Sexual Violence and Substance Use Diagnosed in Emergency Department Discharges in Hawaii, 2005-2014.

BACKGROUND: Substance use (SU) and sexual violence (SV) present unique challenges when contextualizing their relationship due to underreporting of SU and SV. Both are significant public health concerns with a large magnitude and expense to the overall U.S. and to the state of Hawaii, which is identified as a high-intensity drug-trafficking area. Since substance users have a higher risk for sexual violence than the general public, this study aims to analyze the proportion and demographics of emergency department (ED) visit individuals reporting sexual violence with or without substance use disorder and examine how the number of ED visits of individuals diagnosed with SV and SU disorder compare to all individuals. METHODS: Data from the Healthcare Cost and Utilization Project was used to examine the relationship between SV and SU. The database contained 3.5 million observations for 24 Hawaii hospitals from 2005-2014. The data was summarized in descriptive statistics and Chi-square tests were run to assess statistical significance for variables of interest. RESULTS: A greater proportion of individuals reporting sexual violence also reported substance use disorders compared to the general population of individuals. While 8% of all ED visits were related to SU, 17% of ED visits involving SV were also related to SU, demonstrating a statistically significant association between SV and SU. CONCLUSIONS: There is a greater need to further understand the complexity of the relationship between substance use and sexual violence. Sexual violence and substance use disorders share a complex relationship; survivors of sexual abuse may develop a substance use disorder, and those who use drugs and alcohol may be at an increased risk for sexual violence. Results from this study demonstrate visits for individuals reporting sexual violence have a greater proportion of substance use disorder than visits for the general population.

Factors associated with selection of practice in primary care and rural health among medical and nursing students in China.

BACKGROUND: China has a shortage of physicians and nurses in primary care and rural health. This study explores factors that influence the choices of medical and nursing students in China to select a career in primary care, or in rural health. METHODS: A total of 3826 medical students and 1771 nursing students were surveyed in China. Data were analysed using descriptive statistics, Chi-squared tests, and logistic regression models. RESULTS: The majority of medical and nursing students were willing to practice primary care (55% and 59%, respectively). Yet, only 16% and 5% of medical and nursing students, respectively, desired to work in a village or small city. The most common reasons cited to not practice primary care is the lack of opportunities for clinical skills improvement, academic and personal development, and networking. Medical students who were living in a rural residence between ages 1 and 15years were more likely to report a willingness to work in a rural location (OR: 2.18, 95% CI: 1.33-3.58) or in primary care (OR: 1.72, 95% CI: 1.31-2.25). CONCLUSION: More efforts are needed to understand how preferences among medical and nursing students influence their career choices and change in choices over time. Understanding the concerns of students can help to tailor interventions in healthcare education and training to increase student satisfaction with their career choice and enrolment counts in medical and nursing fields.

Two rare cases of bullous pemphigoid associated with immune checkpoint inhibitors.

Bullous pemphigoid is a rare and severe adverse reaction to immune-checkpoint inhibitors that can be life-threatening. Here, we present two cases of bullous pemphigoid secondary to nivolumab and ipilimumab+nivolumab therapy, respectively. Both cases presented months after discontinuation of immunotherapy. Our first case highlights the life-threatening nature of bullous pemphigoid due to its potential to cause laryngeal oedema. Our second case illustrates that cytotoxic T-lymphocyte-associated protein-4 inhibitors can rarely lead to bullous pemphigoid, in addition to programmed cell death-1 (PD-1) and programmed cell death ligand-1 (PD-L1) inhibitors. Both cases emphasise the importance of skin examinations and dermatological follow-up for patients during and even after discontinuation of immunotherapy.

Considering Health Literacy, Health Decision Making, and Health Communication in the Social Networks of Vulnerable New Mothers in Hawai'i: A Pilot Feasibility Study.

Health literacy is understudied in the context of social networks. Our pilot study goal was to consider this research gap among vulnerable, low-income mothers of minority ethnic background in the state of Hawai'i, USA. Recruitment followed a modified snowball sampling approach. First, we identified and interviewed seven mothers ("egos") in a state-sponsored home visiting program. We then sought to interview individuals whom each mother said was part of her health decision-making network ("first-level alters") and all individuals whom the first-level alters said were part of their health decision-making networks ("second-level alters"). Health literacy was self-reported using a validated item. A total of 18 people were interviewed, including all mothers (n = 7), 35% of the first-level alters (n = 7/20), and 36% of the second-level alters (n = 4/11). On average, the mothers made health decisions with 2.9 people (range: 1-6); partners/spouses and mothers/mothers-in-law were most common. One mother had low health literacy; her two first-level alters also had low health literacy. Across the full sample, the average number of people in individuals' health decision networks was 2.5 (range: 0-7); 39% of those interviewed had low health literacy. This can inform the design of future studies and successful interventions to improve health literacy.

Insights in Public Health: Outpatient Care Gaps for Patients Hospitalized with Ambulatory Care Sensitive Conditions in Hawai'i: Beyond Access and Continuity of Care.

Ambulatory care sensitive conditions (ACSCs) are conditions that can generally be managed in community-based healthcare settings, and, if managed well, should not require hospital admission. A 5-year, mixed methods study was recently concluded that (1) documented disparities in hospitalizations for ACSCs in Hawai'i through quantitative analysis of state-wide hospital discharge data; and (2) identified contributing factors for these hospitalizations through patient interviews. This Public Health Insights article provides deeper context for, and consideration of, a striking study finding: the differences between typical measures of access to care and the quality of patient/provider interactions as reported by study participants. The themes that emerged from the patients' stories of their own potentially preventable hospital admissions shed light on the importance of being heard, trust, communication, and health knowledge in their relationships with their providers. We conclude that improving the quality of the relationship and level of engagement between the patient and community/outpatient providers may help reduce hospitalizations for ACSCs in Hawai'i and beyond. These interpersonal-level goals should be supported by systems-level efforts to improve health care delivery and address health disparities.

Patient Perspectives in Comparing Hospitals for Childbirth: Insights from Hawai'i.

Childbirth is a national priority area for healthcare quality improvement. Patient perspectives are increasingly valued in healthcare, yet Asian American and Pacific Islander (AAPI) perspectives of healthcare quality are often understudied, particularly from individuals with limited English proficiency (LEP). Our study goal was to understand factors that consumers in Hawai'i, including AAPI and those with LEP, use to compare patient care in hospitals, especially for childbirth. A total of 400 women ages 18 years and older with a recent childbirth completed an in-person interview in English (n=291), Tagalog (n=42), Chinese (n=36), or Marshallese (n=31) on O'ahu, Hawai'i. Participants described if (yes/no), and how (open-ended), they believed hospitals in the state varied in providing patient care. Open-ended responses were coded by two independent raters using the framework approach. Respondents were 53.3% Asian, 30.8% Pacific Islander, 13.5% White, and 2.5% other race/ethnicity; 17.8% reported limited English proficiency. Overall, 66.8% of respondents affirmed that local hospitals varied in patient care; Marshallese, other Pacific Islanders, and non-English speakers were significantly less likely to say that Hawai'i hospitals varied in patient care. Among those who endorsed hospital variation, commonly reported themes about this variation were: (1) patient experience, (2) patient overall impression, (3) childbirth options (eg, waterbirths), (4) staff, (5) facilities (eg, "emergency capabilities"), (6) high-tech levels of care, and (7) the hospital's area of focus (eg, "women and children"). We provide insights into factors that diverse patients use to compare patient care in hospitals in Hawai'i to add value, relevance, and engagement to healthcare quality research and dissemination efforts.

Mantle cell lymphoma presenting with exaggerated skin reaction to insect bites.

We present the case of a 62-year-old African-American woman with medical history of hypertension and hyperlipidaemia who presented to dermatology clinic for 'bug bites'. Skin examination showed resolving bullae on the shins and postinflammatory pigment changes. Histopathology showed eosinophilic spongiosis and direct immunofluorescence (DIF) was negative for IgG, IgM, IgA and C3. After returning to clinic with recurrent severe bullous eruptions, the patient presented with anaemia, lymphocytosis, posterior cervical lymphadenopathy and weight loss. An exuberant bite reaction in the setting of lymphoma was suspected. Further workup with haematology revealed elevated IgG level and total protein levels. Flow cytometry showed a B cell lymphoma subtype. Extensive imaging was positive for diffuse lymphadenopathy, with accompanying evidence of Ebstein-Barr virus infection. Our case highlights the importance of considering exuberant arthropod bite reaction in the setting of undiagnosed lymphoma in a patient with bullous eruption and negative DIF.

Data gaps in adolescent fertility surveillance in middle-income countries in Latin America and South Eastern Europe: Barriers to evidence-based health promotion.

Adolescent health is a major global priority. Yet, as recently described by the World Health Organization (WHO), increased recognition of the importance of adolescent health rarely transforms into action. One challenge is lack of data, particularly on adolescent fertility. Adolescent pregnancy and childbirth are widespread and affect lifetime health and social outcomes of women, men, and families. Other important components of adolescent fertility include abortion, miscarriage, and stillbirth. Access to reliable, consistently-collected data to understand the scope and complexity of adolescent fertility is critical for designing strong research, developing meaningful policies, building effective programs, and evaluating success in these domains. Vital surveillance data can be challenging to obtain in general, and particularly in low- and middle-income countries and other under-resourced settings (including rural and indigenous communities in high-income countries). Definitions also vary, making comparisons over time and across locations challenging. Informed by the Adolescence and Motherhood Research project in Brazil and considering relevance to the Southern Eastern European (SEE) context, this article focuses on challenges in surveillance data for adolescent fertility for middle-income countries. Specifically, we review the literature to: (1) discuss the importance of understanding adolescent fertility generally, and (2) highlight relevant challenges and complexity in collecting adolescent fertility data, then we (3) consider implications of data gaps on this topic for selected middle-income countries in Latin America and SEE, and (4) propose next steps to improve adolescent fertility data for evidence-based health promotion in the middle-income country context.

Understanding of Key Obstetric Quality Terminology by Asian and Pacific Islander Subgroups: Implications for Patient Engagement and Health Equity.

Introduction Comprehension of healthcare terminology across diverse populations is critical to patient education and engagement. Methods Women in Oahu, Hawai'i with a recent delivery were interviewed about their understanding of ten common obstetric terms. Health literacy was assessed by the rapid estimate of adult literacy in medicine (REALM). Multivariable models predicted total terms comprehended by demographic factors. Results Of 269 participants, self-reported primary race was 20.5% Japanese, 19.0% Native Hawaiian, 19.0% White, 16.7% Filipino, 11.5% other Asian, 9.7% other Pacific Islander, and 3.7% other race/ethnicity; 12.7% had low health literacy. On average, participants understood 6.0 (SD: 2.2) of ten common obstetric terms. Comprehension varied by term, ranging from 97.8% for "Breastfeeding" to 27.5% for "VBAC routinely available." Models showed (1) being Filipino, Japanese, Native Hawaiian, or other Pacific Islander (vs. white); (2) having low (vs. adequate) health literacy; (3) having a high school (vs. a college) degree; and (4) being under 25-years-old (vs. 35 +) were significantly associated with less comprehension. Discussion Participants were unfamiliar with common obstetrics terminology. Comprehension struggles were more common among populations with maternal health disparities, including Asian and Pacific Islander subgroups, and those with low health literacy.

Key Factors in Obstetric Delivery Decision-Making among Asian and Pacific Islander Women by English Proficiency.

Childbirth is the most common reason women are hospitalized in the United States. Understanding (1) how expectant mothers gather information to decide where to give birth, and (2) who helps make that decision, provides critical health communication and decision-making insights. Diverse Asian American and Pacific Islander (AA/PI) perspectives on such topics are understudied, particularly among those with limited English proficiency (LEP). LEP is defined as having a limited ability to read, write, speak, or understand English. To address this research gap, we interviewed 400 women (18+ years) with a recent live birth on O'ahu, Hawai'i. Participants completed a 1-hour, in-person interview in English (n=291), Tagalog (n=42), Chinese (n=36), or Marshallese (n=31). Women were asked (1) what information was most important in deciding where to deliver and why; and (2) who participated in the decision-making and why. Responses were compared by LEP (n=71; 18%) vs English-proficient (n=329; 82%) in qualitative and quantitative analyses. Both LEP and English-proficient participants reported their obstetrician as the most important source of health information. Significantly more LEP participants valued advice from family or acquaintances as important sources of information compared to English-proficient participants. The top three health decision-makers for both those with LEP and English-proficient participants were themselves, their obstetrician, and their spouse, which did not differ significantly by language proficiency. These findings provide insights into health information sources and decision-making across diverse AA/PI populations, including those with LEP, and can help direct health interventions such as disseminating patient education and healthcare quality information.

Psychosocial Impact of Postinflammatory Hyperpigmentation in Patients with Acne Vulgaris.

Background: Acne vulgaris is a common, often socially distressing skin condition primarily seen in young adults. Quality of life studies have shown that people with acne are more introverted with increased social setting anxiety compared to a control group. Unfortunately, patients with acne may have residual postinflammatory hyperpigmentation, amplifying impaired psychosocial effects. Objective: To quantify the impact of postinflammatory hyperpigmentation in patients with acne using a psychometric scale. Design: A clinic-based survey was conducted among US adults with facial acne and postinflammatory hyperpigmentation. Outcomes included age, race, gender, and acne-related quality of life. A board-certified dermatologist rated each patient's acne severity and postinflammatory hyperpigmentation. Setting: Dermatology clinic, Anheuser Busch Institute and Des Peres Hospital, Saint Louis, Missouri. Participants: 48 subjects (25 patients with acne and postinflammatory hyperpigmentation; 23 with acne only). Measurements: Acne Quality of Life survey, dermatologist rating of acne and postinflammatory hyperpigmentation severity. Results: Subjects with postinflammatory hyperpigmentation reported statistically significant poorer mean scores on the Acne Quality of Life survey than subjects with acne only. Sixty percent of patients with postinflammatory hyperpigmentation had a "very markedly" impact to at least one aspect of the Acne Quality of Life survey scale compared to none of the acne only patients. There was no association between provider-reported hyperpigmentation severity and psychosocial impact. No differences in psychosocial impact were noted between males and females. Conclusion: Patients with acne and postinflammatory hyperpigmentation had poorer quality-of-life scores compared to patients with only acne. Having postinflammatory hyperpigmentation with acne negatively impacted self-perceptions and social/emotional functioning, especially in groups.

Hidradenitis suppurativa, neutrophilic dermatoses and diverticular disease in a young African-American patient.

Hidradenitis suppurativa (HS) is a chronic skin disorder of the terminal follicular epithelium of apocrine sweat glands, manifesting as painful and exudative papules, pustules, cysts or nodules. This inflammatory condition often presents with other systemic and cutaneous disorders. We present the case of an African-American man with HS who was also diagnosed with neutrophilic dermatoses and diverticular disease. Neutrophilic dermatosis was identified based on histopathology findings. Our patient underwent multiple surgeries for flaring of his skin condition. Colchicine and doxycycline were started, but the patient was not able to tolerate them. Humira was planned for treatment of HS and neutrophilic dermatosis but could not be pursued because of the pericolic abscess. Colonoscopy and radiological investigation revealed multiple colonic diverticuli, for which he initially underwent percutaneous drainage followed by surgical removal of sigmoid mass and colocutaneous fistula. Culture from the specimen revealed abnormal growth of Actinomyces.

Concurrent pityriasis rosea and Bell's palsy.

Pityriasis rosea is a dermatological disease with a well-documented clinical appearance, but less is known about causes and treatment. Bell's palsy is a neurological condition leading to acute idiopathic hemifacial paralysis. Recent studies indicate that human herpesvirus (HHV) 6-7 reactivation may be a contributing factor to both conditions. We report a case of the 2 concurrent diagnoses that supports a common contributing factor and suggests further awareness and research into the role HHV 6-7 may play in the aetiology of both conditions.

Fingolimod (Gilenya) and melanoma.

The Food and Drug Administration (FDA) had approved fingolimod usage for multiple sclerosis in 2010. Melanoma after the usage of fingolimod immunomodulation was reported rarely in clinical trials, and only two case reports exist in the published literature, both occurring in Europe. Most of the incidences reported in clinical trials were in-situ, whereas both case reports were of malignant melanoma. Fingolimod has been found to inhibit metastatic melanoma growth in a mouse model that depends on vascular endothelial growth factor (VEGF)-induced angiogenesis for metastasis. However, there are numerous pathways of angiogenesis and tumour growth found in vivo by which melanoma can expand that do not mandate VEGF. We report a case of superficial spreading malignant melanoma occurring after fingolimod therapy in the USA.

Vulvar Dermatoses: A Review and Update.

The purpose of this article is to review six important inflammatory dermatoses of the vulva and to update readers on the new advancements in treatment of these mucosal conditions. Psoriasis, lichen sclerosis, lichen simplex chronicus and lichen planus are common vulvar conditions that cause pruritis and/or pain. PIasma cell vulvitis and desquamative inflammatory vaginitis are rare and challenging to be recognized, which often remain undiagnosed.

Length of Stay and Deaths in Diabetes-Related Preventable Hospitalizations Among Asian American, Pacific Islander, and White Older Adults on Medicare, Hawai'i, December 2006-December 2010.

INTRODUCTION: The objective of this study was to compare in-hospital deaths and length of stays for diabetes-related preventable hospitalizations (D-RPHs) in Hawai'i for Asian American, Pacific Islander, and white Medicare recipients aged 65 years or older. METHODS: We considered all hospitalizations of older (>65 years) Japanese, Chinese, Native Hawaiians, Filipinos, and whites living in Hawai'i with Medicare as the primary insurer from December 2006 through December 2010 (n = 127,079). We used International Classification of Diseases - 9th Revision (ICD-9) codes to identify D-RPHs as defined by the Agency for Healthcare Research and Quality. Length of stays and deaths during hospitalization were compared for Asian American and Pacific Islander versus whites in multivariable regression models, adjusting for age, sex, location of residence (Oahu, y/n), and comorbidity. RESULTS: Among the group studied, 1,700 hospitalizations of 1,424 patients were D-RPHs. Native Hawaiians were significantly more likely to die during a D-RPH (odds ratio [OR], 3.92; 95% confidence interval [CI], 1.42-10.87) than whites. Filipinos had a significantly shorter length of stay (relative risk [RR], 0.77; 95% CI, 0.62-0.95) for D-RPH than whites. Among Native Hawaiians with a D-RPH, 59% were in the youngest age group (65-75 y) whereas only 6.3% were in the oldest (≥85 y). By contrast, 23.2% of Japanese were in the youngest age group, and 32.2% were in the oldest. CONCLUSION: This statewide study found significant differences in the clinical characteristics and outcomes of D-RPHs for Asian American and Pacific Islanders in Hawai'i. Native Hawaiians were more likely to die during a D-RPH and were hospitalized at a younger age for a D-RPH than other studied racial/ethnic groups. Focused interventions targeting Native Hawaiians are needed to avoid these outcomes.

Utilization of Children with Special Health Care Needs (CSHCN) Screener© by O'ahu's pediatricians.

O'ahu's primary care physicians are in the process of implementing the Patient-Centered Medical Home (PCMH) model. The Medical Home Task Force recommends the implementation of the Children with Special Health Care Needs (CSHCN) Screener© as one of the two quality improvement programs that must be completed by each participating physician. This study sought to find how many pediatricians practice population health management and to determine barriers for incorporating population health management and care registries into practices. An online survey of 55 pediatricians in Hawai'i was conducted between January 10, 2012 and March 10, 2012. The survey contained questions regarding knowledge and use of population health management and investigated the utilization rate of the Screener©. This survey provides baseline data on the implementation of this recommended screener, and informs the process that will be necessary to ensure maximal adoption of recommendations. Sixty percent of the survey participants have not incorporated population health management into their routine practice. Twenty three percent did not have knowledge of population health management and 85% did not use a chronic disease registry. As of August 2011, 95% had not screened their patients with the Screener©. Reasons included not having heard of the Screener© and never having considered using a systematic process to ask patients to assess their health. Based on results, there are important educational goals that need to be accomplished in order for Hawai'i's physicians to transform their practices into effective PCMHs. Physicians will likely need instructional and monetary support to effectively change their practices into PCMHs.