day's stool collection for A. lumbricoides and T. trichiura. Low sensitivity of the Kato-Katz for detection of hookworm infection may be related to rapid degeneration of delicate hookworm eggs with time.

Concurrent comparison of three water contact measurement tools in four endemic villages of the Philippines. The schistosomiasis transmission ecology in the Philippines project (STEP)

BACKGROUND

Schistosomiasis japonica is a chronic helminthic infection contracted through contact with water infested with Schistosoma japonicum. The infection is associated with severe disease and is an important public health concern in Philippines.

OBJECT

To estimate the agreement in the frequency of water contact between bimonthly interviews, self-administered diaries and observations.

METHODS

A total of 286 individuals were followed over either a 4 or a 6 months period. Agreement between direct observation and both the bimonthly and diary methods were estimated.

RESULTS

The agreement between the observation and the bimonthly interview was 71.8% when days without any water contacts were considered, but decreased to 23.3% when only days with at least some water contact were considered. The agreement between the observation and the diary was 78.7% when days without any water contacts were considered and 40.8% when only days with some water contacts were considered.

CONCLUSIONS

Agreement about the degree of water contact is poor between the different measurement tools. This has important implications for future research, since a high degree of measurement error can severely bias any results from studies involving water contact.

Estimating sensitivity and specificity of a faecal examination method for Schistosoma japonicum infection in cats, dogs, water buffaloes, pigs, and rats in Western Samar and Sorsogon Provinces, The Philippines

Schistosoma japonicum causes a chronic parasitic disease, which persists as a major public health concern in The Philippines, the People's Republic of China and Indonesia. This infection is unique among helminthic zoonoses because it can infect humans and more than 40 other mammals. The objective of this study was to estimate the sensitivity and specificity of the Danish Bilharziasis Laboratory technique in cats, dogs, pigs, water buffaloes and rats in the Philippines. Faecal samples from each animal were collected on up to five occasions on five consecutive days in four villages of Sorsogon and Western Samar Provinces between January and July 2003. The faecal samples were analysed with the filtration and sedimentation Danish Bilharziasis Laboratory technique. Sensitivity and specificity of one, two, three, four, and five faecal samples were estimated using a Bayesian latent class approach. A total of 59, 43, 74, and 80% of the censored cats, dogs, pigs, and water buffaloes in the four villages were sampled, respectively. For all species, the sensitivity estimates when using the results of only 1 day of sampling were less than 80%. However, the sensitivity improved to at least 96% in all species when three or more faecal samples were collected on three separate days. The specificity was estimated to be above 92% across all species, even if just a single sample is used. The prevalences and 95% credible intervals of S. japonicum, adjusted for imperfect sensitivity and specificity, in cats, dogs, pigs, rats, and water buffaloes were 11.9% (6.8-18.3%), 19.9% (15.1-25.2%), 2.9% (1.1-5.2%), 31.3% (18.3-45.6%) and 6.3% (2.1-12.6%), respectively. Our results suggest that the Danish Bilharziasis Laboratory technique is valid for the detection of infection with S. japonicum in animals, and that sensitivity estimates are excellent when faecal samples are collected on at least three different days. Monitoring S. japonicum infection in animal reservoirs with a valid test could contribute to more effective public health control programmes.

Double-blind placebo-controlled study of concurrent administration of albendazole and praziquantel in schoolchildren with schistosomiasis and geohelminths

A double-blind placebo-controlled study of the concurrent administration of albendazole and praziquantel was conducted in>1500 children with high prevalences of geohelminths and schistosomiasis. The study sites were in China and the Philippines, including 2 strains of Schistosoma japonicum, and 2 different regions of Kenya, 1 each with endemic Schistosoma mansoni or Schistosoma haematobium. Neither medication affected the cure rate of the other. There was no difference between the side effect rate from albendazole or the double placebo. Praziquantel-treated children had more nausea, abdominal pain, and headache but these side effects were statistically more common in children with schistosomiasis, suggesting a strong influence of dying parasites. The subjects were followed for 6 months for changes in infection status, growth parameters, hemoglobin, and schistosomiasis morbidity. In all 4 sites, a significant 6-month increase in serum hemoglobin was observed in children who received praziquantel, strongly supporting population-based mass treatment.

Immunity and morbidity in schistosomiasis japonicum infection

Schistosomiasis japonica differs significantly from Schistosoma mansoni infection in several epidemiologic, immunologic, and operational characteristics for control. Because of numerous nonhuman hosts, transmission remains high despite aggressive case finding and treatment of human cases. Diagnosis of infection using the Kato-Katz stool technique is less sensitive and specific in this than in other species of human schistosomes, making case finding and treatment a less effective approach to control. Clinically, morbidity induced by S. japonicum appears unrelated to intensity of infection, and is more severe than that of S. mansoni in terms of liver pathology and stunting of child growth and development. Both hepatic enlargement and fibrosis appear to be reversible and preventable with aggressive treatment but several operational characteristics for control of infection due to S. japonicum make the community impact of case-finding and treatment with praziquantel less pronounced than would have been predicted by the analysis of individual cases. In the Philippines, rebound morbidity following reinfection mandates short treatment intervals between screening and treatment to have a significant impact on morbidity, while in China inapparent infection (infection not diagnosed by a single stool examination) appears to be a common cause for persistent hepatic pathology. The authors conclude that for S. japonicum, mass treatment or targeted mass treatment is a more cost-effective approach than case-finding and treatment for control.

Schistosomiasis japonica and childhood nutritional status in northeastern Leyte, the Philippines: a randomized trial of praziquantel versus placebo

The hypothesis that infection with Schistosoma japonicum causes decreased nutritional status was studied in a randomized trial among 170 males and females, mean (SD) age 11.4 (3.5) years, residing in an endemic region of northeastern Leyte, Philippines. The S. japonicum-infected children were randomized to receive praziquantel or placebo and followed-up six months after randomization. Stature, weight, triceps, subscapular, and calf skinfold thicknesses and their sum, and hemoglobin level were measured at baseline and follow-up. Schistosoma japonicum eggs were detected in Kato-Katz stool smears and the intensity of infection was assessed by quantitative egg count. Intensities of hookworm, ascaris, and trichuris infections were also measured. The six-month levels of the anthropometric measures and hemoglobin were adjusted for age and their baseline levels and then compared between the praziquantel and placebo groups. Treatment interactions were also analyzed by sex. Baseline anthropometric and hemoglobin levels and parasite infection intensities were the same in the two groups. At six months, the praziquantel group had significantly higher hemoglobin levels (P < 0.001) and sum of skinfolds (P < 0.001) than the placebo group. Males had a significantly greater increase in hemoglobin levels with treatment than did females. The hemoglobin increase was not due to changes in hookworm intensity. The results show that schistosomiasis japonica caused decreased nutritional status in children and probably is partly responsible for the malnutrition and reduction in growth for age described in prior cross-sectional studies.

Child growth and schistosomiasis japonica in northeastern Leyte, the Philippines: cross-sectional results

The association between schistosomiasis japonica and child growth was studied cross-sectionally in 1,561 males and females aged 4-19.9 years residing in an endemic region of northeastern Leyte, The Philippines. Stature, weight, upper arm muscle area, and sum of triceps and subscapular skinfold thicknesses were measured and related to presence of Schistosoma japonicum eggs in Kato stool smears and to the intensity of infection assessed by quantitative egg count. The presence of hookworm, ascaris, and trichuris eggs was also measured. Multivariable models were used to control for the effects of age, age2, and polyparasitism on growth. The prevalence of schistosomiasis was 31% in males and 22% in females, with the maximum prevalence in adolescence. In 8-19-year-old subjects, the intensity of schistosomiasis japonica was significantly related in males to reduced arm muscle area and sum of skinfolds (both P less than 0.01) and in females to reduced stature, weight, arm muscle area, and sum of skinfolds (all P less than 0.01). The greatest age-specific differences were during adolescence in both males and females. The growth retarding effects of intensity of schistosomiasis japonica were independent of the influence of other parasites, notably hookworm. Due to the magnitude of the schistosomiasis-associated growth differences in adolescence, adult body size, function and productivity may be affected.

Morbidity due to schistosomiasis japonica in the People's Republic of China

Transmission and morbidity induced by Schistosoma japonicum were evaluated in 825 individuals undergoing periodic treatment with praziquantel on Jishan island, Jiangxi Providence, in the People's Republic of China. Eggs of S. japonicum were found in the stools of 39.4% of the population; 70% of those infected were less than 20 years of age. Hepatomegaly greater than 3 cm in the midsternal line was detected by physical examination and ultrasonography in 75% and 90% of individuals, respectively, regardless of infection status. Symmer's clay pipe-stem fibrosis of the liver was detected by ultrasonography in 20% of all individuals. Hepatitis B surface antigen and antibody to hepatitis C were found in 11% and less than 1% of the population, respectively. Our study suggests that, despite intermittent chemotherapy, morbidity due to S. japonicum is still a significant problem in China.

Adoptive transfer of modulation of granuloma formation and hepatosplenic disease in murine schistosomiasis japonica by serum from chronically infected animals

The course of disease due to Schistosoma japonicum in C57BL/6J mice was examined. Animals infected with 25 cercariae of the Philippine strain of S. japonicum for 9 wk develop a peak portal hypertension of 13 +/- 0.6 cm H2O and mean hepatic granuloma area of 459 X 10(3) micrometers 2. By 30 wk, disease manifestations were reduced; mean portal pressure was 7 +/- 0.5 cm H2O and mean hepatic granuloma area was 12 X 10(3) micrometers 2. Adoptive transfer of serum but not 1 X 10(8) spleen or 4 X 10(7) lymph node cells from chronically infected mice resulted in lowering portal pressure and decreasing granuloma size in recipients. Granuloma formation in the sensitized lung model was also suppressed by serum from chronically infected mice. The immunosuppressive component of this serum was localized in the IgG1 fraction.

Adoptive transfer of modulation of granuloma formation and hepatosplenic disease in murine schistosomiasis japonica by serum from chronically infected animals

The course of disease due to Schistosoma japonicum in C57BL/6J mice was examined. Animals infected with 25 cercariae of the Philippine strain of S. japonicum for 9 wk develop a peak portal hypertension of 13 +/- 0.6 cm H2O and mean hepatic granuloma area of 459 X 10(3) micrometers 2. By 30 wk, disease manifestations were reduced; mean portal pressure was 7 +/- 0.5 cm H2O and mean hepatic granuloma area was 12 X 10(3) micrometers 2. Adoptive transfer of serum but not 1 X 10(8) spleen or 4 X 10(7) lymph node cells from chronically infected mice resulted in lowering portal pressure and decreasing granuloma size in recipients. Granuloma formation in the sensitized lung model was also suppressed by serum from chronically infected mice. The immunosuppressive component of this serum was localized in the IgG1 fraction.