Small Independent Primary Care Practices Serving Socially Vulnerable Urban Populations.

PURPOSE: This mixed methods study sought to describe the extent to which family physicians in urban communities serve socially vulnerable patients and to better understand their practices, their challenges, and the structural supports that could facilitate their patient care. METHODS: We conducted a quantitative analysis of questionnaire data from 100% of US physicians recertifying for family medicine from 2017 to 2020. We conducted qualitative analysis of in-depth interviews with 22 physician owners of urban, small, independent practices who reported that the majority of their patients were socially vulnerable. RESULTS: In 2020, in urban areas across the United States, 19.3% of family physicians served in independent practices with 1 to 5 clinicians, down from 22.6% in 2017. Nearly one-half of these physicians reported that >10% of their patients were socially vulnerable. Interviews with 22 physicians who reported that the majority of their patients were socially vulnerable revealed 5 themes: (1) substantial time spent addressing access issues and social determinants of health, (2) minimal support from health care entities, such as independent practice associations and health plans, and insufficient connection to community-based organizations, (3) myriad financial challenges, (4) serious concerns about the future, and (5) deep personal commitment to serving socially vulnerable patients in independent practice. CONCLUSIONS: Small independent practices serving vulnerable patients in urban communities are surviving because deeply committed physicians are making personal sacrifices. Health equity-focused policies could decrease the burden on these physicians and bolster independent practices so that socially vulnerable patients continue to have options when seeking primary care.

Champions for School Health-An NASN Initiative to Increase Vaccine Confidence, Equity, and Uptake in COVID-19 and School-Required Vaccinations: Part 2.

NASN, with generous funding from Kaiser Permanente (KP) and partnered with the Institute for Educational Leadership, developed and implemented the Champions for School Health (CSH) grant initiative. The CSH initiative awarded 54 Implementation Grants in two funding cycles in 2022, funding school districts and community-based organizations (CBOs) to increase access to the pediatric COVID-19 vaccine as well as school-required immunizations and to increase vaccine confidence among underserved populations in KP's footprint: California, Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia, Washington, and the District of Columbia. These grantees administered a total of 17,630 COVID-19 vaccines to individuals ages 5 or older and 34,025 routine immunizations, of which 8,233 school-required vaccinations went to children of ages 5-11 years. Over 851,000 people were reached by vaccine education events in all nine KP markets. A notable takeaway from the project's results was the new partnerships created and the continuation of existing partnerships by the grantees. NASN's implementation of the CSH initiative and results provides a model and a source of critical data on how school health services and community-based organizations can partner to provide hyper-local responses to community/public health crises. This Part 2 article provides an overview of the key results of the project.

Prevalence and Characteristics of Adolescents with Autism Spectrum Disorder in the New York-New Jersey Metropolitan Area.

PURPOSE: Almost all epidemiologic studies estimating autism spectrum disorder (ASD) prevalence have focused on school-age children. This study provides the first population-based data on the prevalence and expression of ASD among adolescents in a large US metropolitan region. METHODS: Active multiple source ASD surveillance of adolescents aged 16-years was conducted according to the Autism and Developmental Disabilities Monitoring (ADDM) Network method in a four-county New Jersey metropolitan region. Prevalence estimates are provided, characteristics are described and comparison of the distribution and characteristics of ASD is offered for this cohort, at 8 and 16-years. RESULTS: ASD prevalence was 17.7 per 1000 (95% CI: 16.3-19.2)]. One-in-55 males and one in 172 females were identified with ASD. High-SES was positively associated with ASD and White adolescents had higher ASD prevalence (22.2 per 1000) than Hispanic adolescents (13.1 per 1000). One in four study-confirmed individuals with ASD did not have an ASD diagnosis. A majority of ASD adolescents (58.8%) had a co-occurring neuropsychiatric disorder. White and High-SES individuals had greater likelihood of co-occurring disorder. The demographic distribution and functional profile of ASD was similar in this cohort at 8 and 16-years. CONCLUSION: Approximately one-in-55 adolescents in our area had ASD, in 2014, and one-in-4 16-year-olds with ASD was not diagnosed. A majority (3-in-5) of the adolescents with ASD had a co-occurring neuropsychiatric disorder. ASD under-identification and the high frequency of co-disorders in adolescents with ASD pose significant challenges to care and support.

Objective assessment of physician work in infrainguinal arterial bypass surgery.

OBJECTIVE: The purpose of this study is obtain robust objective data from the Vascular Quality Initiative on physician work in infrainguinal artery bypass surgery. Operative time, patient comorbidities, anatomical complexity, consequences of adverse outcomes, and postoperative length of stay all factor into procedure relative value unit assignment and physician reimbursement. METHODS: Baseline demographics and comorbidities were identified among 74,920 infrainguinal bypass surgeries in Vascular Quality Initiative between 2003 and 2022. Investigation into areas of progressive complexity over time was conducted. Bypasses were divided into 10 cohorts based on inflow and target arteries and conduit type. Mean operative times, lengths of stay, major morbidity rates, and 90-day mortality rates were identified across the various bypasses. Comparison of relative value unit per minute service time during the acute inpatient hospital admission was performed between the most 4 common bypasses and 14 commonly performed highly invasive major surgeries across several subdisciplines. RESULTS: Patients undergoing infrainguinal arterial bypass have an advanced combination of medical complexities highlighted by diabetes mellitus in 40%, hypertension in 88%, body mass index >30 in 30%, coronary artery disease that has clinically manifested in 31%, renal insufficiency in 19%, chronic obstructive pulmonary disease in 27%, and prior lower extremity arterial intervention (endovascular and open combined) in >50%. The need for concomitant endarterectomy at the proximal anastomosis site of infrainguinal bypasses has increased over time (P < .001). The indication for bypass being limb-threatening ischemia as defined by ischemic rest pain, pedal tissue loss, or acute ischemia has also increased over time (P < .001), indicating more advanced extent of arterial occlusion in patients undergoing infrainguinal bypass. Finally, there has been a significant (P < .001) progression in the percentage of patients who have undergone a prior ipsilateral lower extremity endovascular intervention at the time of their bypass (increasing from 9.9% in 2003-2010 to 31.9% in the 2018-2022 eras). Among the 18 procedures investigated, the 4 most commonly performed infrainguinal bypasses were included in the analysis. These ranked 14th, 16th, 17th and 18th as the most poorly compensated per minute service time during the acute operative inpatient stay. CONCLUSIONS: Infrainguinal arterial bypass surgery has an objectively undervalued physician work relative value unit compared with other highly invasive major surgeries across several subdisciplines. There are elements of progressive complexity in infrainguinal bypass patients over the past 20 years among a patient cohort with a very high comorbidity rate, indicating escalating intensity for infrainguinal bypass.

SELENOF is a new tumor suppressor in breast cancer.

Epidemiological evidence has indicated an inverse association between selenium status and various types of cancer, including breast cancer. Selenoproteins are the primary mediators of selenium effects in human health. We have previously reported loss of heterozygosity in breast tumor samples of the gene for one of the selenoproteins, SELENOF. The function of SELENOF remains unclear and whether SELENOF levels impact breast cancer risk or outcome is unknown. The mining of breast cancer patient databases revealed that SELENOF mRNA is significantly lower in late-stage tumor samples and lower levels of SELENOF also predict poor patient outcome from breast cancer. Genetically manipulating SELENOF in human breast cancer cells or in the murine mammary gland by overexpression, silencing or knockout impacted cell viability by affecting both proliferation and cell death. Restoring SELENOF can attenuate a number of aggressive cancer phenotypes in breast cancer cells, including clonogenic survival, and enhance the response to drugs or radiation used in breast cancer therapy. Importantly, enhancing SELENOF expression reduced in vivo tumor growth in a murine xenograft model of breast cancer. These data indicate that SELENOF is a new tumor suppressor in breast cancer.

Racial and Ethnic Minority Pregnant Patients with Low-Income Experiences of Perinatal Care: A Scoping Review.

Purpose: The maternal mortality ratio for the United States (US) has consistently risen over recent decades. This mortality is especially pronounced within minority populations who experience a maternal mortality and morbidity rate that are much higher than their non-Hispanic white counterparts. Qualitative data are critical in gaining true insight from minority pregnant and postpartum persons. Such data should serve as the basis for building interventions and programs that seek to eradicate perinatal inequities. This review examines the qualitative literature on racial and ethnic minority pregnant patients with low income and their experiences during perinatal care (PNC) to identify recurrent themes that can be addressed through targeted interventions. Methods: PubMed, CINAHL, and Web of Science databases were searched for qualitative studies on racial and ethnic minority pregnant patients with low income and their experiences during PNC. Twenty-two articles were included for analysis. Thematic synthesis was performed to identify categories and recurring themes in each article. Results: Five major categories were identified as consistent experiences of pregnant patients with PNC clinicians: support, education, connection, communication, and trust. Of these, clinician support was the most consistently coded category. Eighteen of the 23 articles discussed tangible support patients had received from their clinicians, such as care coordination and referrals to support services. The second most coded category was education, which was represented in 16 articles. Education was mostly represented negatively as lack of adequate perinatal care education given during the perinatal period. Finally, the categories of connection, communication, and trust were represented by 18, 17, and 17 articles, respectively. Conclusions: These qualitative studies provided specific examples of what racial and ethnic minority pregnant patients with low income deemed positive and negative during the perinatal period and outline ways that these experiences can be improved. Future studies can take the experiences reported in this review to help inform interventions to improve patient experiences and health outcomes that minority persons face in the perinatal period.

Interventions Addressing Social Needs in Perinatal Care: A Systematic Review.

Introduction: Health is impacted by a wide range of nonmedical factors, collectively termed the social determinants of health (SDoH). As the mechanisms by which these factors influence wellness and disease continue to be uncovered, health systems are beginning to assess their roles in addressing patient's social needs. This study seeks to identify and analyze clinic-based interventions aimed at addressing patients' social needs in perinatal care, including prenatal, antepartum, and postpartum care. Methods: We conducted a search of six databases through May 2020 for articles describing screening or intervention activities addressing social needs in at least one SDoH domain as defined by Healthy People 2020. We required that studies include pregnant or postpartum women and be based in a clinical setting. Results: Thirty-one publications describing 26 unique studies were identified. Most studies were either randomized-controlled trials (n=10) or observational studies (n=7) and study settings were both public and private. The mean age of women ranged from 17.4 to 34.1 years. Most studies addressed intimate partner violence (n=19). The next most common need addressed was social support (n=5), followed by food insecurity (n=3), and housing (n=2). Types of interventions varied from simple screening to ongoing counseling and case management. There was wide heterogeneity in outcomes investigated. Most IPV interventions that included counseling or ongoing support resulted in reduced IPV recurrence and severity. No intervention with only screening showed a reduction in rate of IPV. Conclusion: This systematic review shines light on several avenues to support pregnant and postpartum women through interventions that embed acknowledgment of social needs and actions addressing these needs into the clinical environment. The results of this review suggest that interventions with counseling or ongoing support may show promise in alleviating social risk factors and improving some clinical outcomes. However, the strength of this evidence is limited by the paucity of studies. More rigorous research is imperative to augment the knowledge of social needs interventions, especially in domains outside of IPV.

Muscle-specific deletion of SLK/Stk2 enhances p38 activity and myogenesis in mdx mice.

Duchenne's muscular dystrophy (DMD) is a severe muscle wasting disorder characterized by the loss of dystrophin expression, muscle necrosis, inflammation and fibrosis. Ongoing muscle regeneration is impaired by persistent cytokine stress, further decreasing muscle function. Patients with DMD rarely survive beyond their early 20s, with cardiac and respiratory dysfunction being the primary cause of death. Despite an increase in our understanding of disease progression as well as promising preclinical animal models for therapeutic intervention, treatment options for muscular dystrophy remain limited and novel therapeutic targets are required. Many reports suggest that the TGFß signalling pathway is activated in dystrophic muscle and contributes to the pathology of DMD in part by impairing the differentiation of myoblasts into mature myofibers. Here, we show that in vitro knockdown of the Ste20-like kinase, SLK, can partially restore myoblast differentiation downstream of TGFß in a Smad2/3 independent manner. In an mdx model, we demonstrate that SLK is expressed at high levels in regenerating myofibers. Muscle-specific deletion of SLK reduced leukocyte infiltration, increased myogenin and utrophin expression and enhanced differentiation. This was accompanied by resistance to eccentric contraction-induced injury in slow fiber type-enriched soleus muscles. Finally, we found that these effects were partially dependent on the upregulation of p38 signalling. Collectively, these results demonstrate that SLK downregulation can restore some aspects of disease progression in DMD.

Impaired autophagy correlates with golden retriever muscular dystrophy phenotype.

INTRODUCTION: Duchenne muscular dystrophy (DMD) and golden retriever muscular dystrophy (GRMD) are X-linked disorders caused by mutations in the DMD gene. Autophagy was recently identified as a secondary therapeutic target for DMD. We hypothesized that autophagy would be reduced in GRMD. METHODS: Autophagic gene and protein expression was assessed in normal and GRMD skeletal muscles and correlated with phenotypic biomarkers. RESULTS: Muscles were differentially affected. Autophagy gene levels were lower than normal in the GRMD cranial sartorius (CS) but similar in the vastus lateralis (VL). Protein markers of autophagic flux, LC3B-II and p62, were higher in both GRMD muscles, in keeping with impaired autophagy. Protein levels correlated with a more severe phenotype. Autophagic structures were found in necrotic, fast-twitch GRMD myofibers. DISCUSSION: Our data suggest that autophagy is impaired in certain GRMD muscles. Differential GRMD CS involvement emphasizes that therapeutic modulation of autophagy could require specific muscle targeting. Muscle Nerve 58: 418-426, 2018.

Whole genome sequencing reveals a 7 base-pair deletion in DMD exon 42 in a dog with muscular dystrophy.

Dystrophin is a key cytoskeletal protein coded by the Duchenne muscular dystrophy (DMD) gene located on the X-chromosome. Truncating mutations in the DMD gene cause loss of dystrophin and the classical DMD clinical syndrome. Spontaneous DMD gene mutations and associated phenotypes occur in several other species. The mdx mouse model and the golden retriever muscular dystrophy (GRMD) canine model have been used extensively to study DMD disease pathogenesis and show efficacy and side effects of putative treatments. Certain DMD gene mutations in high-risk, the so-called hot spot areas can be particularly helpful in modeling molecular therapies. Identification of specific mutations has been greatly enhanced by new genomic methods. Whole genome, next generation sequencing (WGS) has been recently used to define DMD patient mutations, but has not been used in dystrophic dogs. A dystrophin-deficient Cavalier King Charles Spaniel (CKCS) dog was evaluated at the functional, histopathological, biochemical, and molecular level. The affected dog's phenotype was compared to the previously reported canine dystrophinopathies. WGS was then used to detect a 7 base pair deletion in DMD exon 42 (c.6051-6057delTCTCAAT mRNA), predicting a frameshift in gene transcription and truncation of dystrophin protein translation. The deletion was confirmed with conventional PCR and Sanger sequencing. This mutation is in a secondary DMD gene hotspot area distinct from the one identified earlier at the 5' donor splice site of intron 50 in the CKCS breed.

Náuseas, vómitos, diarrea, estreñimiento e hiporexia en la alimentación del niño con cáncer / Nausea, vomiting, diarrhea, constipation and decreased appetite in feeding the child with cancer

Entre las manifestaciones digestivas que se presentan en el tratamiento del niño con cáncer, bien sea por la quimioterapia, la radioterapia, los medicamentos subyacentes a estas terapias o a la misma enfermedad per sé, se encuentran las náuseas, los vómitos, la diarrea, el estreñimiento y la disminución del apetito. Todos ellos, junto con la pérdida de la actividad física y los cambios en los hábitos alimentarios, pueden conllevar a malnutrición. Es necesario así entonces realizar algunas sugerencias preventivas nutricionales y de puericultura, para evitar la morbilidad secundaria a ello.

Among the digestive symptoms that occur in the treatment of children with cancer, either gy chemotherapy, radiotherapy, drug therapy or underlying these the same disease per se, include nausea, vomiting, diarrea, constipation and the decline and loss of appetite. They, along with the loss of physycal activit and changes in eating habits, can lead to malnutrition. Need and then make some suggestions preventive nutrition and childcare, to avoid the morbidity secondary to it.

Exceso de peso y preguntas frecuentes sobre la alimentación del niño con cáncer / Overweight and frequently asked questions about feeding the child with cancer

Durante el tratamiento del niño con cáncer, es posible requerir el uso de corticoides, los cuales como efecto adverso tienen el aumento en el apetito, que unido al sedentarismo de estos niños, incrementan de peso y pueden concurrir en sobrepeso y obesidad, malnutrición que es tan dañina como la desnutrición. Es necesario un control y seguimiento estricto por parte del pediatra y nutricionista infantil en estos niños con malnutrición.

During the treatment of children with cancer, may require the use of corticosteroids, which have the adverse effect of increased appetite, which together with the inactivity of theses children, increased weight and may attend overweight and obesity, malnutrition that is as harmful as malnutrition. It is necessary to control and closely monitored by the pediatrician and infant nutritionist in these children with malnutrition.

Antropometría en niños de la consulta externa del Hospital Universitario del Valle de Cali, Colombia, según la OMS / Anthropometry in children ambulatory from Hospital Universitario del Valle

Objetivo: Valorar por medio de antropometría, a los niños que asisten a la Consulta Externa del Hospital Universitario del Valle “Evaristo García” (HUV) de Cali, Colombia por medio de los patrones de crecimiento infantil de la OMS entre el 1 de julio y el 31 de diciembre de 2010. Materiales y Métodos: Estudio descriptivo observacional no experimental (N=214 niños), edad (E) entre los 0 meses y 17 años, que asistieron al HUV. Se dividieron en 3 grupos: 0 meses a 2 años; >2 años a 4 años y 11 meses, y 5 a 18 años. Se le realizó una historia clínica completa, peso (P), talla (T) y perímetro cefálico (PC) y diagnóstico de primera vez según sistema comprometido. Se aplicó el software Nutritional Statistical System (NSS)®, el cual utiliza como guía de referencia los patrones de crecimiento infantil de la OMS, teniendo como indicadores antropométricos para cada grupo de edad el P/E, el P/T, la T/E, el Índice de masa corporal (IMC), y el PC/E y PC/T. Se realizó su análisis estadístico como porcentajes, promedios, moda, me d i a , me diana y desviación estándar. Conclusiones: Todos los indicadores antropométricos utilizados estuvieron afectados con algún tipo de déficit nutricional, siendo el IMC el menos afectado con un 24,5% y el más afectado es el P/E con un 58,1%. En cuanto a los excesos nutricionales, se encontró que el sobrepeso y la obesidad presentan porcentajes de 17,3% y 3,1% respectivamente. Según los diagnósticos de primera vez, la anomalía con mayor porcentaje de tipo respiratorio con el 18,2%. El indicador PC se utilizó para correlacionarlo con la E, pero es aconsejable utilizarlo igualmente para la talla, lo que podría dar un mejor criterio de diagnóstico.

Objective: To assess through anthropometry, children attending the outpatient clinic of the Hospital Universitario del Valle "Evaristo Garcia" (HUV) Cali, Colombia through the Child Growth Standards WHO between July 1 and on December 31, 2010. Materials and Methods: Descriptive observational nonexperimental (N = 214 children), aged (A) 0 months to 17 years, who attended the HUV. They were divided into 3 groups: 0 months to 2 years; > 2 years to 4 years and 11 months, and 5 to 18 years. They underwent a complete medical history, weight (W), height (H) and head circumference (HC) and the first time as diagnosis of compromised system. Nutritional software was applied, which uses as a reference guide to childhood growth patterns by WHO, with the anthropometric indicators for each age group the W/A, W/H, H/A, BMI, and HC/A and HC/H. Statistical analysis was performed as percentages, averages, mode, mean, median and standard deviation. Conclusions: All anthropometric indicators used were affected with some type of nutritional deficiency, with a BMI less affected with 24.5% and the most affected is the W/A 58.1%. In terms of nutritional excesses, it was found that overweight and obesity have percentages of 17.3% and 3.1% respectively. According to the first diagnosis of the anomaly with the greatest percentage of respiratory type with 18.2%. The indicator HC was used to correlate with A, but it is advisable to use also for H, which could give a better diagnostic criteria.

Actualización en el manejo nutricional de la diarrea infantil / Update on nutritional management of infant diarrhea

Los niños con enfermedad diarreica (ED) continúan siendo un problema de salud pública en los países en vía de desarrollo como el nuestro. Es necesario definir una serie de términos que ayudan al mejor entendimiento en el manejo de la ED como son su etiología, la manera de hidratar, las intolerancias, las fórmulas infantiles, y la dieta absorbente o astringente. Sigue siendo válido en el manejo de la ED, el concepto “primero hidratar, para luego alimentar”. El tratamiento incluye desde lactancia materna, fórmulas infantiles especiales, dieta absorbente o astringente, zinc, probióticos, antibióticos y en casos extremos hasta de nutrición parenteral.

Children with diarrheal disease (DD) remains a public health problem in developing countries like ours. It isnecessary to define a set of terms that help the better understanding of the management of DD, such as theircauses, how to hydrate, intolerance, infant formulas, and diet absorbent or astringent. Remains valid in the management of DD, the term "hydrate first, then feed." Treatment ranges from breastfeeding, special infantformulas, diet absorbent and astringent, zinc, probiotics, antibiotics, andinextremecasesof parenteral nutrition.

Recomendaciones para la alimentación del Niño sano y hospitalizado / Recommendations for feeding of the healthy and hospitalized children

Una de las etapas más importantes de la vida postnatal son sus primeros meses de vida, tanto en el desarrollo psicomotor, social y afectivo como en el cognoscitivo, que son fundamentales dentro de la estructura del niño. Nuestro referente, con relación al estado nutricional de la niñez colombiana son las principales conclusiones de la Encuesta Nacional de la Situación Nutricional en Colombia (ENSIN 2005). Los objetivos propuestos por el grupo de profesionales que participaron en el Consenso Colombiano sobre alimentación normal en el niño menor de dos años de edad, incluyen asegurar un crecimiento adecuado y un patrón de hábitos de vida saludables, promocionar una alimentación saludable, recomendar normas de alimentación para lactantes y niños, realizar guías alimentarias donde participen expertos nacionales, y proporcionar guías prácticas para los padres o tutores de niños. La alimentación del niño hospitalizado estable colabora con su bienestar y pronta recuperación, contando con que el grupo tratante posea los conocimientos necesarios para prestar la atención del niño hospitalizado estable quien estará acompañado entodo momento por sus familiares, convirtiendo la alimentación en un acto social. Los administradoresdeben satisfacer las necesidades del paciente, incluso ofreciendo al niño un ambiente cuasi-familiar.

One of the most important stages of postnatal life are the first months of life, both in psychomotor development, social and emotional as the cognitive, which are fundamental in the structure of the child. Ourrelation with the nutritional status of Colombian children are the main findings from the National Survey of the Nutritional Situation in Colombia (ENSIN 2005). The objectives proposed by the group of professionals who participated in the Consensus of Colombian normal feeding in children under two years old, include ensuring adequate growth and a pattern of healthy lifestyles, promoting healthy eating, food standards recommended for infants and children, making dietary guidelines which involve national experts, and provide practical guidelines for parents or guardians of children. The stable supply of hospitalized children working with their welfare and speedy recovery, with the dealer group has the necessary knowledge to provide care for hospitalized children who will be stable at all times accompanied by their families, making food in a social act. Managers must meet patient needs, even offering the child a quasifamily atmosphere.