Embracing Diversity, Equity, Inclusion, and Accessibility in Eosinophilic Gastrointestinal Diseases.

Eosinophilic gastrointestinal diseases (EGIDs) including eosinophilic esophagitis (EoE) are rare diseases in which eosinophils abnormally infiltrate the gastrointestinal tract. Because these are rare diseases, there is limited information regarding race and ethnicity in EGIDs and even less is known about the impact of socioeconomic factors. There is some evidence that access to care in rural settings may be affecting epidemiologic understanding of EGIDs in the pediatric populations. Future work should try to evaluate bias in research and strive for representation in clinical trials and medicine.

Correlations Between Relative Prevalence of Celiac Disease and Sociodemographic Variables in the United States.

INTRODUCTION: We evaluated the associations between celiac disease (CD) prevalence and regional sociodemographic variables in the United States. METHODS: The outcome was CD relative prevalence, defined as number of patients with CD among those in a Medicare registry per 3-digit ZIP code. Linear regression models assessed associations between relative prevalence of CD and sociodemographic variables. RESULTS: CD relative prevalence was positively correlated with median income, urban area, and proximity to a CD specialty center and negatively correlated with Black race, Latino/Hispanic ethnicity, and median social deprivation index score ( P < 0.01, all). DISCUSSION: CD relative prevalence is associated with indicators of economic advantage.

Enhancing diversity, equity, inclusion, and accessibility in eosinophilic gastrointestinal disease research: the consortium for eosinophilic gastrointestinal disease researchers' journey.

In response to the social inequities that exist in health care, the NIH-funded Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR) recently formed a diversity committee to examine systemic racism and implicit bias in the care and research of eosinophilic gastrointestinal diseases (EGIDs). Herein, we describe our process, highlighting milestones and issues addressed since the committee's inception, which we hope will inspire other researchers to enhance diversity, equity, inclusion, and accessibility (DEIA) in their fields. Our journey began by establishing mission and vision statements to define the purpose of the committee. Regular discussion of diversity-related topics was incorporated into existing meetings and web-based materials were shared. This was followed by educational initiatives, including establishing a library of relevant publications and a speaker series to address DEIA topics. We then established a research agenda focused on the following actionable items: (1) to define what is known about the demographics of EGIDs by systematic review of population-based studies; (2) to develop a practical tool for reporting participant demographics to reduce bias in EGID literature; (3) to examine health disparities in the care of individuals with eosinophilic esophagitis who present to the emergency department with an esophageal food impaction; (4) to examine how access to a gastroenterologist affects the conclusions of published research examining the prevalence of pediatric eosinophilic esophagitis; and (5) to develop a model for examining the dimensions of diversity, and provide a framework for CEGIR's ongoing projects and data capture. In addition to promoting consciousness of DEIA, this initiative has fostered inclusivity among CEGIR members and will continue to inspire positive changes in EGID care and research.

Diversity in Eosinophilic Gastrointestinal Disease Research To address systemic bias in patient care and research in eosinophilic gastrointestinal diseases, the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR) recently formed a diversity committee. The CEGIR diversity committee has defined its purpose through mission and vision statements and developed structured educational and research initiatives to enhance diversity, equity, inclusivity, and accessibility (DEIA) in all CEGIR activities. Here, we share the process of formation of our diversity committee, highlighting milestones achieved and summarizing future directions. We hope that this report will serve as a guide and an inspiration for other researchers to enhance DEIA in their fields.

Impact of monsoon season rainfall spells on the ecosystem carbon exchanges of Himalayan Chir-Pine and Banj-Oak-dominated forests: a comparative assessment.

The Chir-Pine (Pinus roxburghii) and Banj-Oak (Quercus leucotrichophora)-dominated ecosystems of central Himalaya provide significant green services. However, responses of these ecosystems, with respect to ecosystem carbon flux variability, to changing microclimate are not yet studied. Since quantification of ecosystem responses to fluctuation in the microclimate, particularly rainfall, is expected to be beneficial for management of these ecosystems, this study aims (i) to quantify and compare amplitude of rainfall-induced change in the carbon fluxes of Chir-Pine and Banj-Oak-dominated ecosystems using wavelet methods, and (ii) to quantify and compare dissimilarities in the ecosystem exchanges due to varying rainfall spell and amount. Eddy covariance-based continuous daily micrometeorological and flux data, during the 2016-2017 monsoon seasons (total 244 days, 122 days of June-September), from two sites in Uttarakhand, India, are used for this purpose. We find that both Chir-Pine and Banj-Oak-dominated ecosystems are the sinks of carbon, and Chir-Pine-dominated ecosystem sequesters around 1.8 times higher carbon than the Banj-Oak. A systematic enhancement in the carbon assimilation of the Chir-Pine-dominated ecosystem is noted with increasing rainfall spell following a statistically significant power-law relationship. We have also identified a rainfall amount threshold for Chir-Pine and Banj-Oak-dominated ecosystems (10 ± 0.7 and 17 ± 1.2 mm, respectively) that resulted in highest ecosystem carbon assimilation in monsoon. The general inference of this study accentuates that Banj-Oak-dominated ecosystem is more sensitive to maximum rain within a spell whereas the Chir-Pine-dominated ecosystem is more responsive to increasing rainfall spell duration.

How Telehealth Can be Used to Improve Maternal and Child Health Outcomes: A Population Approach.

Mobile applications and telehealth services are being used to unprecedented degrees in maternal and child care, with uncertain impact on population health outcomes. In this article, we will review the role of the COVID-19 pandemic in accelerating large scale implementation of telehealth services, known and anticipated impacts on maternal and child health and related inequities, and potential strategies to optimize outcomes at the population level.

Medicaid member perspectives on innovation in prenatal care delivery: A call to action from pregnant people using unscheduled care.

BACKGROUND: Low-income women using prenatal care have shared concerns as well as unique needs not met by traditional prenatal care. Our objective was to explore user ideas on addressing unmet needs driving unscheduled care utilization and use findings to inform interventions to improve perinatal outcomes. METHODS: We performed a secondary analysis of qualitative interviews among purposively sampled, Medicaid-insured pregnant women with varied degrees of unscheduled care utilization. Interviews explored barriers and facilitators of health and ideas for improvement in care delivery, with a focus on the potential role of community health workers and social support. We extracted material on participants' perceived gaps and ideas, used modified grounded theory to develop general and subset themes by study group, and then mapped themes to potential intervention features. RESULTS: We identified intervention targets in three thematic domains: social support, care delivery, and access, noting sub-group differences. Participants with four or more unscheduled visits during pregnancy ("Group 1") wanted individualized help navigating resources, coaching, and peer support, while participants with a first unscheduled care visit after 36 weeks of pregnancy ("Group 2) wanted these services to be optional. Group 1 participants wanted flexible appointments, less wait time, discharge education and improved communication with providers, while Group 2 participants sought stable insurance coverage. CONCLUSIONS: Findings suggest acceptable approaches to improve social support, care delivery, and access via stratified, targeted interventions. IMPLICATIONS: Targeted interventions to improve prenatal care that incorporate user ideas and address unique unmet needs of specific subgroups may improve perinatal outcomes. LEVEL OF EVIDENCE: III.

Racial Inequities in Preventable Pregnancy-Related Deaths in Louisiana, 2011-2016.

OBJECTIVE: To examine preventable pregnancy-related deaths in Louisiana by race and ethnicity and maternal level of care to inform quality improvement efforts. METHODS: We conducted a retrospective observational descriptive analysis of Louisiana Pregnancy-Associated Mortality Review data of 47 confirmed pregnancy-related deaths occurring from 2011 to 2016. The review team determined cause of death, preventability, and contributing factors. We compared preventability by race-ethnicity and maternal level of care of the facility where death occurred (from level I: basic care to level IV: regional perinatal health center) using odds ratios (ORs) and 95% CIs. RESULTS: The rate of pregnancy-related death among non-Hispanic black women (22.7/100,000 births, 95% CI 15.5-32.1, n=32/140,785) was 4.1 times the rate among non-Hispanic white women (5.6/100,000, 95% CI 2.8-10.0, n=11/197,630). Hemorrhage (n=8/47, 17%) and cardiomyopathy (n=8/47, 17%) were the most common causes of pregnancy-related death. Among non-Hispanic black women who experienced pregnancy-related death, 59% [n=19] of deaths were deemed potentially preventable, compared with 9% (n=1) among non-Hispanic white women (OR 14.6, 95% CI 1.7-128.4). Of 47 confirmed pregnancy-related deaths, 58% (n=27) occurred at level III or IV birth facilities. Compared with those at level I or II birth facilities (n=2/4, 50%), pregnancy-related deaths occurring at level III or IV birth facilities (n=14/27, 52%) were not less likely to be categorized as preventable (OR 2.0, 95% CI 0.5-8.0). CONCLUSION: Compared with non-Hispanic white women, pregnancy-related deaths that occurred among non-Hispanic black women in Louisiana from 2011 to 2016 were more likely to be preventable. The proportion of deaths that were preventable was similar between lower and higher level birth facilities. Hospital-based quality improvement efforts focused on addressing hemorrhage, hypertension, and associated racial inequities may prevent pregnancy-related deaths in Louisiana.

Lesbian, Gay, Bisexual, and Transgender Health: Obstetrician-Gynecologists' Training, Attitudes, Knowledge, and Practice.

BACKGROUND: Deficits in provider training may contribute to disparities impacting lesbian, gay, bisexual, transgender, and gender nonconforming (LGB-TGNC) individuals. METHODS: We sent an anonymous online survey to randomly selected members of the American Congress of Obstetricians and Gynecologists and stratified responses by the history of training. We used logistic regression to predict impact of previous training on provider comfort with LGB-TGNC patients, and secondary outcomes, including provider practices, knowledge, and attitudes. RESULTS: Two hundred twenty-eight of 428 (53.3%) surveys were completed. Of the 169 providers currently practicing gynecology, 72 respondents (42.6%) reported previous training in LGB-TGNC health. Those who self-identified or had a close contact identifying as LGB-TGNC were more likely to report previous training (68.1% vs. 49.5%, p = 0.02). When adjusting for demographic differences, providers reporting previous training were not more likely to be comfortable taking care of transgender/gender-nonconforming patients (aOR 1.8, 95% CI 0.95-3.40). They were more likely to report practice changes such as eliciting sexual orientation (aOR 2.15, 95% CI 1.08-4.28) and gender identity (aOR 3.02, 95% CI 1.07-8.52). Training was not independently associated with differences in provider knowledge (aOR 1.33, 95% CI 0.68-2.58) or likelihood of providing independent medical or surgical care for gender affirmation (aOR 1.64, 95% CI 0.78-3.45). CONCLUSIONS: Less than half of board-certified obstetrician-gynecologists reported training in LGB-TGNC health, with evidence of a familiarity effect in who seeks training and provides care that accounts for differences in attitudes, knowledge, and practices. Training efforts to advance LGB-TGNC health must address bias and comfort in addition to clinical competencies.

Adherence to a Gluten-free Diet: Assessment by Dietician Interview and Serology.

We aimed to determine whether tissue transglutaminase (tTG) autoantibody positivity was associated with dietitian-assessed adherence to a gluten-free diet in pediatric patients with celiac disease and identify areas where adherence falters. We reviewed the records of children with celiac disease who had a standardized evaluation of adherence by a registered dietitian. A negative tTG value was not associated with good adherence (P = NS). Adherent and nonadherent children differed with respect to purposeful and accidental gluten exposure (P < 0.0001), knowledge (P = 0.003), cross-contact (P = 0.003), potential exposure via medications and cosmetics (P = 0.004), and potential exposure while at restaurants (P < 0.0001), but not with respect to potential exposure at school (P = NS). Based on our findings, we suggest that negative tTG levels are not necessarily indicative of good adherence to a gluten-free diet in pediatric patients with celiac disease. A separate assessment of adherence is needed focusing on knowledge, behavior while dining out, and intent to adhere.

Medicaid Coverage of Methadone Maintenance and the Use of Opioid Agonist Therapy Among Pregnant Women in Specialty Treatment.

BACKGROUND: Opioid agonist therapy (OAT) is the standard of care for pregnant women with opioid use disorder (OUD). Medicaid coverage policies may strongly influence OAT use in this group. OBJECTIVE: To examine the association between Medicaid coverage of methadone maintenance and planned use of OAT in the publicly funded treatment system. RESEARCH DESIGN: Retrospective cross-sectional analysis of treatment admissions in 30 states extracted from the Treatment Episode Data Set (2013 and 2014). SUBJECTS: Medicaid-insured pregnant women with OUD (n=3354 treatment admissions). MEASURES: The main outcome measure was planned use of OAT on admission. The main exposure was state Medicaid coverage of methadone maintenance. Using multivariable logistic regression models adjusting for sociodemographic, substance use, and treatment characteristics, we compared the probability of planned OAT use in states with Medicaid coverage of methadone maintenance versus states without coverage. RESULTS: A total of 71% of pregnant women admitted to OUD treatment were 18-29 years old, 85% were white non-Hispanic, and 56% used heroin. Overall, 74% of admissions occurred in the 18 states with Medicaid coverage of methadone maintenance and 53% of admissions involved planned use of OAT. Compared with states without Medicaid coverage of methadone maintenance, admissions in states with coverage were significantly more likely to involve planned OAT use (adjusted difference: 32.9 percentage points, 95% confidence interval, 19.2-46.7). CONCLUSIONS: Including methadone maintenance in the Medicaid benefit is essential to increasing OAT among pregnant women with OUD and should be considered a key policy strategy to enhance outcomes for mothers and newborns.

Photographic Assessment of Cephalometric Measurements in Skeletal Class II Cases: A Comparative Study.

INTRODUCTION: Cephalometry has many limitations of which radiation exposure is most important. Hence, there is a need to resort to other safer methods which could give equal if not better results. AIM: The purpose of this study was to compare and correlate the craniofacial measurements obtained from cephalometric radiographs and analogous measurements from standardized facial profile photographs in skeletal class II cases. MATERIALS AND METHODS: A total of 30 lateral cephalograms and profile photographs of patients exhibiting skeletal class II malocclusion, in the age group of 19-25 years of age, were examined in this study using Dolphin software (version 11.8). A standardized protocol was followed for all the lateral cephalograms and photographs. A total of 15 parameters were studied in this study out of which seven were angular and eight were linear parameters. Angular parameters included Frankfort Mandibular Plane Angle (FMA), Mandibular Plane-Occlusal Plane (MP-OP) angle, Occlusal Plane (OP) angle, gonial angle, ANB angle, facial angle and convexity whereas linear parameters included Anterior Facial Height (AFH), Ramal height, Posterior Facial Height: Anterior Facial Height (PFH/ AFH), convexity (in mm), Nasion perpendicular- Point A, Nasion perpendicular- Pogonion, Witts and Mandibular body length. All these parameters were digitised on both the cephalogram and photographs and were compared using one sample-2 tailed t-test, Pearson correlation coefficient. Bland-Altman Plot was considered to find comparison between the measurements from photographs and cephalograms in skeletal class II patients. RESULTS: On comparing the angular cephalometric and photographic variables for the skeletal class II subjects we found the cephalometric parameters like FMA, MP-OP angle, OP, gonial angle, convexity (in degrees) to have an insignificant difference compared to the analogous photographic measurements. On comparing the linear cephalometric and photographic variables, it was found that all the cephalometric parameters like AFH, ramal height, PFH/AFH, N perp-Point A, N perp-Poghad a good relationship with the analogous photographic measurements. CONCLUSION: The photographic method can be considered as a repeatable and reproducible method if a homogeneous protocol is followed. Thus, photographic measurements may reflect to be a rational and practical diagnostic substitute to measurements obtained from cephalograms in Class II malocclusion subjects.

Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome.

Rates of maternal morbidity and mortality are rising in the United States. Non-Hispanic Black women are at highest risk for these outcomes compared to those of other race/ethnicities. Black women are also more likely to be late to prenatal care or be inadequate users of prenatal care. Prenatal care can engage those at risk and potentially influence perinatal outcomes but further research on the link between prenatal care and maternal outcomes is needed. The objective of this article is to review literature illuminating the relationship between prenatal care utilization, social determinants of health, and racial disparities in maternal outcome. We present a theoretical framework connecting the complex factors that may link race, social context, prenatal care utilization, and maternal morbidity/mortality. Prenatal care innovations showing potential to engage with the social determinants of maternal health and address disparities and priorities for future research are reviewed.

Impact of the roll out of comprehensive emergency obstetric care on institutional birth rate in rural Nepal.

BACKGROUND: Increasing institutional births rates and improving access to comprehensive emergency obstetric care are central strategies for reducing maternal and neonatal deaths globally. While some studies show women consider service availability when determining where to deliver, the dynamics of how and why institutional birth rates change as comprehensive emergency obstetric care availability increases are unclear. METHODS: In this pre-post intervention study, we surveyed two exhaustive samples of postpartum women before and after comprehensive emergency obstetric care implementation at a hospital in rural Nepal. We developed a logistic regression model of institutional birth factors through manual backward selection of all significant covariates within and across periods. Qualitatively, we analyzed birth stories through immersion crystallization. RESULTS: Institutional birth rates increased after comprehensive emergency obstetric care implementation (from 30 to 77%, OR 7.7) at both hospital (OR 2.5) and low-level facilities (OR 4.6, p < 0.01 for all). The logistic regression indicated that comprehensive emergency obstetric care availability (OR 5.6), belief that the hospital is the safest birth location (OR 44.8), safety prioritization in decision-making (OR 7.7), and higher income (OR 1.1) predict institutional birth (p ≤ 0.01 for all). Qualitative analysis revealed comprehensive emergency obstetric care awareness, increased social expectation for institutional birth, and birth planning as important factors. CONCLUSION: Comprehensive emergency obstetric care expansion appears to have generated significant demand for institutional births through increased safety perceptions and birth planning. Increasing comprehensive emergency obstetric care availability increases birth safety, but it may also be a mechanism for increasing the institutional birth rate in areas of under-utilization.

Determinants of institutional birth among women in rural Nepal: a mixed-methods cross-sectional study.

BACKGROUND: Encouraging institutional birth is an important component of reducing maternal mortality in low-resource settings. This study aims to identify and understand the determinants of persistently low institutional birth in rural Nepal, with the goal of informing future interventions to reduce high rates of maternal mortality. METHODS: Postpartum women giving birth in the catchment area population of a district-level hospital in the Far-Western Development Region of Nepal were invited to complete a cross-sectional survey in 2012 about their recent birth experience. Quantitative and qualitative methods were used to determine the institutional birth rate, social and demographic predictors of institutional birth, and barriers to institutional birth. RESULTS: The institutional birth rate for the hospital's catchment area population was calculated to be 0.30 (54 home births, 23 facility births). Institutional birth was more likely as age decreased (ORs in the range of 0.20-0.28) and as income increased (ORs in the range of 1.38-1.45). Institutional birth among women who owned land was less likely (OR = 0.82 [0.71, 0.92]). Ninety percent of participants in the institutional birth group identified safety and good care as the most important factors determining location of birth, whereas 60 % of participants in the home birth group reported distance from hospital as a key determinant of location of birth. Qualitative analysis elucidated the importance of social support, financial resources, birth planning, awareness of services, perception of safety, and referral capacity in achieving an institutional birth. CONCLUSION: Age, income, and land ownership, but not patient preference, were key predictors of institutional birth. Most women believed that birth at the hospital was safer regardless of where they gave birth. Future interventions to increase rates of institutional birth should address structural barriers including differences in socioeconomic status, social support, transportation resources, and birth preparedness.

Addressing reproductive health disparities as a healthcare management priority: pursuing equity in the era of the Affordable Care Act.

PURPOSE OF REVIEW: To summarize the newest available evidence on maternal and reproductive health disparities, and to describe elements of the Affordable Care Act most likely to impact these disparities. RECENT FINDINGS: Significant racial and ethnic disparities in maternal and reproductive health outcomes have persisted in recent years, contributing to poor outcomes and increasing costs. Pregnancy-related mortality ratios are up to three times higher in Black women compared with non-Hispanic White women, with the risk of severe maternal morbidity also significantly higher in Black and Hispanic women. Unintended pregnancy is twice as likely in minority women. Insurance status, socioeconomic status, and broader social determinants of health are implicated in these disparities. Coverage changes associated with the Affordable Care Act may provide some opportunities to reach communities most at risk. Delivery innovation, payment reform, and further public financing of key services are examples of further management approaches that can be used to address reproductive health disparities. SUMMARY: The Affordable Care Act offers important opportunities to address persistent reproductive health disparities, but significant gaps remain. Efforts must be made to reduce the negative outcomes and high financial and human costs associated with disparities in reproductive health.