Dental Health Utilization in Palau: Feasibility of an Oral Cancer Screening Program.

Background: Cancer is the second leading cause of death in the Western Pacific region. The prevalent tradition of chewing betel nut in Palau, an island nation in this region, is a risk factor in the development of oral cancer. Oral cancer is the fifth most common cancer in Palau, and the prognosis can be improved with early detection facilitated by visual inspection of the oral cavity by dentists. The purpose of this study is to assess the feasibility of oral cancer screening using existing dental health infrastructure in Palau. Methods: A mixed methods approach was used to explore topics related to the use of dental care resources in Palau. Primary outcome measures were collected using an electronic survey with closed- and open-ended questions addressing dental health utilization as well as barriers and facilitators to accessing dental care. Secondary measures assessed knowledge, attitudes, and beliefs about betel nut use and oral cancer. Open-ended survey questions were analyzed and coded to develop themes based in grounded theory. Results: Two hundred twenty-three surveys were completed. The mean age was 42.7 years, 80% identified as female, and most (94.3%) report having seen a dentist in Palau. Dental care is seen as important (mean score 82.3/100), and 57.9% reported it was easy to access a dentist. Themes regarding facilitators include multilevel resources and transportation. Themes regarding barriers include cost and availability of dentists/appointments. Approximately half of the respondents were current users of betel nut. Conclusion: Our results suggest facilitators are in place to promote seeking and obtaining dental care; however, existing infrastructure may not support an oral cancer screening program. These data provide important areas to address that can improve access and support the implementation of oral cancer screening through existing dental care in the future.

Effectiveness of Recruitment Strategies of Latino Smokers: Secondary Analysis of a Mobile Health Smoking Cessation Randomized Clinical Trial.

BACKGROUND: Latinos remain disproportionately underrepresented in clinical trials, comprising only 2%-3% of research participants. In order to address health disparities, it is critically important to increase enrollment of Latino smokers in smoking cessation trials. There is limited research examining effective recruitment strategies for this population. OBJECTIVE: The purpose of this study was to compare the effectiveness of direct versus mass and high- versus low-effort recruitment strategies on recruitment and retention of Latino smokers to a randomized smoking cessation trial. We also examine how the type of recruitment might have influenced the characteristics of enrolled participants. METHODS: Latino smokers were enrolled into Decídetexto from 4 states-New Jersey, Kansas, Missouri, and New York. Participants were recruited from August 2018 until March 2021. Mass recruitment strategies included English and Spanish advertisements to the Latino community via flyers, Facebook ads, newspapers, television, radio, church bulletins, and our Decídetexto website. Direct, high-effort strategies included referrals from clinics or community-based organizations with whom we partnered, in-person community outreach, and patient registry calls. Direct, low-effort strategies included texting or emailing pre-existing lists of patients who smoked. A team of trained bilingual (English and Spanish) recruiters from 9 different Spanish-speaking countries of origin conducted recruitment, assessed eligibility, and enrolled participants into the trial. RESULTS: Of 1112 individuals who were screened, 895 (80.5%) met eligibility criteria, and 457 (457/895, 51.1%) enrolled in the trial. Within the pool of screened individuals, those recruited by low-effort recruitment strategies (both mass and direct) were significantly more likely to be eligible (odds ratio [OR] 1.67, 95% CI 1.01-2.76 and OR 1.70, 95% CI 0.98-2.96, respectively) and enrolled in the trial (OR 2.60, 95% CI 1.81-3.73 and OR 3.02, 95% CI 2.03-4.51, respectively) compared with those enrolled by direct, high-effort strategies. Among participants enrolled, the retention rates at 3 months and 6 months among participants recruited via low-effort strategies (both mass and direct) were similar to participants recruited via direct, high-effort methods. Compared with enrolled participants recruited via direct (high- and low-effort) strategies, participants recruited via mass strategies were less likely to have health insurance (44.0% vs 71.2% and 71.7%, respectively; P<.001), lived fewer years in the United States (22.4 years vs 32.4 years and 30.3 years, respectively; P<.001), more likely to be 1st generation (92.7% vs 76.5% and 77.5%, respectively; P=.007), more likely to primarily speak Spanish (89.3% vs 65.8% and 66.3%, respectively), and more likely to be at high risk for alcohol abuse (5.8 mean score vs 3.8 mean score and 3.9 mean score, respectively; P<.001). CONCLUSIONS: Although most participants were recruited via direct, high-effort strategies, direct low-effort recruitment strategies yielded a screening pool more likely to be eligible for the trial. Mass recruitment strategies were associated with fewer acculturated enrollees with lower access to health services-groups who might benefit a great deal from the intervention. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03586596; https://clinicaltrials.gov/ct2/show/NCT03586596. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-DOI: 10.1016/j.cct.2020.106188.

Geographic disparities in head and neck cancer survival in Upstate New York 2011-2019.

PURPOSE: To examine the association between distance to care-center and urban-rural residence on 5-year overall survival (OS) from head and neck cancer (HNC). MATERIALS AND METHODS: Five-year OS was retrospectively measured from date of initial diagnosis for patients with HNC treated at a single tertiary care center. Distances were calculated based on ZIP code of patient's residence and care center. Multilevel Weibull regression was used to adjust for confounders and identify disparities in 5-year all-cause mortality. RESULTS: A total of 670 patients included in study. Multivariable analysis revealed older age or late-stage cancer at diagnosis, and HPV negative status were associated with poorer OS. Patients residing in isolated small rural town (HR = 2.20, p = 0.015) or small rural town (HR = 2.07, p = 0.015) had lower OS. Distance to care center was not associated with OS (HR = 0.996, p = 0.11). CONCLUSIONS: Greater rurality was associated with poorer OS among HNC patients in Upstate New York.

Prevalence of High-Risk Human Papillomavirus in Tonsil Tissue in Healthy Adults and Colocalization in Biofilm of Tonsillar Crypts.

IMPORTANCE: The pathogenesis of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma is currently an important topic of elucidation. The presence of latent HPV infection in tonsil tissue of healthy adults may provide an explanation for a component of this process and contribute to the understanding of HPV-associated squamous cell carcinoma oncogenesis of the oropharynx. OBJECTIVE: To determine the prevalence of oropharyngeal HPV and to determine the spatial relationship between the virus and crypt biofilm in tonsil tissue. DESIGN, SETTING, AND PARTICIPANTS: A retrospective, cross-sectional study was carried out using samples obtained from tonsils that were archived at a university hospital following elective nononcologic tonsillectomy from 2012 to 2015. Samples consisted of formalin-fixed paraffin embedded samples of tumor-free tonsil tissue from 102 adults between the ages of 20 and 39 years. EXPOSURES: Human papillomavirus status was assessed by polymerase chain reaction, and high-risk subtypes 16 and 18 were assessed with quantitative polymerase chain reaction assay. Samples that demonstrated presence of HPV were then analyzed by in situ hybridization to localize the viral capsid protein. These samples were then stained with concanavalin A to establish biofilm presence and morphology. These samples were also stained with diamidino-phenylindole (DAPI) to visualize location of the virus in relation to cell nuclei. These data were then assembled for aggregate analysis to colocalize HPV in the biofilm of the tonsillar crypts. MAIN OUTCOMES AND MEASURES: Outcome measurements were determined prior to data collection and include prevalence of high-risk HPV types 16 and 18 in tonsil tissue of otherwise healthy adults, as well as demonstration with immunohistochemistry of HPV in tonsillar crypt biofilm. RESULTS: In 102 otherwise healthy adults (55 [53.9%] female; age range, 20-39 years), the overall prevalence of HPV in tonsils was 4.9% (n = 5); and high-risk type 16 or 18, 3.9% (n = 4). In this sample population, in situ hybridization colocalized HPV virus to the biofilm of the tonsillar crypts. CONCLUSIONS AND RELEVANCE: Biofilm is present in the tonsillar crypts in a considerable proportion of tonsil tissues and may be reproducibly identified. Human papillomavirus is demonstrated to colocalize to the crypt biofilm. This has important implications with respect to the determination of HPV prevalence rates in the oropharynx. It may also play a role in the pathogenesis of HPV-related oropharyngeal carcinoma.

Emergent treatment of button batteries in the esophagus: evolution of management and need for close second-look esophagoscopy.

OBJECTIVES: The evolving epidemiology of pediatric button battery ingestion is alarming. Currently, assessment of the degree of damage relies heavily on the initial esophagoscopy in a manner similar to the management of caustic ingestion. We have noted that use of this classic approach may delay the return to normal oral intake. Using several cases treated at our institution, we illustrate the value of "close second-look esophagoscopy" (CSLE) in expediting a return to normal oral intake after button battery ingestion. METHODS: We present a retrospective case series. RESULTS: Five patients (11 to 18 months of age) with button batteries trapped in the cervical esophagus were recently managed at our institution. The batteries were lodged in the esophagus for durations ranging from 6 hours to 4 months. Three cases of initial grade III circumferential necrotic injury were downgraded to grade IIa after a CSLE performed 2 to 4 days after removal, and their management was appropriately changed. CONCLUSIONS: The injury and healing of cases of button batteries in the proximal esophagus appear to be variable; caustic injury, electrical mucosal damage, and direct pressure are thought to be several contributory factors. Performing a CSLE within 2 to 4 days after battery removal may provide more useful prognostic information. In certain cases, downgrading of the injury may facilitate an earlier return to an oral diet, use of fewer diagnostic tests, and a shorter hospital stay. The utility and timing of imaging, management of diet and medications, and acceptable follow-up plans are discussed within the context of guiding future research.

Projects in medical education: "Social Justice in Medicine" a rationale for an elective program as part of the medical education curriculum at John A. Burns School of Medicine.

BACKGROUND: Research has shown that cultural competence training improves the attitudes, knowledge, and skills of clinicians related to caring for diverse populations. Social Justice in medicine is the idea that healthcare workers promote fair treatment in healthcare so that disparities are eliminated. Providing students with the opportunity to explore social issues in health is the first step toward decreasing discrimination. This concept is required for institutional accreditation and widely publicized as improving health care delivery in our society. METHODS: A literature review was performed searching for social justice training in medical curricula in North America. RESULTS: Twenty-six articles were discovered addressing the topic or related to the concept of social justice or cultural humility. The concepts are in accordance with objectives supported by the Future of Medical Education in Canada Report (2010), the Carnegie Foundation Report (2010), and the LCME guidelines. DISCUSSION: The authors have introduced into the elective curriculum of the John A. Burns School of Medicine a series of activities within a time span of four years to encourage medical students to further their knowledge and skills in social awareness and cultural competence as it relates to their future practice as physicians. At the completion of this adjunct curriculum, participants will earn the Dean's Certificate of Distinction in Social Justice, a novel program at the medical school. It is the hope of these efforts that medical students go beyond cultural competence and become fluent in the critical consciousness that will enable them to understand different health beliefs and practices, engage in meaningful discourse, perform collaborative problem-solving, conduct continuous self-reflection, and, as a result, deliver socially responsible, compassionate care to all members of society.

Health as a human right: who is eligible?

In Hawaii, health care is a commodity, not a human right: those who can afford it receive care, those who cannot often don't. As health workers and health professional students, we witness the consequences that public policies and budget considerations have on people, on patients, on the health of those that we are dedicated to assisting. Beginning with a case study, we examine the historical antecedents leading to the increasing migration of Micronesians to Hawaii, examine the special relation that (Compact of Free Association) citizens have with the United States, and seek to reframe the political discussion regarding their health care status in this state as a debate in which medical considerations, not political or economic ones, should be the primary voice.