Disparities in surgical health service delivery and outcomes for indigenous children.

BACKGROUND: Evidence of health disparities for Indigenous children requiring surgical care is lacking. We present a systematic review of the literature examining possible disparities in surgical care and outcomes for pediatric patients of Indigenous ethnicity. DATA SOURCES: PubMed, Cochrane, MEDLINE, gray literature. METHODS: Literature review, using PubMed, Cochrane, MEDLINE, and gray literature was conducted to identify articles published more than 2010-2020 examining children's surgical health service delivery (epidemiology, access, operations provided) and outcomes for pediatric patients of Indigenous ethnicity compared with others. Extracted data included study design, setting, participant race/ethnicity, operations examined, and surgical outcomes. Article quality was assessed using the Newcastle-Ottawa Scales. RESULTS: From 411 abstracts, 125 articles were reviewed and 33 included for data abstraction. These were cohort and cross-sectional studies investigating a wide range of patient populations and procedures across the United States, Canada, Australia, and New Zealand. Articles were organized naturally by theme into birth malformations (15 articles), trauma (6 articles), pediatric general surgery/appendicitis (5 articles), pediatric otolaryngology (6 articles), and renal transplant (1 article) surgery. Four articles also described access and resource utilization related to inpatient care. Notable disparities observed included apparent increased prevalence of gastroschisis, rates of traumatic fatality, non accidental injury, and self harm among North American Indigenous children. CONCLUSIONS: Indigenous children appear to be vulnerable to a number of health and treatment outcome disparities related to conditions treated by surgeons. Surgeons are thus uniquely poised to act in identifying and eliminating Indigenous ethnicity-based pediatric health disparities.

Evaluation of State-Mandated Third Trimester Repeat HIV Testing in a Large Tertiary Care Center.

OBJECTIVE: The Illinois Perinatal HIV Prevention Act was passed to ensure universal HIV testing once during pregnancy and was extended in 2018 to add third trimester repeat HIV screening. The objectives of this analysis were to describe uptake of, and patient factors associated with, third trimester repeat HIV testing at a high-volume birthing center. STUDY DESIGN: This is a retrospective cohort study of people who delivered at a single tertiary care hospital in Illinois during 2018. Women who delivered before 27 weeks, had an intrauterine fetal demise, a known diagnosis of HIV, or no HIV test during pregnancy were excluded. Repeat testing was defined as an HIV test at or after 27 weeks' gestation after an earlier negative HIV test during the same pregnancy. The primary outcome was the proportion of people who received repeat testing prior to delivery. Bivariable analyses were performed to identify patient characteristics associated with documentation of repeat HIV testing. RESULTS: Of 12,053 people eligible for inclusion, 3.4% (n = 414) presented without a documented third trimester repeat HIV test. The proportion of people with repeat testing improved from 80 to >99% in the first year. Patient factors were largely not associated with testing performance although multiparous people were more likely to have documented repeat testing. CONCLUSION: Rapid implementation of third trimester repeat HIV testing was achieved without disparity. Patient factors were largely not associated with testing performance which reinforces the goal of a universal screen to test all people equitably and effectively without bias. KEY POINTS: · Little is known about adherence to repeat third trimester HIV testing in pregnancy.. · Universal third trimester HIV screening was implemented with high uptake and without disparity.. · Protocolization of repeat HIV testing in pregnancy may reduce bias compared to risk based-screening..

Highlights of Cardiovascular Disease Prevention Studies Presented at the 2022 American College of Cardiology Scientific Sessions.

PURPOSE OF REVIEW: Focused review highlighting select studies presented at the 2022 American College of Cardiology (ACC) Scientific Sessions. RECENT FINDINGS: Included studies assessed the impact of a low-sodium diet on heart failure outcomes (SODIUM-HF); outcomes of pregnant patients with chronic hypertension treated with antihypertensive therapies (CHAP); cardiovascular outcomes in patients with type 2 diabetes and renal impairment treated with sotagliflozin (SCORED); a safety and efficacy study investigating SLN360, a short interfering RNA targeting lipoprotein(a) (APOLLO); a supermarket and web-based intervention targeting nutrition for cardiovascular risk reduction (SuperWIN); a superiority trial comparing myocardial injury following very mild perioperative hypothermia versus aggressive warming after non-cardiac surgery (PROTECT); and 3-year efficacy outcomes of renal denervation on blood pressure reduction from the SPYRAL HTN-ON MED pilot study. Research presented at the 2022 ACC Scientific Sessions underscores the new potential and meaningful impact of cardiovascular disease prevention and management interventions.

External Validation of an Invasive Bacterial Infection Score for Young Febrile Infants.

OBJECTIVES: The Aronson rule is a point-based clinical decision rule for the identification of febrile infants ≤60 days of age at low risk of invasive bacterial infection (IBI) in the emergency department. This rule uses variables of temperature, age, urinalysis, and absolute neutrophil count. We sought to externally validate this decision rule. METHODS: We conducted a secondary analysis of a multicenter prospective cohort of febrile infants ≤60 days old presenting to the emergency department between December 2008 and May 2013. Infants were excluded if they had clinical sepsis or chronic conditions or were missing any laboratory components of the Aronson score. Our outcome was IBI (bacteremia and/or bacterial meningitis). We assessed the accuracy of the Aronson rule by reporting metrics of diagnostic accuracy with 95% confidence intervals (CIs) at different point thresholds. RESULTS: Of 4130 included patients (780 <21 days of age; 2362 boys), 87 (2.1%) had an IBI, including 65 with isolated bacteremia and 22 with meningitis. Using an Aronson cutoff score of 2 resulted in a sensitivity of 93.1% (95% CI 85.6%-97.4%), specificity of 26.6% (95% CI 25.3%-28.0%), and negative predictive value of 99.4% (95% CI 98.8%-99.8%). Six patients with IBI (3 with bacterial meningitis) were misclassified as low risk when using a threshold of 2. CONCLUSIONS: The Aronson rule demonstrates metrics of diagnostic accuracy that are comparable to the derivation study. Our findings suggest that the rule may be generalizable for the risk stratification of well-appearing febrile infants.

Our Mothers Are Dying: The Current State of Maternal Mortality in Hawai'i and the United States.

In the United States, maternal mortality, defined as all deaths during pregnancy, childbirth, and up to 365 days after the end of pregnancy, is among the highest of all developed nations. For every 1 maternal death, there are more than 100 life-threatening complications that occur related to pregnancy. However, maternal morbidity and mortality do not affect all mothers equally. Black and indigenous people are at the highest risk for pregnancy-related complications and death-they are up to 5 times as likely to die from childbearing than white women. To understand this nationwide epidemic, cases of maternal death must be thoroughly reviewed, including the medical, social, and societal circumstances surrounding them. The state of Hawai'i formed the Maternal Mortality Review Committee in 2016 to review cases of maternal mortality, collect accurate data, and develop strategies for prevention. Twenty-five maternal deaths occurred in the state of Hawai'i from 2015 to 2017. More than half of these deaths were deemed preventable. Combined data show that mental health disorders played a significant role in maternal mortality, and approximately a quarter of cases involved substance use. Twenty-three percent of maternal deaths occurred in Native Hawaiian and Pacific Islander women, even though they make up a smaller proportion of women in the state. The collection and analysis of these data are the first steps toward understanding and reducing maternal morbidity and mortality in Hawai'i. Most notably, the striking ethnic disparities in maternal deaths and the preventable nature of many cases demand our immediate attention.

Circadian Clock Interaction with HIF1α Mediates Oxygenic Metabolism and Anaerobic Glycolysis in Skeletal Muscle.

Circadian clocks are encoded by a transcription-translation feedback loop that aligns energetic processes with the solar cycle. We show that genetic disruption of the clock activator BMAL1 in skeletal myotubes and fibroblasts increased levels of the hypoxia-inducible factor 1α (HIF1α) under hypoxic conditions. Bmal1-/- myotubes displayed reduced anaerobic glycolysis, mitochondrial respiration with glycolytic fuel, and transcription of HIF1α targets Phd3, Vegfa, Mct4, Pk-m, and Ldha, whereas abrogation of the clock repressors CRY1/2 stabilized HIF1α in response to hypoxia. HIF1α bound directly to core clock gene promoters, and, when co-expressed with BMAL1, led to transactivation of PER2-LUC and HRE-LUC reporters. Further, genetic stabilization of HIF1α in Vhl-/- cells altered circadian transcription. Finally, induction of clock and HIF1α target genes in response to strenuous exercise varied according to the time of day in wild-type mice. Collectively, our results reveal bidirectional interactions between circadian and HIF pathways that influence metabolic adaptation to hypoxia.

Update and Review on the Surgical Management of Primary Cutaneous Melanoma.

The surgical management of malignant melanoma historically called for wide excision of skin and subcutaneous tissue for any given lesion, but has evolved to be rationally-based on pathological staging. Breslow and Clark independently described level and thickness as determinant in prognosis and margin of excision. The American Joint Committee of Cancer (AJCC) in 1988 combined features from each of these histologic classifications, generating a new system, which is continuously updated and improved. The National Comprehensive Cancer Network (NCCN) has also combined several large randomized prospective trials to generate current guidelines for melanoma excision as well. In this article, we reviewed: (1) Breslow and Clark classifications, AJCC and NCCN guidelines, the World Health Organization's 1988 study, and the Intergroup Melanoma Surgical Trial; (2) Experimental use of Mohs surgery for in situ melanoma; and (3) Surgical margins and utility and indications for sentinel lymph node biopsy (SLNB) and lymphadenectomy. Current guidelines for the surgical management of a primary melanoma of the skin is based on Breslow microstaging and call for cutaneous margins of resection of 0.5 cm for MIS, 1.0 cm for melanomas ≤1.0 mm thick, 1-2 cm for melanoma thickness of 1.01-2 mm, 2 cm margins for melanoma thickness of 2.01-4 mm, and 2 cm margins for melanomas >4 mm thick. Although the role of SLNB, CLND, and TLND continue to be studied, current recommendations include SLNB for Stage IB (includes T1b lesions ≤1.0 with the adverse features of ulceration or ≥1 mitoses/mm²) and Stage II melanomas. CLND is recommended when sentinel nodes contain metastatic deposits.

A Comparison of Patient Satisfaction with Emergency Department Opt-In and Opt-Out Rapid HIV Screening.

Study objective. To compare patient satisfaction with emergency department (ED) opt-in and opt-out HIV screening. Methods. We conducted a survey in an urban ED that provided rapid HIV screening using opt-in (February 1, 2007-July 31, 2007) and opt-out (August 1, 2007-January 31, 2008) approaches. We surveyed a convenience sample of patients that completed screening in each phase. The primary outcome was patient satisfaction with HIV screening. Results. There were 207 and 188 completed surveys during the opt-in and opt-out phases, respectively. The majority of patients were satisfied with both opt-in screening (95%, 95% confidence interval [CI] = 92-98) and opt-out screening (94%, 95% CI = 89-97). Satisfaction ratings were similar between opt-in and opt-out phases even after adjusting for age, gender, race/ethnicity, and test result (adjusted odds ratio 1.3, 95% CI = 0.5-3.1). Conclusions. Emergency department patient satisfaction with opt-in and opt-out HIV screening is similarly high.