Youth survivor perspectives on healthcare and sex trafficking.

PURPOSE: This study aimed to assess the perspectives of youth survivors of sex trafficking on healthcare to improve care for this vulnerable and often unrecognized population. DESIGN AND METHODS: Semi-structured focus groups were conducted with eight survivors in Southern California who interacted with the healthcare system while being sex trafficked. Interviews were audio- and/or video-recorded and transcribed verbatim. The analysis utilized a grounded theory approach, where researchers reviewed the data collected, then inductively generated codes and themes based on the findings from the interviews. RESULTS: The focus group interviews revealed the following themes: unequal treatment, barriers to patient care, risk identifiers, support, and survivor recommendations. CONCLUSIONS: Youth survivors seeking healthcare reported multiple barriers based on their interaction with healthcare providers, such as the lack of provider awareness, education, training, feelings of shame, judgment, fear, racial biases, and lack of empathy. Improving patient outcomes relies on understanding the complexities of human trafficking and implementing an approach to decrease barriers to care. PRACTICE IMPLICATIONS: This study resulted in invaluable survivor recommendations with practical solutions on addressing human trafficking and exploitation in the healthcare system. The solutions proposed by participants included strengthening relationships and experiences with healthcare providers by increasing awareness, establishing rapport, creating a safe space, asking questions about their safety and situation, using a non-judgmental approach, and providing resources.

Notes from the field: outbreak of skin lesions among high school wrestlers--Arizona, 2014.

Skin infections are a common problem among athletes at all levels of competition; among wrestlers, 8.5% of all adverse events are caused by skin infections. Wrestlers are at risk because of the constant skin-to-skin contact required during practice and competition. The most common infections transmitted among high school wrestlers include fungal infections (e.g., ringworm), the viral infection herpes gladiatorum caused by herpes simplex virus-1 (HSV-1), and bacterial infections (e.g., impetigo) caused by Staphylococcus or Streptococcus species, including methicillin-resistant Staphylococcal aureus (MRSA). On February 7, 2014, the Maricopa County Department of Public Health was notified of multiple wrestlers who reported skin lesions 2 weeks after participating in a wrestling tournament at school A. The tournament was held on January 24-25 and included 168 wrestlers representing 24 schools. The county health department initiated an investigation to identify cases of skin lesion, determine lesion etiology, identify risks associated with lesion development, and provide guidance for preventing additional cases.

A plan for community event-based surveillance to reduce Ebola transmission - Sierra Leone, 2014-2015.

Ebola virus disease (Ebola) was first detected in Sierra Leone in May 2014 and was likely introduced into the eastern part of the country from Guinea. The disease spread westward, eventually affecting Freetown, Sierra Leone's densely populated capital. By December 2014, Sierra Leone had more Ebola cases than Guinea and Liberia, the other two West African countries that have experienced widespread transmission. As the epidemic intensified through the summer and fall, an increasing number of infected persons were not being detected by the county's surveillance system until they had died. Instead of being found early in the disease course and quickly isolated, these persons remained in their communities throughout their illness, likely spreading the disease.

Identifying suicidal behavior among adolescents using administrative claims data.

PURPOSE: To assess the safety of psychotropic medication use in children and adolescents, it is critical to be able to identify suicidal behaviors from medical claims data and distinguish them from other injuries. The purpose of this study was to develop an algorithm using administrative claims data to identify medically treated suicidal behavior in a cohort of children and adolescents. METHODS: The cohort included 80,183 youth (6-18 years) enrolled in Tennessee's Medicaid program from 1995-2006 who were prescribed antidepressants. Potential episodes of suicidal behavior were identified using external cause-of-injury codes (E-codes) and ICD-9-CM codes corresponding to the potential mechanisms of or injuries resulting from suicidal behavior. For each identified episode, medical records were reviewed to determine if the injury was self-inflicted and if intent to die was explicitly stated or could be inferred. RESULTS: Medical records were reviewed for 2676 episodes of potential self-harm identified through claims data. Among 1162 episodes that were classified as suicidal behavior, 1117 (96%) had a claim for suicide and self-inflicted injury, poisoning by drugs, or both. The positive predictive value of code groups to predict suicidal behavior ranged from 0-88% and improved when there was a concomitant hospitalization but with the limitation of excluding some episodes of confirmed suicidal behavior. CONCLUSIONS: Nearly all episodes of confirmed suicidal behavior in this cohort of youth included an ICD-9-CM code for suicide or poisoning by drugs. An algorithm combining these ICD-9-CM codes and hospital stay greatly improved the positive predictive value for identifying medically treated suicidal behavior.

"We need to be heard. We need to be seen": A thematic analysis of black maternal experiences of birthing and postnatal care in England within the context of Covid-19.

OBJECTIVE: Inequalities for Black women within maternity settings are longstanding, with evidence showing higher mortality, complications and distress compared to White women. The Covid-19 pandemic saw unprecedented changes to maternity services, with emerging evidence highlighting a disproportionate impact on mothers from ethnically minoritized backgrounds. This uniquely positioned study explores Black women's experiences of services during Covid-19. DESIGN: The study used a qualitative design with semi-structured interviews, data were analysed using reflexive thematic analysis. SETTING: The study took was open to all in the UK, participants who took part were from England and were recruited via social media and community led organisations. PARTICIPANTS: The study recruited 13 self-identifying Black women, aged between 23 and 41 who received maternity care across settings (NHS wards, home birth and birthing centre) across England. MEASUREMENT AND FINDINGS: Three themes were generated from the study: 'The Ripples of Covid', 'Inequality within Inequality' and 'Conscientious Change for Maternity Systems', with sub-themes including the impact of regulations, the invisibility of pain and the importance of accountability. Alongside multiple layers of inequality and emotional labour for Black women, the study found connection and advocacy as facilitators of good care. KEY CONCLUSIONS: Supporting existing research, Black women's experiences of maternity services during Covid-19evidence ongoing of structural racism within maternity provision, founded on stereotypes of strength and pain. Though moments of advocacy and connection, however, Covid-19 appeared exacerbated ongoing existing inequalities for Black women. Changes to service provision contributed to isolation, distress, and consequential inadequate care. IMPLICATIONS FOR PRACTICE: The findings, generated by Black women, established important implications for practice and policy, including an emphasis on creating conscientious change of systems through a racialised lens, the importance of meaningful equity, representation, and the need for co-production alongside Black communities.

Clinically Relevant Immune-Cellular Metrics of Inflammation in Meibomian Gland Dysfunction.

Purpose: To determine the reliability and clinical relevance of in vivo confocal microscopy (IVCM)-based immune-cellular metrics of palpebral conjunctival inflammation in meibomian gland dysfunction (MGD). Methods: Sixteen MGD patients and 13 reference controls included in this cross-sectional, retrospective study, had an ocular surface exam, symptom assessment (Ocular Surface Disease Index questionnaire [OSDI]), and palpebral conjunctival IVCM imaging. Bland-Altman analyses, intraclass correlation coefficient (ICCa), Lin's concordance correlation coefficient (ρc), receiver operating characteristic (ROC) analyses, and correlations were performed. Clinical outcome measures were symptom severity (OSDI scores), tear break-up time (TBUT), and corneal fluorescein staining (CFS grade). Results: Compared to controls, patients with MGD had variable symptom severity (average OSDI score: 48.3 ± 7.6, P = 0.0008, range: 8.3-85.42), shorter TBUT (6.8 ± 0.9 seconds, P = 0.002), comparable corneal staining (0.31 ± 0.19, P = 0.20), and greater conjunctival inflammation (epithelial immune cells [EIC]: 477.8 ± 54.2 vs. 123.3 ± 17.2 cells/mm2, P < 0.0001; intraglandular immune cells [IGIC]: 41.9 ± 3.3% vs. 20.33 ± 7.3%, P < 0.01). Immune-cellular metrics had high inter- and intraobserver agreement (ρc: 0.86-0.94; ICCa and Cronbach's α: 0.85-0.97, P < 0.0001). EIC correlated positively with OSDI (rs: 0.49, P = 0.03), while both EIC and IGIC correlated inversely with TBUT (rs: -0.47, -0.45, P < 0.05), and had high accuracy in detecting inflammation (ROC area under the curve [AUC]: 0.97 and 0.89, P ≤ 0.001). Conclusions: EIC and IGIC are increased in highly symptomatic patients with MGD that have minimal corneal staining, and correlate with symptoms and clinical signs. EIC and IGIC may provide reliable and clinically relevant metrics of inflammation.

In Vivo Confocal Microscopy Shows Alterations in Nerve Density and Dendritiform Cell Density in Fuchs' Endothelial Corneal Dystrophy.

PURPOSE: To evaluate corneal nerve and immune cell alterations in Fuchs' endothelial corneal dystrophy (FECD) and pseudophakic bullous keratopathy (PBK) by laser in vivo confocal microscopy (IVCM) as correlated to corneal sensation and endothelial cell loss. DESIGN: Prospective, cross-sectional, controlled study. METHODS: Thirty-three eyes with FECD were compared to 13 eyes with PBK and 17 normal age-matched control eyes at a tertiary referral center. FECD was classified into early (without edema) and late stage (with edema). Corneal IVCM and esthesiometry were performed. Corneal nerve and immune dendritiform cell (DC) alterations were evaluated and correlated to clinical parameters. RESULTS: FECD and PBK eyes showed significantly (P = .001) diminished total nerve length (11.5 ± 1.3 and 2.9 ± 0.7 mm/mm2) and number (8.8 ± 1.1 and 2.2 ± 0.4 n/frame), compared to controls (23.3 ± 8.1 mm/mm2 and 25.9 ± 1.3 n/frame). Decreased nerves corresponded to diminished sensation in FECD (4.9 ± 0.2 cm; R = 0.32; P = .045), compared to controls (5.9 ± 0.04 cm). Early- and late-stage FECD showed significantly reduced total nerve length (13.1 ± 1.4 and 9.9 ± 1.2 mm/mm2, respectively) and number (8.2 ± 2.5 and 6.5 ± 2.1 n/frame), compared to controls (P < .001). DC density was significantly increased in FECD (57.8 ± 10.4 cells/mm2; P = .01), but not in PBK (47.7 ± 11.6 cells/mm2; P = .60) compared to controls (22.5 ± 4.5 cells/mm2). A subset of early FECD patients (7/22) demonstrated very high DC density (>100/mm2). CONCLUSION: IVCM demonstrates profound diminishment of subbasal corneal nerves in early- and late-stage FECD and in PBK, correlating to decreased sensation. Increased DC density in early FECD demonstrates potential subclinical inflammation. The data suggest that reduction in subbasal nerves and increased immune activation may play a role in the pathophysiology of FECD.

Gender and geographic influence on the racial disparity in bladder cancer mortality in the US.

BACKGROUND: In 2005, there were an estimated 63,210 new cases of bladder cancer and 13,180 related deaths in the US. African Americans reportedly have a lower incidence of bladder cancer, but a higher mortality. The objective of this study was to evaluate the gender and geographic differences in bladder cancer survival between Caucasians and African Americans to better understand the racial disparity in bladder cancer survival. STUDY DESIGN: Surveillance Epidemiology and End Results Program (SEER) data were used to evaluate racial differences in bladder cancer survival from 1973 to 1999. Bivariate and multivariate Cox proportional hazard models were performed to determine the relationship between race and survival, adjusting for cancer stage and grade, marital status, region of country, treatment received, and the interaction between race and region. RESULTS: African Americans were diagnosed with higher grade (p < 0.001) and higher stage (p < 0.001) tumors, compared with Caucasians. In the multivariable model, African-American race was an independent predictor of poor survival, adjusting for age, marital status, region of the country, stage, grade, treatment received, and interaction between race and region. Surprisingly, African Americans diagnosed in the Atlanta metropolitan area had a substantially worse survival. CONCLUSIONS: African Americans were diagnosed with more aggressive and more advanced tumors. Adjusted multivariable models demonstrated a survival advantage for Caucasians, with African-American race being an independent predictor of poor survival, especially when diagnosed in the Atlanta metropolitan area. Racial disparity continues to exist in bladder cancer presentation and survival in the US.

Evaluation and disposition of Medicaid-insured children and adolescents with suicide attempts.

OBJECTIVE: Guidelines and quality of care measures for the evaluation of adolescent suicidal behavior recommend prompt mental health evaluation, hospitalization of high-risk youth, and specific follow-up plans-all of which may be influenced by sociodemographic factors. The aim of this study was to identify sociodemographic characteristics associated with variations in the evaluation of youth with suicidal behavior. METHODS: We conducted a large cohort study of youth, aged 7 to 18, enrolled in Tennessee Medicaid from 1995 to 2006, who filled prescriptions for antidepressants and who presented for evaluation of injuries that were determined to be suicidal on the basis of external cause-of-injury codes (E codes) and ICD-9-CM codes and review of individual medical records. Chi-square tests and logistic regression were performed to assess the relationship between sociodemographic characteristics and documentation of mental health evaluation, hospitalization, and discharge instructions. RESULTS: Of 929 episodes of suicidal behavior evaluated in an acute setting, rural-residing youth were less likely to be admitted to a psychiatric hospital (adjusted odds ratio [AOR] 0.72; 95% confidence interval [CI] 0.55-0.95) and more likely to be medically hospitalized only (AOR 1.92; 95% CI 1.39-2.65). Female subjects were less likely to be admitted to a psychiatric hospital (AOR 0.55; 95% CI 0.41-0.74) and more likely to be discharged home (AOR 1.44; 95% CI 1.01-2.04). Only 40% of those discharged to home had documentation of discharge instructions with both follow-up provider and date. CONCLUSIONS: In this statewide cohort of youth with suicidal behavior, there were significant differences in disposition associated with sociodemographic characteristics.

A systematic review of validated methods for identifying Kawasaki disease using administrative or claims data.

PURPOSE: To identify and assess algorithms used to identify Kawasaki syndrome/Kawasaki disease in administrative and claims databases. METHODS: We searched the MEDLINE database from 1991 to September 2012 using controlled vocabulary and key terms related to Kawasaki disease. We also searched the reference lists of included studies. Two investigators independently assessed the full text of studies against pre-determined inclusion criteria. Two reviewers independently extracted data regarding participant and algorithm characteristics. RESULTS: Our searches identified 177 citations of which 22 met our inclusion criteria. All studies used algorithms including International Classification of Diseases, Ninth Revision (ICD-9) code 446.1 either alone, or with evidence of intravenous immunoglobulin (IVIG) administration, or with ICD-10 code M30.3. Six studies confirmed diagnoses by medical chart review. Three of these six studies reported validation statistics, with positive predictive values of 74%, 84%, and 86%, respectively. CONCLUSIONS: All studies that reported algorithms used either the ICD-9 code 446.1 either alone, with evidence of IVIG administration or with ICD-10 code M30.3. The ICD-9 code 446.1 alone produced positive predictive values of 74%, 84%, and 86% in separate studies in Georgia and California. The sensitivity of these codes to detect Kawasaki disease is unknown, as no sampling of medical records for missed true cases of Kawasaki disease was done. Further research would be helpful to determine whether the relatively high positive predictive values found in southern California are seen elsewhere and also to evaluate the performance of other codes to identify cases of Kawasaki disease and the sensitivity of the narrow algorithms that have been used to date.

Effect of extended-release niacin on serum lipids and on endothelial function in adults with sickle cell anemia and low high-density lipoprotein cholesterol levels.

Through bound apolipoprotein A-I (apoA-I), high-density lipoprotein cholesterol (HDL-C) activates endothelial nitric oxide synthase, inducing vasodilation. Because patients with sickle cell disease (SCD) have low apoA-I and endothelial dysfunction, we conducted a randomized, double-blinded, placebo-controlled trial to test whether extended-release niacin (niacin-ER) increases apoA-I-containing HDL-C and improves vascular function in SCD. Twenty-seven patients with SCD with levels of HDL-C <39 mg/dl or apoA-I <99 mg/dl were randomized to 12 weeks of niacin-ER, increased in 500-mg increments to a maximum of 1,500 mg/day, or placebo. The primary outcome was the absolute change in HDL-C level after 12 weeks, with endothelial function assessed before and at the end of treatment. Niacin-ER-treated patients trended to greater increase in HDL-C level compared with placebo treatment at 12 weeks (5.1 ± 7.7 vs 0.9 ± 3.8 mg/dl, 1-tailed p = 0.07), associated with significantly greater improvements in the ratios of low-density lipoprotein to HDL-C levels (1.24 vs 1.95, p = 0.003) and apolipoprotein B to apoA-I levels (0.46 vs 0.58, p = 0.03) compared with placebo-treated patients. No improvements were detected in 3 independent vascular physiology assays of endothelial function. Thus, the relatively small changes in HDL-C levels achieved by the dose of niacin-ER used in our study are not associated with improved vascular function in patients with SCD with initially low levels of apoA-I or HDL-C.

Epidemiological trends of Kawasaki disease among paediatric patients admitted to the Wendy Fitzwilliam Paediatric Hospital, Trinidad, during 2004-2007.

The aim of this study was to determine the epidemiological trends, clinical presentation and outcomes in patients presenting with Kawasaki disease (KD) in Trinidad at the Eric Williams Medical Sciences Complex, a 350-bed teaching hospital, during the years 2004-2007. Using a retrospective study design, data from all established cases during the period 2004-2007 were collected. Overall, 39 confirmed cases of KD occurred in Trinidad and six on the island of Tobago. The majority of patients (40) were 4 years or younger, with a male to female ratio of 2:1. A peak in hospital admissions occurred in 2005, with 15 (33.3%) patients presenting with the disease. A seasonal trend was also observed, with the majority of cases being admitted in the rainy season each year, and a peak of admissions in November. KD is a disease of public health significance in Trinidad and Tobago, affecting predominantly males within the 0- to 4-year age group. Our study emphasises the need for an effective awareness campaign to sensitize both healthcare workers and the general public to KD and its typical presentation. This would raise the level of awareness among physicians and facilitate early diagnosis and treatment.

Racial disparity in bladder cancer: trends in tumor presentation at diagnosis.

PURPOSE: White Americans have a 2-fold higher incidence of bladder cancer than black Americans but the latter have a higher mortality rate. This survival disparity has been attributable largely to the late stage presentation of black patients but other factors likely exist. We examined trends in bladder cancer presentation and survival in white and black patients in a 27-year period to gain additional insight into these factors. MATERIALS AND METHODS: Using Surveillance, Epidemiology, and End Results Program data trends in tumor presentation, treatment and survival were defined in 93,093 patients, including 89,481 white and 3,612 black patients, with bladder cancer. Parameters were measured during 5 and 7-year intervals from 1973 to 1999. Bivariate relationships between patient/disease characteristics, and the time and survival were explored. Cox proportional hazard models were used to examine the independent effect of parameters on disease specific survival. RESULTS: Median followup was 10 years. Black patients consistently presented with higher stage and grade tumors (each p <0.001). This was most pronounced in black women. A trend toward earlier stage presentation was observed in black and white patients with time (p = 0.05 and <0.001, respectively). Ten-year survival in black and white patients with similar tumor stage and grade was consistently worse in black patients, except those with metastasis. An adjusted multivariable model demonstrated a persistent survival disadvantage in black patients (HR 1.35, p <0.001). CONCLUSIONS: Racial disparities in bladder cancer stage, grade, treatment and adjusted survival continue to exist between white and black Americans despite improvements in stage presentation and survival of localized and regional disease. These data provide the rationale to study treatment decision making, access, delay and potential bias in the black community.