"We should be resourcing their liberation:" a qualitative formative study to guide introduction of a systems engineering intervention at a King County, WA juvenile detention center clinic.

BACKGROUND: There are ongoing efforts to eliminate juvenile detention in King County, WA. An essential element of this work is effectively addressing the health needs of youth who are currently detained to improve their wellbeing and reduce further contact with the criminal legal system. This formative study sought to inform adaptation and piloting of an evidence-based systems engineering strategy - the Systems Analysis and Improvement Approach (SAIA) - in a King County juvenile detention center clinic to improve quality and continuity of healthcare services. Our aims were to describe the priority health needs of young people who are involved in Washington's criminal legal system and the current system of healthcare for young people who are detained. METHODS: We conducted nine individual interviews with providers serving youth. We also obtained de-identified quantitative summary reports of quality improvement discussions held between clinic staff and 13 young people who were detained at the time of data collection. Interview transcripts were analyzed using deductive and inductive coding and quantitative data were used to triangulate emergent themes. RESULTS: Providers identified three priority healthcare cascades for detention-based health services-mental health, substance use, and primary healthcare-and reported that care for these concerns is often introduced for the first time in detention. Interviewees classified incarceration itself as a health hazard, highlighting the paradox of resourcing healthcare quality improvement interventions in an inherently harmful setting. Fractured communication and collaboration across detention- and community-based entities drives systems-level inefficiencies, obstructs access to health and social services for marginalized youth, and fragments the continuum of care for young people establishing care plans while detained in King County. 31% of youth self-reported receiving episodic healthcare prior to detention, 15% reported never having medical care prior to entering detention, and 46% had concerns about finding healthcare services upon release to the community. CONCLUSIONS: Systems engineering interventions such as the SAIA may be appropriate and feasible approaches to build systems thinking across and between services, remedy systemic challenges, and ensure necessary information sharing for care continuity. However, more information is needed directly from youth to draw conclusions about effective pathways for healthcare quality improvement.

Dengue virus infection-enhancement activity in neutralizing antibodies of healthy adults before dengue season as determined by using FcγR-expressing cells.

BACKGROUND: Antibodies are critical responses to protect the host from dengue virus(DENV) infection. Antibodies target DENV by two pathologic mechanisms: virus neutralization and infection enhancement. In dengue patients, the absence of neutralizing activity in the presence of FcγR implies that infection-enhancing activity hampers the neutralizing activity of antibodies, which could potentially lead to symptomatic presentations and severe clinical outcomes. METHODS: A total of 100 pair serum samples from adult healthy volunteers were obtained during the dengue season in Ha Noi in 2015 for evaluation of neutralizing and infection-enhancing activity. Additionally, 20 serum samples from acute secondary DENV infection patients were also used as the patient group in this study. PRNT was performed on BHK cells and FcγR-expressing BHK cell lines for all serum samples. RESULTS: Out of 100 residents, positive neutralizing antibodies (N.A) were found in 44.23 and 76.92% for DENV-1; 38.46 and 75% for DENV-2; 19.23 and 15.38% for DENV-3; and 1.92 and 9.62% for DENV-4 for pre and post-dengue season respectively. The percentage of post-exposure residents having positive responses against single, two, or more than three DENV serotypes were 38.46, 44.23 and 15.38%, respectively. A total of 34 residents were DENV seropositive before the dengue season and these individuals demonstrated further elevation of IgG antibodies after the dengue season. At the end of the season, 18 residents were confirmed to be new asymptomatic DENV infection cases. In both groups, N.A titers determined on BHK cells were higher than that on FcγR-expressing BHK cells. In heterotypic N.A responses, N.A titers to the infecting serotype from the samples obtained from pre-exposure group were significantly higher than those of the patient group. However, fold enhancement to the infecting serotypes from the samples in the pre-exposure group was substantially lower as compared to that of the patient group. CONCLUSION: Before and after the dengue season, serum samples from healthy volunteers demonstrated high levels of neutralizing antibodies and low or absence of infection-enhancement activity. The results suggest that while infection-enhancement activity hampers neutralizing activity of antibodies, high levels of DENV neutralizing antibodies set a critical threshold in facilitating the prevention of disease progression.

Income Inequities and Medicaid Expansion are Related to Racial and Ethnic Disparities in Delayed or Forgone Care Due to Cost.

BACKGROUND: Monitoring political and social determinants of delayed or forgone care due to cost is necessary to evaluate efforts to reduce racial and ethnic disparities in access to care. Our objective was to examine the extent to which state Medicaid expansion decisions and personal household income may be associated with individual-level racial and ethnic disparities in delayed or forgone care due to cost, at baseline, before the implementation of the Affordable Care Act. METHODS: We used 2012 Behavioral Risk Factor Surveillance System survey data to examine racial and ethnic differences in delayed or forgone care due to cost in states that do and do not plan Medicaid expansion. We examined personal household income as a social factor that could contribute to racial and ethnic disparities in delayed or forgone care. RESULTS: We found that personal income differences were strongly related to disparities in delayed or forgone care in places with and without plans to expand Medicaid. In addition, while delayed or forgone care disparities between non-Hispanic whites and non-Hispanic blacks were lowest in places with plans to expand Medicaid access, disparities between non-Hispanic whites and Hispanics did not differ by state Medicaid expansion plans. CONCLUSIONS: As access to insurance improves for diverse groups, health systems must develop innovative strategies to overcome social determinants of health, including income inequities, as barriers to accessing care for Hispanic and non-Hispanic blacks. Additional efforts may be needed to ensure Hispanic groups achieve the benefits of investments in health care access.

Just-in-Time Strategies to Reduce the Effect of Interviewer Bias During Trainee Recruitment.

Bias impacts all aspects of medical trainee applications, from grades to narrative reviews. Interviews provide an avenue to become acquainted with applicants beyond their written application, but even the most egalitarian interviewers are subject to implicit biases, including those who hold marginalized identities themselves. Simply building awareness around implicit bias is inadequate to reduce the effect. Here, 5 evidence-informed strategies are presented that can be implemented by faculty on-the-spot to mitigate the impact of implicit bias during the short interview interaction: individuation, mindfulness, perspective taking, stereotype replacement, and counter-stereotypic imaging. These strategies can be used by individual interviewers as one component of a comprehensive plan including institutional changes to promote more equitable recruitment processes.

The Use of "Natural" Substances for Menstrual Hygiene: A Case Report of an Embedded Vaginal Sea Sponge.

BACKGROUND: In early adolescence, irregular menstrual bleeding patterns are common and are frequently due to anovulatory cycles or bleeding disorders. As such, the diagnosis of a vaginal foreign body might initially be missed. CASE: We describe a 14-year-old adolescent female presenting with ongoing irregular menstrual spotting despite reassuring laboratory workup and ultrasonography. She was found to have an embedded vaginal sea sponge eroding through the vaginal wall. On further discussion, she reported using a natural sea sponge for menstrual blood absorption. SUMMARY AND CONCLUSION: In cases of persistent vaginal spotting, vaginal foreign body should be considered in the differential diagnosis. Use of nontraditional menstrual hygiene products could lead to medical complications and negative health outcomes in adolescents.

The Impact of Telehealth on Clinical Education in Adolescent Medicine During the COVID-19 Pandemic: Positive Preliminary Findings.

Purpose: Following the start of the COVID-19 pandemic, much of clinical care rapidly transitioned to telehealth, shifting the clinical training milieu for most trainees. In the wake of this shift, educators have attempted to keep learners engaged in patient care and optimize medical education as much as possible. There is, however, limited understanding of the effect of telehealth on clinical education. The aim of our study was to better understand the educational experience of pediatric and Adolescent Medicine trainees participating in clinical encounters via telehealth in a specialty consultation Adolescent Medicine Clinic at a quaternary pediatric care hospital. Methods: Using a web-based anonymous questionnaire, we surveyed trainees rotating through the Adolescent Medicine Clinic between March and June 2020. We used descriptive statistics to evaluate their experiences with telehealth and identify techniques that were effective to facilitate learning during a telehealth visit. Results: Surveys from 12 pediatric and Adolescent Medicine trainees were received, a 75% response rate. Most trainees (83.3%) reported no prior experience with telehealth before the onset of the pandemic. By the end of their rotation, trainees identified techniques that helped facilitate learning during a telehealth visit. The majority of trainees (83.3%) rated their experience as effective or very effective, and all reported interest in incorporating telehealth into their future practice. Conclusions: Pediatric and Adolescent Medicine trainees reported overall positive experiences with telehealth in clinical education and an interest in incorporating this tool into future practice. Additional research is needed to refine techniques in engaging learners through telehealth.

Evaluating the Educational Impact of Telehealth on Adolescent Medicine Trainees: a Qualitative Approach.

Purpose of Review: Telehealth has been swiftly incorporated into clinical practice since the onset of the COVID-19 pandemic, with limited understanding of how it affects trainees' educational experiences. Our study evaluates the impact of telehealth on clinical education in pediatric and Adolescent Medicine trainees during the pandemic. Recent Findings: Previous literature on telehealth focused on provider and patient perceptions in addition to clinical education for students, though none has evaluated the experiences of medical residents and fellows in Adolescent Medicine. Summary: Trainees reported enhanced opportunities for bidirectional observation with attending physicians, increased flexibility for the trainee and families, and the opportunity to engage with adolescents in their home environment. Drawbacks include decreased physical exam skill-building and technological difficulties that can interrupt the learning experience. Telehealth is a valuable tool in clinical education and innovative strategies are needed to refine and enhance these educational experiences for pediatric and Adolescent Medicine trainees.

Neutralization Potency of Sera from Vietnamese Patients with Japanese Encephalitis (JE) against Genotypes I and V JE Viruses.

Japanese encephalitis virus (JEV) is classified into 5 genotypes (GI, GII, GIII, GIV, and GV), and the GI and GIII strains are the most widely distributed in JE endemic areas. In recent years, GV JEV has been detected in China and Korea, suggesting that GV JEV may invade other JE endemic areas, including Vietnam, and that more attention should be paid to the JEV strains circulating in these areas. In this study, we investigated the neutralization ability of the sera collected from 22 Vietnamese patients with JE who lived in northern Vietnam against the GI and GV JEV strains. In most cases, the ratios of the titer against GV to that against GI (GV:GI) were equal to or less than 1:4. However, the titer against GV JEV was equivalent (1:1) to that against GI JEV in only a few cases, and no serum had a ratio higher than 1:1. Thus, our results did not show convincing evidence that GV JEV was emerging in northern Vietnam in 2014.

Neighborhood safety and adipose tissue distribution in African Americans: the Jackson Heart Study.

OBJECTIVE: Patterns of fat distribution are heavily influenced by psychological stress, sex, and among women, by menopause status. Emerging evidence suggests the lack of perceived neighborhood safety due to crime may contribute to psychological stress and obesity among exposed residents. Our objective is to determine if perceived neighborhood safety is associated with abdominal adiposity among African-American men and women, and among pre- and postmenopausal women in the Jackson Heart Study. DESIGN AND METHODS: We examined associations between perceived neighborhood safety, fat distribution, and other individual-level covariates among Jackson Heart Study participants (N = 2,881). Abdominal adiposity was measured via computed tomography scans measuring the volumes of visceral, subcutaneous and total adipose tissue. We also measured body mass index (BMI), and waist circumference. Multivariable regression models estimated associations between perceived neighborhood safety, adiposity, and covariates by sex and menopause status. RESULTS: Adjusting for all covariates, women who strongly disagreed their neighborhood was safe from crime had a higher BMI compared to women who felt safe [Std B 0.083 95% CI (0.010, 0.156)]. Premenopausal women who felt most unsafe had higher BMI, waist circumference, and volumes of visceral and total adipose tissue than those who felt safe [Std B 0.160 (0.021, 0.299), Std B 0.142 (0.003, 0.280), Std B 0.150 (0.014, 0.285), Std B 0.154 (0.019, 0.290), respectively]. We did not identify associations between neighborhood safety and adiposity among men and postmenopausal women. CONCLUSIONS: Our data suggest that abdominal adipose tissue distribution patterns are associated with perceived neighborhood safety in some groups, and that patterns may differ by sex and menopause status, with most associations observed among pre-menopausal women. Further research is needed to elucidate whether there are causal mechanisms underlying sex and menopause-status differences that may mediate associations between perceived safety and abdominal adiposity and potential protective factors that may modify this risk.

Dietary fiber intake and cardiometabolic risks among US adults, NHANES 1999-2010.

BACKGROUND: Dietary fiber may decrease the risk of cardiovascular disease and associated risk factors. We examined trends in dietary fiber intake among diverse US adults between 1999 and 2010, and investigated associations between dietary fiber intake and cardiometabolic risks including metabolic syndrome, cardiovascular inflammation, and obesity. METHODS: Our cross-sectional analysis included 23,168 men and nonpregnant women aged 20+ years from the 1999-2010 National Health and Nutrition Examination Survey. We used weighted multivariable logistic regression models to estimate predicted marginal risk ratios and 95% confidence intervals for the risks of having the metabolic syndrome, inflammation, and obesity associated with quintiles of dietary fiber intake. RESULTS: Consistently, dietary fiber intake remained below recommended adequate intake levels for total fiber defined by the Institute of Medicine. Mean dietary fiber intake averaged 15.7-17.0 g. Mexican Americans (18.8 g) consumed more fiber than non-Hispanic whites (16.3 g) and non-Hispanic blacks (13.1 g). Comparing the highest with the lowest quintiles of dietary fiber intake, adjusted predicted marginal risk ratios (95% confidence interval) for the metabolic syndrome, inflammation, and obesity were 0.78 (0.69-0.88), 0.66 (0.61-0.72), and 0.77 (0.71-0.84), respectively. Dietary fiber was associated with lower levels of inflammation within each racial and ethnic group, although statistically significant associations between dietary fiber and either obesity or metabolic syndrome were seen only among whites. CONCLUSIONS: Low dietary fiber intake from 1999-2010 in the US, and associations between higher dietary fiber and a lower prevalence of cardiometabolic risks suggest the need to develop new strategies and policies to increase dietary fiber intake.