Seminar: Scalable Preprocessing Tools for Exposomic Data Analysis.

BACKGROUND: The exposome serves as a popular framework in which to study exposures from chemical and nonchemical stressors across the life course and the differing roles that these exposures can play in human health. As a result, data relevant to the exposome have been used as a resource in the quest to untangle complicated health trajectories and help connect the dots from exposures to adverse outcome pathways. OBJECTIVES: The primary aim of this methods seminar is to clarify and review preprocessing techniques critical for accurate and effective external exposomic data analysis. Scalability is emphasized through an application of highly innovative combinatorial techniques coupled with more traditional statistical strategies. The Public Health Exposome is used as an archetypical model. The novelty and innovation of this seminar's focus stem from its methodical, comprehensive treatment of preprocessing and its demonstration of the positive effects preprocessing can have on downstream analytics. DISCUSSION: State-of-the-art technologies are described for data harmonization and to mitigate noise, which can stymie downstream interpretation, and to select key exposomic features, without which analytics may lose focus. A main task is the reduction of multicollinearity, a particularly formidable problem that frequently arises from repeated measurements of similar events taken at various times and from multiple sources. Empirical results highlight the effectiveness of a carefully planned preprocessing workflow as demonstrated in the context of more highly concentrated variable lists, improved correlational distributions, and enhanced downstream analytics for latent relationship discovery. The nascent field of exposome science can be characterized by the need to analyze and interpret a complex confluence of highly inhomogeneous spatial and temporal data, which may present formidable challenges to even the most powerful analytical tools. A systematic approach to preprocessing can therefore provide an essential first step in the application of modern computer and data science methods. https://doi.org/10.1289/EHP12901.

Affirming and Inclusive Care Training for Medical Students and Residents to Reduce Health Disparities Experienced by Sexual and Gender Minorities: A Systematic Review.

Purpose: Providing inclusive and comprehensive gender-affirming care is critical to reducing health disparities (gaps in care) experienced by sexual and gender minorities (SGM). Currently, little is known about how medical students and residents are being trained to address the health needs of SGM persons or of the most effective methods. Methods: We conducted a systematic review of the research literature from 2000 to 2020 on the effectiveness of teaching medical students and residents on knowledge, attitudes, and skills in addressing the health of SGM persons and the strength of the research sample, design, and methods used. Results: We identified a total of 36 articles that assessed the impact of medical student and resident education on knowledge, comfort, attitudes, confidence, and skills in working with SGM patients. All studies utilized quasi-experimental designs, and found efficacious results. No study examined the impact of training on patient outcomes. Conclusion: Future studies will need to be powered and designed to assess the impact of training on patient outcomes.

The role of histological subtypes in the survival of patients diagnosed with cutaneous or mucosal melanoma in the United States of America.

BACKGROUND: Literature presents limited information on histological subtypes and their association with other factors influencing the survival of melanoma patients. To explore the risk of death due to melanoma associated with histological subtypes, this retrospective study used the Surveillance, Epidemiology, and End Results program (SEER) data from 1998 to 2019. METHODS: A total of 27,532 patients consisting of 15,527 males and 12,005 females. The Hypertabastic Accelerated Failure Time model was used to analyze the impact of histology on the survival of patients with cutaneous or mucosal melanoma. RESULTS: The median survival time (MST) for cutaneous patients was 149 months, whereas those diagnosed with mucosal melanoma was 34 months. Nodular melanoma had a hazard ratio of 3.40 [95% CI: (2.94, 3.94)] compared to lentigo maligna melanoma. Across all histological subtypes, females had a longer MST, when compared to males. The hazard ratio (HR) of distant to localized melanoma was 9.56 [95% CI: (7.58, 12.07)]. CONCLUSIONS: Knowledge of patients' histological subtypes and their hazard assessment would enable clinicians and healthcare providers to perform personalized treatment, resulting in a lower risk of complication and higher survivability of melanoma patients. Significant factors were stage of the disease, age, histology, sex, and income. Focus should be placed on high-risk populations with severe and aggressive histological subtypes. Programs that emphasize preventive measures such as awareness, education, and early screening could reduce risk.

COVID-19 Vaccine Hesitancy and Uptake among Minority Populations in Tennessee.

COVID-19 vaccine hesitancy and uptake among Southern states in the US has been problematic throughout the pandemic. To characterize COVID-19 vaccine hesitancy and uptake among medically underserved communities in Tennessee. We surveyed 1482 individuals targeting minority communities in Tennessee from 2 October 2021 to 22 June 2022. Participants who indicated that they did not plan to receive or were unsure whether to receive the COVID-19 vaccine were considered vaccine-hesitant. Among participants, 79% had been vaccinated, with roughly 5.4% not likely at all to be vaccinated in the next three months from the date that the survey was conducted. When focusing particularly on Black/AA people and white people, our survey results revealed a significant association between race (Black/AA, white, or people of mixed Black/white ancestry) and vaccination status (vaccinated or unvaccinated) (p-value = 0.013). Approximately 79.1% of all participants received at least one dose of a COVID-19 vaccine. Individuals who were concerned with personal/family/community safety and/or wanted a return to normalcy were less likely to be hesitant. The study found that the major reasons cited for refusing the COVID-19 vaccines were distrust in vaccine safety, concerns about side effects, fear of needles, and vaccine efficacy.

Vaccine Confidence and Uptake of the Omicron Bivalent Booster in Tennessee: Implications for Vulnerable Populations.

The COVID-19 Omicron variant and its subvariants are now the dominant variants circulating in the US. Therefore, the original COVID-19 vaccine cannot offer full protection. Instead, vaccines that target the spike proteins of the Omicron variants are warranted. Hence, the FDA recommended the development of a bivalent booster. Unfortunately, despite the safety and immunogenicity of the Omicron bivalent boosters from Pfizer and Moderna, uptake in the US has been poor. At this time, only 15.8% of individuals in the US aged five and older have received the Omicron bivalent booster (OBB). The rate is 18% for those aged 18 and older. Poor vaccine confidence and booster uptake are often fueled by misinformation and vaccine fatigue. These result in more problems associated with vaccine hesitancy, which are particular prevalent in Southern states in the US. In Tennessee, the OBB vaccination rate for eligible recipients is only 5.88% at time of writing (16 February 2023). In this review, we discuss (1) the rationale for developing the OBBs; (2) the efficacy and safety of the bivalent boosters; (3) the adverse events associated with these boosters; (4) vaccine hesitancy associated with the OBBs uptake in Tennessee; (5) implications for vulnerable populations, disparities in uptake of OBBs in Tennessee, and strategies to improve vaccine confidence and OBB uptake. In support of public health, it is essential that we continue to provide education, awareness, and vaccine access to the vulnerable and medically underserved populations in Tennessee. Receiving the OBBs is the most effective method to date of protecting the public against severe COVID disease, hospitalization, and death.

An Analysis of COVID-19 Mortality During the Dominancy of Alpha, Delta, and Omicron in the USA.

BACKGROUND: The objective of the study was to measure the risk of death due to COVID-19 in relation to individuals' characteristics, and severity of their disease during the dominant periods of Alpha, Delta, and Omicron variants have influenced mortality rates. METHODS: This study was conducted using COVID-19 Centers for Disease Control and Prevention (CDC) Case Surveillance Public Data Taskforce for 57 states, and United States territories between January 1, 2020 and March 20, 2022. Multivariable binary Hyperbolastic regression of type I was used to analyzes the data. RESULTS: Seniors and ICU-admitted patients had the highest risk of death. For each additional percent increase in fully vaccinated individuals, the odds of death deceased by 1%. The odds of death prior to vaccine availability, compared to post vaccine availability, was 1.27. When comparing the time periods each variant was dominant, the odds of death was 3.45-fold higher during Delta compared to Alpha. All predictor variables had P-values ≤.001. CONCLUSION: There was a noticeable difference in the odds of death among subcategories of age, race/ethnicity, sex, PMCs, hospitalization, ICU, vaccine availability, variant, and percent of fully vaccinated individuals.

Transforming Medical Education to Provide Gender-Affirming Care for Transgender and Gender-Diverse Patients: A Policy Brief.

Transgender and gender-diverse (TGD) patients experience a greater burden of health disparities compared with their heterosexual/cisgender counterparts. Some of the poorer health outcomes observed in these populations are known to be associated with the prevalence of implicit bias, bullying, emotional distress, alcoholism, drug abuse, intimate partner violence, sexually transmitted infections (eg, human immunodeficiency virus and human papilloma virus), and cancer. The TGD populations face unique barriers to receiving both routine and gender-affirming health care (acquiring hormones and gender-affirming surgeries). Additional barriers to implementing affirming care training for TGD patients are lack of expertise among medical education faculty and preceptors both in undergraduate and in graduate medical education programs. Drawing on a systematic review of the literature, we propose a policy brief aimed at raising awareness about gender-affirming care among education planners and policy makers in government and advisory bodies.

Curricular Interventions in Medical Schools: Maximizing Community Engagement Through Communities of Practice.

This article explains the importance of a communities of practice (CoP) model for continually aligning medical education and clinical transformation with contemporary health issues. It describes the evolution and advantages of using CoP as a model for transforming medical education and clinical practice and applies the CoP methodology to addressing the changing needs of socially vulnerable populations (LGBTQ [lesbian, gay, bisexual, transgender, and queer/questioning], persons experiencing homelessness, and migrant farm workers). In conclusion, this article describes CoP-led activities, achievements, and value creation in medical education by the National Center for Medical Education Development and Research established at the Meharry Medical College.

The Current State of Antiracism Curricula in Undergraduate and Graduate Medical Education: A Qualitative Study of US Academic Health Centers.

PURPOSE: We undertook a study to evaluate the current state of pedagogy on antiracism, including barriers to implementation and strengths of existing curricula, in undergraduate medical education (UME) and graduate medical education (GME) programs in US academic health centers. METHODS: We conducted a cross-sectional study with an exploratory qualitative approach using semistructured interviews. Participants were leaders of UME and GME programs at 5 institutions participating in the Academic Units for Primary Care Training and Enhancement program and 6 affiliated sites from November 2021 to April 2022. RESULTS: A total of 29 program leaders from the 11 academic health centers participated in this study. Three participants from 2 institutions reported the implementation of robust, intentional, and longitudinal antiracism curricula. Nine participants from 7 institutions described race and antiracism-related topics integrated into health equity curricula. Only 9 participants reported having "adequately trained" faculty. Participants mentioned individual, systemic, and structural barriers to implementing antiracism-related training in medical education such as institutional inertia and insufficient resources. Fear related to introducing an antiracism curriculum and undervaluing of this curriculum relative to other content were identified. Through learners and faculty feedback, antiracism content was evaluated and included in UME and GME curricula. Most participants identified learners as a stronger voice for transformation than faculty; antiracism content was mainly included in health equity curricula. CONCLUSIONS: Inclusion of antiracism in medical education requires intentional training, focused institutional policies, enhanced foundational awareness of the impact of racism on patients and communities, and changes at the level of institutions and accreditation bodies.

The COVID-19 Vaccine and Pregnant Minority Women in the US: Implications for Improving Vaccine Confidence and Uptake.

The American College of Obstetricians and Gynecologists (AGOG) recommends the FDA-approved Pfizer and Moderna mRNA COVID-19 vaccines and boosters for all eligible pregnant women in the US. However, COVID-19 vaccine confidence and uptake among pregnant minority women have been poor. While the underlying reasons are unclear, they are likely to be associated with myths and misinformation about the vaccines. Direct and indirect factors that deter minority mothers in the US from receiving the mRNA COVID-19 vaccines require further investigation. Here, we examine the historical perspectives on vaccinations during pregnancy. We will examine the following aspects: (1) the influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccinations during pregnancy; (2) the exclusion of pregnant and lactating women from COVID-19 vaccine trials; (3) COVID-19 vaccine safety during pregnancy, obstetric complications associated with symptomatic COVID-19 during pregnancy, COVID-19 vaccine hesitancy among pregnant minority women, and racial disparities experienced by pregnant minority women due to the COVID-19 pandemic as well as their potential impact on pregnancy care; and (4) strategies to improve COVID-19 vaccine confidence and uptake among pregnant minority women in the US. COVID-19 vaccine hesitancy among minority mothers can be mitigated by community engagement efforts that focus on COVID-19 vaccine education, awareness campaigns by trusted entities, and COVID-19-appropriate perinatal counseling aimed to improve COVID-19 vaccine confidence and uptake.

Breakthrough COVID-19 Infections in the US: Implications for Prolonging the Pandemic.

The incidence of COVID-19 breakthrough infections-an infection that occurs after you have been vaccinated-has increased in frequency since the Delta and now Omicron variants of the SARS-CoV-2 coronavirus have become the dominant strains transmitted in the United States (US). Evidence suggests that individuals with breakthrough infections, though rare and expected, may readily transmit COVID-19 to unvaccinated populations, posing a continuing threat to the unvaccinated. Here, we examine factors contributing to breakthrough infections including a poor immune response to the vaccines due to the fact of advanced age and underlying comorbidities, the natural waning of immune protection from the vaccines over time, and viral variants that escape existing immune protection from the vaccines. The rise in breakthrough infections in the US and how they contribute to new infections, specifically among the unvaccinated and individuals with compromised immune systems, will create the need for additional booster vaccinations or development of modified vaccines that directly target current variants circulating among the general population. The need to expedite vaccination among the more than 49.8 million unvaccinated eligible people in the US is critical.

Meharry Medical College Mobile Vaccination Program: Implications for Increasing COVID-19 Vaccine Uptake among Minority Communities in Middle Tennessee.

To end or curtail the COVID-19 pandemic, it is essential to incorporate mobile vaccination programs into the national vaccination strategy. Mobile COVID-19 vaccination programs play an important role in providing comprehensive vaccination from federally qualified institutions to underserved communities facing a higher risk for COVID-19 acquisition. The Meharry Medical College COVID-19 mobile vaccine program (MMC-MVP) has provided lifesaving COVID-19 vaccines, free of charge, to communities throughout Middle Tennessee. Mobile deployment is vital for those forced to travel long distances to get vaccinated and who have limited access to medical providers or vaccine clinics, lack access to public transportation, or may be homebound. The MMC-MVP, established on 13 April 2021, via funding from the Bloomberg Foundation, is sourced with infectious disease experts, nurse practitioners, and community engagement personnel to provide COVID-19 vaccinations and information in a culturally competent manner to diverse communities in Middle Tennessee. To provide broader access to COVID-19 vaccinations and vaccine-related information, the MMC-MVP partnered with the Tennessee Community Engagement Alliance, Vanderbilt University School of Nursing COVID-19 vaccine strike teams, non-academic, community-based organizations, and faith-based organizations. During the September 2021 COVID-19 surge in Tennessee, the MMC-MVP provided nearly 5000 free COVID-19 vaccinations to targeted, underserved communities. The MMC-MVP has provided vaccine equity in communities with the highest risk for acquiring COVID-19 and with greatest need in this pandemic.

The effect of homelessness on viral suppression in an underserved metropolitan area of middle Tennessee: potential implications for ending the HIV epidemic.

BACKGROUND: A wealth of scientific evidence supports the effectiveness of HIV prophylaxis and treatment. Homelessness is strongly associated with the health status and viral suppression among underserved populations and can undermine the national plan to eliminate HIV by 2030. This retrospective observational study examined the extent in which homelessness affects HIV treatment in an underserved urban area of Middle Tennessee in 2014-2019. RESULTS: Among 692 HIV-seropositive patients, the proportion of homeless patients increased from 13.5% in 2014 to 27.7% in 2019, thrice the national average for HIV-seropositive people (8.4%) and twice that of HIV positive patients who are participating in Ryan White programs nationwide (12.9%). Our findings suggest that homeless patients were half as likely to achieve viral suppression as compared to those who had a permanent/stable home [OR 0.48 (0.32-0.72), p-value < 0.001]. CONCLUSION: Our study indicates that homelessness may play an important role in viral suppression among persons living with HIV/AIDS in Middle Tennessee.

Trending the evidence on opioid use disorder (OUD) continuum of care among rural American Indian/Alaskan Native (AI/AN) tribes: A systematic scoping review.

BACKGROUND: American Indian/Alaskan Native (AI/AN) communities are second only to White Americans in mortality from opioid use disorder (OUD), while the smallest racial/ethnic minority population group in the USA. Those in rural communities experience significant health care disparities, including poorer treatment access for substance use disorder. This systematic scoping review aimed to trend the emerging evidence on opioid use disorder (OUD) management among rural AI/AN communities as well as workforce training needs. METHOD: We searched the Medline, Embase, PsycInfo, SSCI, and Digital theses databases for empirical study publications on OUD management among AI/AN rural communities across the continuum of prevention, treatment and care. Eight studies met the following criteria: (a) focused on OUD; (b) sampled rural AI/AN members; (c) investigated prevention, treatment and/or care perspectives and/or practices or health provider preparation; and (d) published during the period 2009-2020. Included studies met the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) quality control standards. FINDINGS: Six of eight of the studies (75%) were surveys with community members and other stakeholders on OUD management within rural AI/AN communities rather than active interventions within this population. Moreover, five of eight of the studies (63%) reported a preference for culturally grounded health and wellness interventions with rural AI/AN, involving families, and community interventionists, utilizing community reinforcement approaches. Three of eight studies (37.5%) reported need for the cultural adaption of medication-assisted treatments (MAT) and use of culturally informed recovery care approaches. One of eight studies (12.5%) proposed to use culturally adapted contingency management behavioral approaches for OUD treatment and recovery care. CONCLUSION: The evidence is trending to endorse culturally adapted OUD management with rural AI/AN communities, prioritizing prevention education, and use of MAT with cultural adaptation and whole person approaches to sustainable recovery care. Mental health care should be a part OUD prevention, treatment and recovery care in rural AI/AN rural communities.

The Effects of Social, Personal, and Behavioral Risk Factors and PM2.5 on Cardio-Metabolic Disparities in a Cohort of Community Health Center Patients.

(1) Background: Cardio-metabolic diseases (CMD), including cardiovascular disease, stroke, and diabetes, have numerous common individual and environmental risk factors. Yet, few studies to date have considered how these multiple risk factors together affect CMD disparities between Blacks and Whites. (2) Methods: We linked daily fine particulate matter (PM2.5) measures with survey responses of participants in the Southern Community Cohort Study (SCCS). Generalized linear mixed modeling (GLMM) was used to estimate the relationship between CMD risk and social-demographic characteristics, behavioral and personal risk factors, and exposure levels of PM2.5. (3) Results: The study resulted in four key findings: (1) PM2.5 concentration level was significantly associated with reported CMD, with risk rising by 2.6% for each µg/m3 increase in PM2.5; (2) race did not predict CMD risk when clinical, lifestyle, and environmental risk factors were accounted for; (3) a significant variation of CMD risk was found among participants across states; and (4) multiple personal, clinical, and social-demographic and environmental risk factors played a role in predicting CMD occurrence. (4) Conclusions: Disparities in CMD risk among low social status populations reflect the complex interactions of exposures and cumulative risks for CMD contributed by different personal and environmental factors from natural, built, and social environments.

Preparing Medical Students to Address the Needs of Vulnerable Patient Populations: Implicit Bias Training in US Medical Schools.

Little is known about how medical students are trained to identify and reduce their own biases toward vulnerable patient groups. A survey was conducted among US medical schools to determine whether their curricula addressed physician implicit biases toward three vulnerable patient groups: lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals, persons experiencing homelessness, and migrant farmworkers. Of 141 US medical schools, 71 (50%) responded. Survey respondents indicated that implicit bias is not routinely addressed in medical education, and training specific to vulnerable populations is infrequent. Recommendations for incorporating implicit bias training in medical school curricula are discussed.

Communities of Practice: Transforming Medical Education and Clinical Practice for Vulnerable Populations.

The report defines the theory behind communities of practice as a model to transform medical education and clinical practice for vulnerable populations (LGBTQ, persons experiencing homelessness, and migrant farm workers). It also offers lessons learned from this model to demonstrate value creation by communities of practice in medical education.

Systematic Review of Opioid Use Disorder Treatment Training for Medical Students and Residents.

BACKGROUND: Opioid use and overdose represent a major public health crisis in the United States. Training in opioid use disorder treatment is a complex and multi-faceted endeavor with topics that range from harm reduction and overdose reversal to medication-assisted treatment. METHODS: We conducted a systematic review of literature on medical school opioid training to assess the current state of medical student and resident training to treat opioid use disorder. RESULTS: Seven total studies were identified that evaluated medical student or resident trainings. All the studies showed some positive change in knowledge, confidence, attitudes, and/or practice behavior of the participants. DISCUSSION: Six of the seven studies were conducted among medical residents, and only two included medical students. The reviewed studies effectively addressed specific aspects of effective opioid use disorder treatment. More studies are needed that include medical students, and on effective, all-inclusive training strategies for opioid use disorder curricula.

A Systematic Review of the Effectiveness of Interventions Designed to Teach U.S. Medical Students to Address Interpersonal Violence across the Life Course.

PURPOSE: Interpersonal violence (IV) is a leading cause of morbidity, disability, adverse mental health conditions, and mortality. Without additional training, physicians are likely to limit their attention to the presenting trauma without recognizing or addressing potential long-term effects. METHODS: A systematic review of the literature was conducted using PRISMA guidelines to identify original studies that focused on how medical students are taught to address IV across the life course. RESULTS: Twenty-nine (29) articles were identified that sought to teach medical students how to respond to IV at different stages of the patient's life course. CONCLUSIONS: Research findings suggest that teaching medical students about IV can have a positive impact on their knowledge, attitudes, and skills. Despite the near universal support by medical and professional associations to address it, the evidence base for how to address IV effectively in the medical curriculum is still lacking.