Evaluating the impact of sugar-sweetened beverages tax on overweight, obesity, and type 2 diabetes in an affluent Asian setting: A willingness-to-pay survey and simulation analysis.

BACKGROUND: The potential health effects of taxing sugar-sweetened beverages (SSBs) has been insufficiently examined in Asian contexts. This study aimed to assess the impact of SSB taxation on the prevalence of obesity/overweight and type 2 diabetes mellitus (T2DM) in Hong Kong using a willingness-to-pay (WTP) survey and simulation analysis. METHODS: A random telephone survey was conducted with 1000 adults from May to June 2020. We used a contingent valuation approach to assess individuals' WTP for SSBs under four tax payment scenarios (5%, 10%, 40%, and 50% of the current market price). Based on the WTP, a simulation analysis was conducted to project changes in SSB purchase and associated reductions in the prevalence of obesity/overweight and T2DM over a 10-year simulation period. FINDINGS: When 5% and 10% taxation rates were introduced, approximately one-third of the population were unwilling to maintain their SSB purchase. Our simulation demonstrated a gradual decline in the prevalence of obesity/overweight and diabetes with a more pronounced decrease when higher taxation rates were introduced. 10% taxation resulted in a mean reduction of 1532.7 cases of overweight/obesity per 100 thousand population at the sixth year, while T2DM prevalence decreased by 267.1 (0.3%). CONCLUSIONS: This study underscores the effects of an SSB tax on purchase behaviors and health outcomes in an affluent Asia setting, with a more pronounced influence on adult population. These findings are expected to inform policymakers in making decisions regarding an effective and equitable tax rate on SSBs.

Cost effectiveness of hepatitis C direct acting agents.

INTRODUCTION: Introduction of direct acting antivirals (DAA) has transformed treatment of chronic hepatitis C (HCV) and made the elimination of HCV an achievable goal set forward by World Health Organization by 2030. Multiple barriers need to be overcome for successful eradication of HCV. Availability of pan-genotypic HCV regimens has decreased the need for genotype testing but maintained high efficacy associated with DAAs. AREAS COVERED: In this review, we will assess the cost-effectiveness of DAA treatment in patients with chronic HCV disease, with emphasis on general, cirrhosis, and vulnerable populations. EXPERT OPINION: Multiple barriers exist limiting eradication of HCV, including cost to treatment, access, simplified testing, and implementing policy to foster treatment for all groups of HCV patients. Clinically, DAAs have drastically changed the landscape of HCV, but focused targeting of vulnerable groups is needed. Public policy will continue to play a strong role in eliminating HCV. While we will focus on the cost-effectiveness of DAA, several other factors regarding HCV require on going attention, such as increasing public awareness and decreasing social stigma associated with HCV, offering universal screening followed by linkage to treatment and improving preventive interventions to decrease spread of HCV.

Unfavorable transcriptome profiles and social disadvantage in hematopoietic cell transplantation: a CIBMTR analysis.

Patient-reported outcomes (PROs) capture subjective social determinants of health (SDOHs), which can affect health outcomes through the stress response pathway. The conserved transcriptional response to adversity (CTRA) is a stress-mediated proinflammatory transcriptomic pattern that has been linked to adverse hematopoietic cell transplant (HCT) outcomes. This study examined the association of pretransplant CTRA with patient-reported SDOHs in allogeneic HCT recipients. In this cross-sectional study, pre-HCT SDOH-related PROs included the 36-Item Short Form Health Survey and the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT). CTRA was assessed by RNA sequencing of whole blood specimens, with mixed effects linear regression models relating CTRA expression to PRO scores while controlling for age, sex, race, disease, and performance status. Among 121 patients, the median age was 54 years, 42% were female, and 91% were White. CTRA was elevated in participants reporting lower scores on the FACT-BMT (P = .003), including the general (P = .003) and BMT-specific (P = .014) components. Effects were driven by the social well-being domain (P = .0001). This corresponded to an 8% to 15% difference in CTRA RNA expression across a 4 standard deviation range in patient-reported SDOHs. Ancillary bioinformatics analyses confirmed the association of well-being with reduced proinflammatory transcription pathway activity [cyclic AMP response element-binding protein, (CREB), NF-κB, and activating protein-1 (AP-1)]. In conclusion, HCT-treated patients who experience unfavorable social conditions show elevated CTRA expression in pretransplant blood samples. These data highlight the biologic sequelae of social well-being and community context and suggest a potential molecular mechanism for the impact of social gradients in HCT outcomes. Targeting this pathway could optimize outcomes in this high-risk population.

Exploring Health Care Disparities in Maternal-Child Simulation-Based Education.

AIM: The purpose of this study was to explore student experiences within a health care disparity simulation, embedded in maternal-child content. BACKGROUND: Health care disparities related to race and ethnicity in the maternal-child population are daunting among African American and Hispanic women. METHOD: Participants completed the Simulation Effectiveness Tool-Modified, a rapid-fire huddle questionnaire, and a demographic instrument. All students participated in structured debriefing. RESULTS: Student responses ( n = 69) demonstrated effectiveness in learning via this scenario. CONCLUSION: The rapid-fire huddle and debriefing are important elements when health care disparities are introduced into nursing curricula.

Exploring Access and Utilization of Early Intervention Services Among Families Experiencing Homelessness: A Qualitative Study.

Children experiencing homelessness face particular barriers to accessing early interventions. Our study sought to explore the experiences of families in accessing Early Intervention Program services (EI) while living in a family shelter. Semi-structured in-depth interviews were undertaken with nineteen caregivers who had recently experienced or were contemporaneously experiencing homelessness from three shelter sites in Boston, Massachusetts. Our findings demonstrate the role of the shelter both in inhibiting and promoting access to early intervention. Shelter-related barriers included limited physical space, lack of care continuity amidst frequent relocations, and mistrust due to feelings of stigma. Early interventionists played a crucial role in mitigating challenges but were often unable to fully overcome these and other barriers tied to shelter environments. Effective strategies included flexibility in accommodating shifting schedules, provision of socioemotional support, and proactively linking caregivers to additional upstream resources. Efforts to mitigate shelter-related challenges will require interdisciplinary collaboration at both local and state levels. Further efforts should focus on providing increased continuity of care in a manner that acknowledges the structural barriers of homelessness.

Measuring capacity to use evidence-based interventions in community-based organizations: A comprehensive, scoping review.

Introduction: Community-based organizations (CBOs) are well-positioned to incorporate research evidence, local expertise, and contextual factors to address health inequities. However, insufficient capacity limits use of evidence-based interventions (EBIs) in these settings. Capacity-building implementation strategies are popular, but a lack of standard models and validated measures hinders progress in the field. To advance the literature, we conducted a comprehensive scoping review. Methods: With a reference librarian, we executed a comprehensive search strategy of PubMed/Medline, Web of Science Core Collection, and EBSCO Global Health. We included articles that addressed implementation science, capacity-building, and CBOs. Of 5527 articles, 99 met our inclusion criteria, and we extracted data using a double-coding process. Results: Of the 99 articles, 47% defined capacity explicitly, 31% defined it indirectly, and 21% did not define it. Common concepts in definitions were skills, knowledge/expertise, and resources. Of the 57 articles with quantitative analysis, 48 (82%) measured capacity, and 11 (23%) offered psychometric data for the capacity measures. Of the 99 studies, 40% focused exclusively on populations experiencing inequities and 22% included those populations to some extent. The bulk of the studies came from high-income countries. Conclusions: Implementation scientists should 1) be explicit about models and definitions of capacity and strategies for building capacity, 2) specify expected multi-level implementation outcomes, 3) develop and use validated measures for quantitative work, and 4) integrate equity considerations into the conceptualization and measurement of capacity-building efforts. With these refinements, we can ensure that the necessary supports reach CBO practitioners and critical partners for addressing health inequities.

Hiding in plain sight: How incorporating honest discussion of racial and social (in)justice into medical education can inspire change.

The carnage wrought by systemic racism through social, judicial, and health injustices compels us to work towards a system that is fair and just for patients and colleagues. The evidence that change is necessary in medicine is hiding in plain sight in literature, oral histories, medical records, and news media. Notwithstanding this evidence, changing a system 400 years in the making will require a major paradigm shift. One of the many ways our department sought to catalyze such a shift was through media consumption, reflection, and discussion. Reading and studying literature and humanities in medicine can awaken our consciousness by making medicine an embodied practice that considers the totality of patients' lives in ways that a disembodied, purely scientific approach cannot. Thus, we started a Racial and Social Justice Book Club to normalize discussions about racial and social (in)justice and examine everything through an anti-racist lens. Herein, we describe our experiences in the inaugural year of the Book Club, a space to lend credence and dignity to the voices, experiences, and stories of folks who have long been marginalized by power structures in America, including medicine.

Physician Perspectives on the Effect of Topical Steroid Costs on Patients and Proposed Solutions.

IMPORTANCE: Rising costs of topical steroids have increased overall health care and patient out-of-pocket costs while increasing administrative burden on dermatologists and office staff. OBJECTIVE: To explore factors affecting the decision-making process for dermatologists around topical steroid prescriptions, determine the association of insurance coverage and cost, and assess willingness to implement solutions to decrease out-of-pocket topical steroid costs for patients. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study was conducted from June to November 2020 and used semistructured interviews of 16 dermatologists who reflected a mix of physicians in academic, nonacademic, and private practice until thematic saturation was reached. Each interview was independently coded by 2 researchers. Code frequency and interrater reliability were determined using NVIVO software. Data analysis was conducted from November 2020 to March 2021. MAIN OUTCOMES AND MEASURES: Factors influencing dermatologist decision-making around topical steroid selection, outcomes of unaffordable medications on patients, solution recommendations, and perspectives on a system to automatically substitute topical steroid for cheaper alternatives of the same class and vehicle. RESULTS: Of the 16 dermatologists, 8 (50.0%) were women, 8 (50.0%) were men, 1 (6.3%) was Asian, 2 (12.5%) were Latinx, and 12 (75.0%) were White. The interrater reliability ranged from κ = 0.86 to κ = 0.98, indicating excellent agreement. Most physicians (13 [81%]) thought about costs regularly when making choices about topical steroids. All physicians identified a scenario in which patients could not obtain medication based on cost. In these cases, 15 (94%) reported that they try to find an alternative medication by calling the pharmacist or insurance company. Despite a desire to consider cost at the time of prescribing, physicians reported not knowing medication costs before prescribing because of the variability of insurance coverage (15 [94%]), lack of transparency (12 [75%]), and fluctuating drug prices (12 [75%]). In addition to affecting patients, 14 physicians (88%) reported that a patient's inability to afford medications increases administrative burden. Physicians suggested that they were open to solutions that focused on increased cost transparency (10 [63%]) and improved electronic health record technologies. Furthermore, 14 (88%) were willing to use a system to allow the substitution of one topical steroid for another of the same class and vehicle. CONCLUSIONS AND RELEVANCE: The results of this qualitative study suggest that opacity around drug costs reduces access for patients and is followed by administrative stress for physicians and staff. Dermatologists are receptive to systems that provide greater transparency for drug costs or automate substitution of equivalent cheaper drugs for patients.

Towards gender equity in artificial intelligence and machine learning applications in dermatology.

There has been increased excitement around the use of machine learning (ML) and artificial intelligence (AI) in dermatology for the diagnosis of skin cancers and assessment of other dermatologic conditions. As these technologies continue to expand, it is essential to ensure they do not create or widen sex- and gender-based disparities in care. While desirable bias may result from the explicit inclusion of sex or gender in diagnostic criteria of diseases with gender-based differences, undesirable biases can result from usage of datasets with an underrepresentation of certain groups. We believe that sex and gender differences should be taken into consideration in ML/AI algorithms in dermatology because there are important differences in the epidemiology and clinical presentation of dermatologic conditions including skin cancers, sex-specific cancers, and autoimmune conditions. We present recommendations for ensuring sex and gender equity in the development of ML/AI tools in dermatology to increase desirable bias and avoid undesirable bias.

Dynamic assessment of insulin secretion and insulin resistance in Asians with prediabetes.

AIMS/HYPOTHESIS: Prediabetes and type 2 diabetes are highly prevalent in Asia. Understanding the pathophysiology of abnormal glucose homeostasis in Asians will have important implications for reducing disease burden, but there have been conflicting reports on the relative contributions of insulin secretion and action in disease progression. In this study, we aimed to assess the contribution of ß-cell dysfunction and insulin resistance in the Asian prediabetes phenotype. METHODS: We recruited 1679 Asians with prediabetes (n = 659) or normoglycemia (n = 1020) from a multi-ethnic population in Singapore. Participants underwent an oral glucose tolerance test, an intravenous glucose challenge, and a hyperinsulinemic-euglycemic clamp procedure to determine glucose tolerance, ß-cell responsivity, insulin secretion, insulin clearance and insulin sensitivity. RESULTS: Participants with prediabetes had significantly higher glucose concentrations in the fasting state and after glucose ingestion than did normoglycemic participants. Insulin sensitivity (M/I ratio) was ~15% lower, acute insulin response (AIR) to intravenous glucose and ß-cell responsivity to oral glucose were ~35% lower, but total insulin secretion rate in the fasting state and after glucose ingestion was ~10% greater in prediabetic than in normoglycemic participants. The decrease in ß-cell function with worsening glucose homeostasis in Asians with prediabetes was associated with progressively greater defects in AIR rather than M/I. However, analysis using static surrogate measures (HOMA indices) of insulin resistance and ß-cell function revealed a different pattern. CONCLUSIONS: Lower AIR to intravenous glucose and ß-cell responsivity to oral glucose, on a background of mild insulin resistance, are the major contributors to the dysregulation of glucose homeostasis in Asians with prediabetes.

The 2019 Conference on Health and Active Transportation: Research Needs and Opportunities.

Active transportation (AT) is widely viewed as an important target for increasing participation in aerobic physical activity and improving health, while simultaneously addressing pollution and climate change through reductions in motor vehicular emissions. In recent years, progress in increasing AT has stalled in some countries and, furthermore, the coronavirus (COVID-19) pandemic has created new AT opportunities while also exposing the barriers and health inequities related to AT for some populations. This paper describes the results of the December 2019 Conference on Health and Active Transportation (CHAT) which brought together leaders from the transportation and health disciplines. Attendees charted a course for the future around three themes: Reflecting on Innovative Practices, Building Strategic Institutional Relationships, and Identifying Research Needs and Opportunities. This paper focuses on conclusions of the Research Needs and Opportunities theme. We present a conceptual model derived from the conference sessions that considers how economic and systems analysis, evaluation of emerging technologies and policies, efforts to address inclusivity, disparities and equity along with renewed attention to messaging and communication could contribute to overcoming barriers to development and use of AT infrastructure. Specific research gaps concerning these themes are presented. We further discuss the relevance of these themes considering the pandemic. Renewed efforts at research, dissemination and implementation are needed to achieve the potential health and environmental benefits of AT and to preserve positive changes associated with the pandemic while mitigating negative ones.

Prevalence and predictors of cost-related medication nonadherence in individuals with cardiovascular disease: Results from the Behavioral Risk Factor Surveillance System (BRFSS) survey.

Medication nonadherence is highly prevalent among patients with chronic cardiovascular disease. Poor adherence has been associated with increased morbidity and mortality. Medication cost is a major driver for medication nonadherence. Utilizing data from the 2016 to 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey, we estimated the prevalence of cost-related medication nonadherence (CRMNA) among the overall population and among individuals who reported a history of diabetes, atherosclerotic cardiovascular disease (ASCVD), or hypertension. We then performed multivariable logistic regression to analyze sociodemographic factors associated with CRMNA. Our study population consisted of 142,577 individuals of whom 24% were older than 65 years, 47% were men, 66% were White, 17% Black, 35% had hypertension, 13% had diabetes mellitus, and 10% had ASCVD. CRMNA was reported in 10% of the overall population, 12% among those with hypertension, 17% among those with diabetes, and 17% among those with ASCVD. Age below 65 years, female gender, unemployment, lower income, lower educational attainment, having at least 1 comorbidity, and living in a state that did not expand Medicaid were independently associated with CRMNA. The prevalence of CRMNA increased with greater number of these high-risk sociodemographic factors. We conclude that the prevalence of CRMNA is 10% among U.S. adults overall and is higher among those with common chronic diseases. Risk factors associated with CRMNA should be addressed in order to improve adherence rates and health outcomes among high-risk individuals.

The Current Status of Concussion Assessment Scales: A Critical Analysis Review.

¼: Concussion is a complex pathophysiologic process that affects the brain; it is induced by biomechanical forces, with alteration in mental status with or without loss of consciousness. ¼: Concussion assessment tools may be broadly categorized into (1) screening tests such as the SAC (Standardized Assessment of Concussion), the BESS (Balance Error Scoring System), and the King-Devick (KD) test; (2) confirmatory tests including the SCAT (Sport Concussion Assessment Tool), the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), and the VOMS (Vestibular Oculomotor Screening); and (3) objective examinations such as brain network activation (BNA) analysis, imaging studies, and physiologic markers. ¼: The KD, child SCAT3 (cSCAT3), child ImPACT (cImPACT), and VOMS tests may be used to evaluate for concussion in the pediatric athlete. ¼: Future work with BNA, functional magnetic resonance imaging, diffusion tensor imaging, and serum biomarkers may provide more objective assessment of concussion, neurologic injury, and subsequent recovery.

Exploring an Emerging Measurement Issue in Older Adult Maltreatment: Exploitation of Older Adults' Residences.

Despite nationwide housing challenges that might lead to the exploitation of older adults' housing resources, exploitation of older adults' residences has not been a focus of measurement in the rapidly developing field of elder abuse and neglect. Rather, measures of older adult abuse and exploitation used in the research literature emphasize specific property, money, or resources being taken. Two composites are used to illustrate exploitation of older adults' residences by trusted others on whom the older adults depended with potentially serious implications for environmental safety and ultimately the older adults' housing stability. As part of a larger study on older adult maltreatment, police reports were coded for abuse and financial exploitation as well as misuse of the older adult's residence that threatened the older adult's housing security and/or exerted control over the older adult. Nearly one in ten (9.2%) police reports involving older adult victims and known/trusted perpetrators described exploitation of residences. Residence exploitation was separable from financial exploitation and less likely to co-occur with neglect. Considering the importance of housing stability to older adult well-being, consequences of maltreatment by a known/trusted other, and a national housing crisis, we propose that exploitation of older adults' residences warrants further measurement and practice attention. Findings are relevant to advancing theory in older adult maltreatment (e.g., application of white-collar crime versus betrayal trauma and family violence theories).

A versatile, cost-effective, and flexible wearable biosensor for in situ and ex situ sweat analysis, and personalized nutrition assessment.

Point-of-care (POC) diagnostics have shown excellent potential in rapid biological analysis and health/disease monitoring. Here, we introduce a versatile, cost-effective, flexible, and wearable POC biomarker patch for effective sweat collection and health monitoring. We design and fabricate channels/patterns on filter paper using wax printing technology, which can direct sweat to collection and biomarker detection zones on the proposed platform. The detection zones are designed to measure the amount of collected sweat, in addition to measuring the sweat pH, and glucose (a potential diabetic biomarker), and lactate concentrations. It is significantly challenging to measure glucose in human sweat by colorimetric methods due to the extremely low glucose levels found in this medium. However, we overcame this issue by effectively engineering our wearable biosensor for optimal intake, storage, and evaporation of sweat. Our design concentrates the colorant (indicator) into a small detection zone and significantly increases the sensitivity for the sweat glucose sensing reactions. The device can thus detect glucose in physiological glucose concentration range of 50-300 µM. This cost-effective and wearable biosensor can provide instant in situ quantitative results for targets of interest, such as glucose, pH, and lactate, when coupled with the imaging and computing functionalities of smartphones. Meanwhile, it is also feasible to extract the air-dried sweat from the storage zone for further ex situ measurements of a broader portfolio of biomarkers, leading to applications of our wearable biosensor in personalized nutrition and medicine.

Shifting from "Community-Placed" to "Community-Based" Research to Advance Health Equity: A Case Study of the Heatwaves, Housing, and Health: Increasing Climate Resiliency in Detroit (HHH) Partnership.

Extreme summertime heat is a significant public health threat that disproportionately impacts vulnerable urban populations. Research on health impacts of climate change (including increasing intensity, duration, and frequency of hot weather) is sometimes designed and implemented without the involvement of the communities being studied, i.e., "community-placed" not "community-based." We describe how the Heatwaves, Housing, and Health: Increasing Climate Resiliency in Detroit (HHH) partnership engaged relevant communities by integrating a community-based participatory research (CBPR) approach into an existing, academic-designed research project through a steering committee of community and academic partners. Using a case study approach, we analyze program documentation, partnership evaluation questionnaires, and HHH steering committee meeting notes. We describe the CBPR process by which we successfully collected research data in Detroit during summer 2016, engaged in collaborative analysis of data, and shared results with Detroit residents. Evaluations of the partnership over 2 years show community involvement in research; enhanced capacities; success in securing new grant funding; and ways that CBPR strengthened the validity, relevance, and translation of research. Engaging communities as equal partners using CBPR, even after a study is underway, can strengthen research to understand and address the impacts of extreme heat on health and equity in urban communities.

Assessment of test method variables for in vitro skin irritation testing of medical device extracts.

Skin irritation is an important component of the biological safety evaluation of medical devices. This testing has typically been performed using in vivo models. However, in an effort to reduce the need for in vivo testing, alternative methods for assessing skin irritation potential in vitro have been developed using a Reconstructed Human Epidermis (RhE) model. During the development of the protocol for the round robin validation of in vitro irritation testing for medical device extracts, it became clear that there were three points in the procedure where different options may be validated within each laboratory for routine testing: sample exposure time (18 vs 24h), SDS positive control concentration, and cytokine (IL-1α) release testing. The goal of our study was to evaluate the effect of these variables. EpiDerm™ tissues were exposed to extracts of three plain polymer samples, and four polymers embedded with known irritant chemicals. Exposures were performed for 18 and 24h. Resulting tissue viability was assessed by MTT reduction and IL-1α release was assessed by ELISA. Testing was also performed using various concentrations of SDS ranging from 0.5 to 1% (w/v). Overall, results were similar for samples tested and 18 and 24h, but the 18h exposure time has the potential to have an impact on the results of some sample types. IL-1α testing was shown to be useful to clarify conflicting tissue viability results. Use of a lower concentration of SDS as a positive control can help prevent issues that arise from excessive tissue damage often caused by 1% SDS.