Enhancing the health knowledge and health literacy of recently resettled refugees through classroom-based instructional methods.

Health education can elevate health literacy, which is associated with health knowledge, health-seeking behaviors and overall improved health outcomes. Refugees are particularly vulnerable to the effects of low health knowledge and literacy, which can exacerbate already poor health stemming from their displacement experience. Traditional learning methods including classroom-based instruction are typically how health-related information is presented to refugees. Through a series of interactive classes focused on specific health topics relevant to the resettled refugee population, this study evaluated the effectiveness of a classroom-based health education model in enhancing the health knowledge of recently resettled refugees. We used the Wilcoxon signed-rank test to evaluate differences in pre- and post-class knowledge through test performance. We found a significant improvement in health knowledge in two refugee groups: females and those who were employed. Culturally and socially sensitive considerations including language inclusiveness, class timing, transportation and childcare provisions are important when creating an educational program for individuals with refugee backgrounds. Developing focused approaches to instruction that enhance health knowledge could lead to better health literacy and ultimately improve health-related behaviors and outcomes in the refugee population.

Breast Cancer Screening in the Intermediate-Risk Population: Falling Through the Cracks?

Breast cancer screening guidelines vary for women at intermediate risk (15%-20% lifetime risk) for developing breast cancer across jurisdictions. Currently available risk assessment models have differing strengths and weaknesses, creating difficulty and ambiguity in selecting the most appropriate model to utilize. Clarifying which model to utilize in individual circumstances may help determine the best screening guidelines to use for each individual.

Representation of patients with non-English language preferences in motor vehicle collision trauma and emergency medicine research.

BACKGROUND: Individuals with non-English language preferences (NELP) represent a growing proportion of the USA population. Prior studies demonstrate disparate health outcomes related to NELP status; however, this patient population is often excluded from medical research. There is a paucity of literature describing the impact of NELP status on trauma, specifically injury and outcomes related to vehicle occupants injured during motor vehicle collisions (MVCs). The goal of this study was to evaluate the representation of patients with NELP in both emergency medicine and trauma literature. METHODS: We conducted a systematic search of US-based publications from 2010 to 2021. Titles, abstracts and full texts of eligible articles were evaluated. Data were extracted using an a priori determined standardised reporting tool to evaluate language as study inclusion/exclusion criteria, manuscript reporting of language, assessment of language as a primary variable and consideration of language in study methodology. RESULTS: A total of 82 studies met inclusion criteria. Twenty-three studies (28%) excluded NELP populations and only one study explicitly included the NELP population. None of the studies evaluated language as a primary outcome of the study or included language as a variable in the analysis. Over half of the studies (53.6%) used a public data set or registry. CONCLUSION: NELP populations are routinely excluded from and are difficult to identify in MVC trauma research. Without appropriate inclusion and identification, it will be difficult to understand the prevalence and outcomes of traumatic injury in NELP patients and to develop culturally and linguistically appropriate interventions.

Systematic review on chronic non-communicable disease in disaster settings.

BACKGROUND: Non-communicable diseases (NCDs) constitute the leading cause of mortality globally. Low and middle-income countries (LMICs) not only experience the largest burden of humanitarian emergencies but are also disproportionately affected by NCDs, yet primary focus on the topic is lagging. We conducted a systematic review on the effect of humanitarian disasters on NCDs in LMICs assessing epidemiology, interventions, and treatment. METHODS: A systematic search in MEDLINE, MEDLINE (PubMed, for in-process and non-indexed citations), Social Science Citation Index, and Global Health (EBSCO) for indexed articles published before December 11, 2017 was conducted, and publications reporting on NCDs and humanitarian emergencies in LMICs were included. We extracted and synthesized results using a thematic analysis approach and present the results by disease type. The study is registered at PROSPERO (CRD42018088769). RESULTS: Of the 85 included publications, most reported on observational research studies and almost half (48.9%) reported on studies in the Eastern Mediterranean Region (EMRO), with scant studies reporting on the African and Americas regions. NCDs represented a significant burden for populations affected by humanitarian crises in our findings, despite a dearth of data from particular regions and disease categories. The majority of studies included in our review presented epidemiologic evidence for the burden of disease, while few studies addressed clinical management or intervention delivery. Commonly cited barriers to healthcare access in all phases of disaster and major disease diagnoses studied included: low levels of education, financial difficulties, displacement, illiteracy, lack of access to medications, affordability of treatment and monitoring devices, and centralized healthcare infrastructure for NCDs. Screening and prevention for NCDs in disaster-prone settings was supported. Refugee status was independently identified both as a risk factor for diagnosis with an NCD and conferring worse morbidity. CONCLUSIONS: An increased focus on the effects of, and mitigating factors for, NCDs occurring in disaster-afflicted LMICs is needed. While the majority of studies included in our review presented epidemiologic evidence for the burden of disease, research is needed to address contributing factors, interventions, and means of managing disease during humanitarian emergencies in LMICs.

Association between patient-physician gender concordance and patient experience scores. Is there gender bias?

BACKGROUND: Patient satisfaction, a commonly measured indicator of quality of care and patient experience, is often used in physician performance reviews and promotion decisions. Patient satisfaction surveys may introduce gender-related bias. OBJECTIVE: Examine the effect of patient and physician gender concordance on patient satisfaction with emergency care. METHODS: We performed a cross-sectional analysis of electronic health record and Press Ganey patient satisfaction survey data of adult patients discharged from the emergency department (2015-2018). Logistic regression models were used to examine relationships between physician gender, patient gender, and physician-patient gender dyads. Binary outcomes included: perfect care provider score and perfect overall assessment score. RESULTS: Female patients returned surveys more often (n=7 612; 61.55%) and accounted for more visits (n=232 024; 55.26%). Female patients had lower odds of perfect scores for provider score and overall assessment score (OR: 0.852, 95% CI: 0.790, 0.918; OR: 0.782, 95% CI: 0.723, 0.846). Female physicians had 1.102 (95% CI: 1.001, 1.213) times the odds of receiving a perfect provider score. Physician gender did not influence male patients' odds of reporting a perfect care provider score (95% CI: 0.916, 1.158) whereas female patients treated by female physicians had 1.146 times the odds (95% CI: 1.019, 1.289) of a perfect provider score. CONCLUSION: Female patients prefer female emergency physicians but were less satisfied with their physician and emergency department visit overall. Over-representation of female patients on patient satisfaction surveys introduces bias. Patient satisfaction surveys should be deemphasized from physician compensation and promotion decisions.

A pilot study of a Community Health Agent-led type 2 diabetes self-management program using Motivational Interviewing-based approaches in a public primary care center in São Paulo, Brazil.

BACKGROUND: Rates of noncommunicable diseases (NCDs) such as type 2 diabetes are escalating in low and middle-income countries such as Brazil. Scalable primary care-based interventions are needed to improve self-management and clinical outcomes of adults with diabetes. This pilot study examines the feasibility, acceptability, and outcomes of training community health agents (CHAs) in Motivational Interviewing (MI)-based counseling for patients with poorly controlled diabetes in a primary care center in São Paulo, Brazil. METHODS: Nineteen salaried CHAs participated in 32 h of training in MI and behavioral action planning. With support from booster training sessions, they used these skills in their regular monthly home visits over a 6 month period with 57 diabetes patients with baseline HbA1cs > 7.0%. The primary outcome was patients' reports of the quality of diabetes care as measured by the Portuguese version of the Patient Assessment of Chronic Illness Care (PACIC) scale. Secondary outcomes included changes in patients' reported diabetes self-management behaviors and in A1c, blood pressure, cholesterol and triglycerides. We also examined CHAs' fidelity to and experiences with the intervention. RESULTS: Patients reported improvements over the 6 month period in quality of diabetes care received (PACIC score improved 33 (+/-19) to 68 (+/-21) (p < .001)). They reported increases in physical activity (p = .001), consumption of fruits and vegetables (p < .001) and medication adherence (p = .002), but no decreases in consumption of high-fat foods (p = .402) or sweets (p = .436). Participants had mean 6-month A1c levels 0.34% points lower than at baseline (p = .08) and improved mean LDL (-16.1 mg/dL, p = .005) and triglyceride levels (-38.725 mg/dL, p = .002). Of the 16 CHAs observed in fidelity assessments, 13 were categorized as medium- or high-performing on MI skills, while 3 were low-performing. CHAs expressed enthusiasm about learning new skills, and many described a shift from advice-giving to encouraging patients to define their own goals. CONCLUSION: In resource-scarce settings, it is essential to fully utilize existing primary care resources to stem the epidemic of diabetes and other NCDs. Our pilot results support the potential of training CHAs to incorporate effective diabetes self-management support into their routine patient encounters. TRIAL REGISTRATION: NCT02994095 12/14/2016 Registered retrospectively.

Refugee Resettlement Patterns and State-Level Health Care Insurance Access in the United States.

We sought to evaluate the relationship between state-level implementation of the Patient Protection and Affordable Care Act (ACA) and resettlement patterns among refugees. We linked federal refugee resettlement data to ACA expansion data and found that refugee resettlement rates are not significantly different according to state-level insurance expansion or cost. Forty percent of refugees have resettled to states without Medicaid expansion. The wide state-level variability in implementation of the ACA should be considered by federal agencies seeking to optimize access to health insurance coverage among refugees who have resettled to the United States.

DEPTOR is a stemness factor that regulates pluripotency of embryonic stem cells.

The mammalian target of rapamycin (mTOR) pathway regulates stem cell regeneration and differentiation in response to growth factors, nutrients, cellular energetics, and various extrinsic stressors. Inhibition of mTOR activity has been shown to enhance the regenerative potential of pluripotent stem cells. DEPTOR is the only known endogenous inhibitor of all known cellular mTOR functions. We show that DEPTOR plays a key role in maintaining stem cell pluripotency by limiting mTOR activity in undifferentiated embryonic stem cells (ESCs). DEPTOR levels dramatically decrease with differentiation of mouse ESCs, and knockdown of DEPTOR is sufficient to promote ESC differentiation. A strong decrease in DEPTOR expression is also observed during human ESCs differentiation. Furthermore, reduction in DEPTOR level during differentiation is accompanied by a corresponding increase in mTOR complex 1 activity in mouse ESCs. Our data provide evidence that DEPTOR is a novel stemness factor that promotes pluripotency and self-renewal in ESCs by inhibiting mTOR signaling.

Negotiating cancer alone: A qualitative study exploring care experiences of racially and ethnically diverse women diagnosed with breast cancer during COVID-19.

COVID-19 has critically impacted cancer care services including reduced screenings, diagnoses, and surgeries; particularly among Black and Latina/x women who already suffer worse outcomes. This qualitative study explored the care experiences of a diverse sample of breast cancer survivors (N = 21; 7 Black, 4 Hispanic, 10 White) undergoing treatment during the pandemic via online semi-structured interviews. Grounded theory analysis yielded the core category "negotiating cancer alone," that included: (1) psychological distress, negotiating the cancer trajectory in isolation; (2) provider/healthcare system diagnostic and treatment delays; (3) heightened anxiety about treatment delays causing cancer progression; (4) supportive care limitations; and (5) disparate experiences of cancer care disruptions. Black and Latina/x women described greater delays in care, financial challenges, treatment complications, and insurance limitations than White women. The study identifies cancer patients' pandemic-related psychological, healthcare system, and health equity challenges and suggests recommendations to support their increased psychological needs during oncologic care disruptions.

Ubiquitin-specific peptidase 9, X-linked (USP9X) modulates activity of mammalian target of rapamycin (mTOR).

The mammalian target of rapamycin (mTOR) is an atypical serine/threonine kinase that responds to extracellular environment to regulate a number of cellular processes. These include cell growth, proliferation, and differentiation. Although both kinase-dependent and -independent functions of mTOR are known to be critical modulators of muscle cell differentiation and regeneration, the signaling mechanisms regulating mTOR activity during differentiation are still unclear. In this study we identify a novel mTOR interacting protein, the ubiquitin-specific protease USP9X, which acts as a negative regulator of mTOR activity and muscle differentiation. USP9X can co-immunoprecipitate mTOR with both Raptor and Rictor, components of mTOR complexes 1 and 2 (mTORC1 and -2), respectively, suggesting that it is present in both mTOR complexes. Knockdown of USP9X leads to increased mTORC1 activity in response to growth factor stimulation. Interestingly, upon initiation of differentiation of C2C12 mouse skeletal myoblasts, knockdown of USP9X increases mTORC2 activity. This increase in mTORC2 activity is accompanied by accelerated differentiation of myoblasts into myotubes. Taken together, our data describe the identification of the deubiquitinase USP9X as a novel mTORC1 and -2 binding partner that negatively regulates mTOR activity and skeletal muscle differentiation.

Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research.

AIMS: Individuals with Limited English Proficiency (LEP) represent a growing percentage of the U.S. population yet face inequities in health outcomes and barriers to routine care. Despite these disparities, LEP populations are often excluded from clinical research studies. The aim of this study was to assess for the inclusion of LEP populations in published acute care stroke research in the U.S. METHODS: A systematic review was conducted of publications from three databases using acute care and stroke specific Medical Subject Heading key terms. The primary outcome was whether language was used as inclusion or exclusion criteria for study participation and the secondary outcome was whether the study explored outcomes by language. RESULTS: A total of 167 studies were included. Twenty-two studies (13.2%) indicated the use of language as inclusion/exclusion criteria within the manuscript or dataset/registry and only 17 studies (10.2%) explicitly included LEP patients either in the study or dataset/registry. Only four papers (2%) include language as a primary variable. CONCLUSIONS: As LEP populations are not routinely incorporated in acute care stroke research, it is critical that researchers engage in language-inclusive research practices to ensure all patients are equitably represented in research studies and ultimately evidence-based practices.

The interrelationship between food security, climate change, and gender-based violence: A scoping review with system dynamics modeling.

Gender-based violence (GBV) is a global public health and human rights problem that is exacerbated by social and environmental stressors for a multitude of interpersonal, cultural, and economic reasons. Through sudden disruptions in the microclimate of a region, climate shocks often have a negative impact on food security, which correlates with increases in GBV. Associations between the various combinations of GBV, climate change, and food insecurity have been documented in the growing international literature, but questions remain about these associations that require further clarification. The impact of the COVID-19 pandemic caused by SARS-CoV-2 provides insight through a real time demonstration into these interactions. This review of the global literature examines the interplay between GBV, climate change, and food insecurity-including recent literature regarding the COVID-19 pandemic. This review covers original research studies employing both quantitative and qualitative methodology, those that conducted secondary analyses of existing data sources and perspective pieces derived from observed evidence. An additional analytic layer of system dynamics modeling allowed for the integration of findings from the scoping review and discovery of additional insights into the interplay between disasters, food insecurity, and GBV. Findings from this review suggest that the development and adaptation of evidence-based, focused interventions and policies to reduce the effects of climate shocks and bolster food security may ultimately decrease GBV prevalence and impact.

Role of CRISPR/Cas9 in the treatment of Duchenne muscular dystrophy and its delivery strategies.

Duchenne muscular dystrophy (DMD) is a neuromuscular disorder brought on by mutations in the DMD gene, which prevent muscle cells from expressing the dystrophin protein. CRISPR/Cas9 technology has evolved as potential option to treat DMD due to its ability to permanently skip exons, restoring the disrupted DMD reading frame and leading to dystrophin restoration. Even though, having potential to treat DMD, the delivery, safety and efficacy of this technology is still challenging. Several delivery methods, including viral vectors, nanoparticles, and electroporation, have been explored to deliver CRISPR/Cas9 to the targeted cells. Despite the potential of CRISPR/Cas9 technology in the treatment of DMD, several limitations need to be addressed. The off-target effects of CRISPR/Cas9 are a major concern that needs to be addressed to avoid unintended mutations. The delivery of CRISPR/Cas9 to the target cells and the immune response due to the viral vectors used for delivery are a few other limitations. The clinical trials of CRISPR/Cas9 for DMD provide valuable insights into the safety and efficacy of this technology in humans and the limitations that need to be known. Therefore, in this review we insightfully discussed the challenges and limitations of CRISPR/Cas9 in the treatment of DMD and delivery strategies used, and the ongoing efforts to overcome these challenges and restore dystrophin expression in DMD patients in the ongoing trials.

Emergency medicine physician workforce attrition differences by age and gender.

BACKGROUND: Emergency care workforce concerns have gained national prominence given recent data suggesting higher than previously estimated attrition. With little known regarding characteristics of physicians leaving the workforce, we sought to investigate the age and number of years since residency graduation at which male and female emergency physicians (EPs) exhibited workforce attrition. METHODS: We performed a repeated cross-sectional analysis of EPs reimbursed by Medicare linked to date of birth and residency graduation date data from the American Board of Emergency Medicine for the years 2013-2020. Stratified by gender, our primary outcomes were the median age and number of years since residency graduation at the time of attrition, defined as the last year during the study time frame that an EP provided clinical services. We constructed a multivariate logistic regression model to examine the association between gender and EP workforce attrition. RESULTS: A total of 25,839 (70.2%) male and 10,954 (29.8%) female EPs were included. During the study years, 5905 male EPs exhibited attrition at a median (interquartile range [IQR]) age of 56.4 (44.5-65.4) years, and 2463 female EPs exhibited attrition at a median (IQR) age of 44.0 (38.0-53.9) years. Female gender (adjusted odds ratio 2.30, 95% confidence interval 1.82-2.91) was significantly associated with attrition from the workforce. Male and female EPs had respective median (IQR) post-residency graduation times in the workforce of 17.5 (9.5-25.5) years and 10.5 (5.5-18.5) years among those who exhibited attrition and one in 13 males and one in 10 females exited clinical practice within 5 years of residency graduation. CONCLUSIONS: Female physicians exhibited attrition from the EM workforce at an age approximately 12 years younger than male physicians. These data identify widespread disparities regarding EM workforce attrition that are critical to address to ensure stability, longevity, and diversity in the EP workforce.

Black Women's Perspectives on Breast Cancer Risk Assessment.

PURPOSE: The aim of this study was to gather the perspectives of Black women on breast cancer risk assessment through a series of one-on-one interviews. METHODS: The authors conducted a cross-sectional qualitative study consisting of one-on-one semistructured telephone interviews with Black women in Tennessee between September 2020 and November 2020. Guided by the Health Belief Model, qualitative analysis of interview data was performed in an iterative inductive and deductive approach and resulted in the development of a conceptual framework to depict influences on a woman's decision to engage with breast cancer risk assessment. RESULTS: A total of 37 interviews were completed, and a framework of influences on a woman's decision to engage in breast cancer risk assessment was developed. Study participants identified several emerging themes regarding women's perspectives on breast cancer risk assessment and potential influences on women's decisions to engage with risk assessment. Much of women's decision context was based on risk appraisal (perceived severity of cancer and susceptibility of cancer), emotions (fear and trust), and perceived risks and benefits of having risk assessment. The decision was further influenced by modifiers such as communication, the risk assessment protocol, access to health care, knowledge, and health status. Perceived challenges to follow-up if identified as high risk also influenced women's decisions to pursue risk assessment. CONCLUSIONS: Black women in this study identified several barriers to engagement with breast cancer risk assessment. Efforts to overcome these barriers and increase the use of breast cancer risk assessment can potentially serve as a catalyst to address existing breast cancer disparities. Continued work is needed to develop patient-centric strategies to overcome identified barriers.

Barriers to Implementation of Breast Cancer Risk Assessment: The Health Care Team Perspective.

PURPOSE: To assess health care professionals' perceptions of barriers to the utilization of breast cancer risk assessment tools in the public health setting through a series of one-on-one interviews with health care team members. METHODS: We conducted a cross-sectional qualitative study consisting of one-on-one semistructured telephone interviews with health care team members in the public health setting in the state of Tennessee between May 2020 and October 2020. An iterative inductive-deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual framework to depict influences of provider behavior in the utilization of breast cancer risk assessment. RESULTS: A total of 24 interviews were completed, and a framework of influences of provider behavior in the utilization of breast cancer risk assessment was developed. Participants identified barriers to the utilization of breast cancer risk assessment (knowledge and understanding of risk assessment tools, workflow challenges, and availability of personnel); patient-level barriers as perceived by health care team members (psychological, economic, educational, and environmental); and strategies to increase the utilization of breast cancer risk assessment at the provider level (leadership buy-in, training, supportive policies, and incentives) and patient level (improved communication and better understanding of patients' perceived cancer risk and severity of cancer). CONCLUSIONS: Understanding barriers to implementation of breast cancer risk assessment and strategies to overcome these barriers as perceived by health care team members offers an opportunity to improve implementation of risk assessment and to identify a racially, geographically, and socioeconomically diverse population of young women at high risk for breast cancer.

Refugee and Migrant Health Literacy Interventions in High-Income Countries: A Systematic Review.

Health literacy is a key determinant of health in refugee and migrant populations living in in high-income countries (HICs). We conducted a systematic review of randomized-controlled trials (RCTs) to characterize the scope, methodology, and outcomes of research on interventions aimed at improving health literacy among these vulnerable populations. We searched EMBASE, MEDLINE, PsycINFO, CINAHL, and Web of Science databases to identify RCTs of health literacy intervenions in our target population published between 1997 and 2018. The search yielded 23 RCTs (n = 5625 participants). Study demographics, health literacy topics, interventions, and outcome measures were heterogeneous but demonstrated overall positive results. Only two studies used a common health literacy measure. Few RCTs have been conducted to investigate interventions for improving the health literacy of refugees and migrants in HICs. The heterogeniety of health literacy outcome measures used impeded a robust comparison of intervention efficacy.

Primum Non Nocere: A Case Report of Iatrogenic Fracture of the Mandibular Angle During Excision of an Impacted Third Molar.

Third molar extractions are one of the most commonly performed dental procedures. It is associated with numerous complications, of which mandibular angle fracture is a rare but distressing complication. These can occur as intraoperative and postoperative (late) events. Iatrogenic fractures involving the angle of the mandible represent a unique challenge for management owing to their complex biomechanics and various anatomical factors. Intraoperative fractures occur due to various reasons, which include the position of the tooth, depth of impaction, extent of odontectomy performed, and injudicious use of dental elevators. This exhibited report describes a case of iatrogenic mandibular angle fracture (IFM) during excision of an impacted third molar in a 30-year-old female. Additionally, it discusses the various reasons and preventive strategies to avoid such complications.

Insight of Ethnomedicines in Dentistry: A Brief Review.

Ethnomedicines in the literature compare the therapeutic efficacy of various herbs based on active ingredients of plants and animals. The application of phytomedicines in the field of dentistry is uncommon. The main objective of this article is to access the efficacy of ethnomedicines and newly evolving treatment modalities in reducing post-op complications following dentoalveolar surgeries. Inclusion criteria were selected according to the population, intervention, control, and outcomes (PICO) format. Case reports, case series, retrospective studies, and studies with inappropriate reporting of outcomes were all excluded. An electronic search of English literature in PubMed was performed using the keywords Ethnomedicine, Anti-inflammatory, Analgesics, Therapeutic herbs, Herbal mouthwashes, Third molar surgery. A total of 25 articles were selected, of which three were on herbal mouthwashes and 22 were on anti-inflammatory effect. All the articles were regarding the therapeutic effect of the herbs. The present paper studies various traditionally used therapeutic herbs, their benefits, and shortcomings with their application in dentistry. This study has shown the different herbal alternatives to conventionally used drugs in relation to third molar.