A qualitative study to explore experiences of anti-racism teaching in medical residency programs across the United States and subsequent creation of the SPOC (Support - Pipeline - Outcomes - Community) Model to guide future curricula design.

BACKGROUND: Racism contributes to health disparities and is a serious threat to public health. Teaching physicians about racism, how to address it in medical practice, and developing high quality and sustainable curricula are essential to combating racism. OBJECTIVE: This study aimed to (1) describe the experience of racism and anti-racism teaching in residency programs, and elicit recommendations from key informants, and (2) use these data and formative research to develop recommendations for other residencies creating, implementing, and evaluating anti-racism curricula in their own programs. METHODS: From May to July 2023, 20 faculty and residents were recruited via convenience sampling for key informant interviews conducted via Microsoft Teams. Interviews were audio recorded, transcribed, and coded. An initial list of themes was developed using theoretical frameworks, and then refined using a grounded-theory approach. A brief online optional anonymous demographic survey was sent to participants in August of 2023.  RESULTS: Eighty percent (20/25) of participants approached were interviewed. Seventy-five percent (15/20) answered a brief optional demographic survey. Seven themes emerged: (1) Racism in medicine is ubiquitous; (2) Anti-racism teaching in medicine varies widely; (3) Sustainability strategies should be multifaceted and include recruitment, resource allocation, and outcome measures; (4) Resources are widely available and accessible if one knows where to look; (5) Outcomes and metrics of success should include resident- faculty-, patient- community-, and system-focused outcomes; (6) Curricular strategies should be multilayered, longitudinal, and woven into the curriculum; and (7) Self-reflection and discomfort are necessary parts of the process.  CONCLUSIONS: This study is one of the first to qualitatively examine perspectives of key stakeholders invested in anti-racism teaching for residents. The Support - Pipeline - Outcomes - Community (SPOC) Model, that was developed using information collected during this study, can be used in the future as a guide for others working to design and implement sustainable and high quality anti-racism curricula for residents.

Demographic and travel characteristics and self-reported predeparture SARS-CoV-2 testing behavior in air passengers entering the United States from foreign destinations from July to September 2021.

INTRODUCTION: From January 2021 to June 2022, the United States Centers for Disease Control and Prevention required predeparture SARS-CoV-2 testing for all air passengers arriving into the United States from a foreign country. METHODS: Using data collected during a surveillance project, we described predeparture testing behavior among a convenience sample of international air passengers entering the United States from July to September 2021 at six US ports of entry. We analyzed pairwise relationships between self-reported test type, test timing, demographic and travel characteristics, and COVID-19 vaccination status using chi-square and Fisher's exact tests. RESULTS: Participants were more likely to get a NAAT versus antigen test if they identified as non-Hispanic Asian or Pacific Islander (68.2%, n = 173), non-Hispanic Black (62.6%, n = 147), or if they preferred not to report race and ethnicity (60.8%, n = 209) when compared to those who identified as non-Hispanic White (47.1%, n = 1086, all p < 0.05). Those who identified as Hispanic or Latino (n = 671) were less likely to get a NAAT than the non-Hispanic White group (39.5% vs. 47.1%, p < 0.05). Participants arriving in the US from the Americas were less likely to get a NAAT (38.5%, n = 871) compared to those arriving from Europe (45.5%, n = 1165, p < 0.05). Participants who reported receiving their predeparture test 2 days or 3 or more days before departure were more likely to report receiving a NAAT (52.2%, n = 879, and 60.2%, n = 410, respectively) than those who reported testing within 1 day (41.4%, n = 1040, all p < 0.001) of departure. DISCUSSION: Test type was significantly associated with race and ethnicity, departure region, and test timing. Differences likely reflected regional disparities in the availability of tests at the time of the activity. Discrepancies in predeparture test timing and type worldwide may have consequences for the effectiveness and equity of travel requirements in future pandemics.

SARS-CoV-2 Cases Reported on International Arriving and Domestic Flights: United States, January 2020-December 2021.

Objectives. To describe trends in the number of air travelers categorized as infectious with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2; the virus that causes COVID-19) in the context of total US COVID-19 vaccinations administered, and overall case counts of SARS-CoV-2 in the United States. Methods. We searched the Quarantine Activity Reporting System (QARS) database for travelers with inbound international or domestic air travel, a positive SARS-CoV-2 lab result, and a surveillance categorization of SARS-CoV-2 infection reported during January 2020 to December 2021. Travelers were categorized as infectious during travel if they had arrival dates from 2 days before to 10 days after symptom onset or a positive viral test. Results. We identified 80 715 persons meeting our inclusion criteria; 67 445 persons (83.6%) had at least 1 symptom reported. Of 67 445 symptomatic passengers, 43 884 (65.1%) reported an initial symptom onset date after their flight arrival date. The number of infectious travelers mirrored the overall number of US SARS-CoV-2 cases. Conclusions. Most travelers in the study were asymptomatic during travel, and therefore unknowingly traveled while infectious. During periods of high community transmission, it is important for travelers to stay up to date with COVID-19 vaccinations and consider wearing a high-quality mask to decrease the risk of transmission. (Am J Public Health. 2023;113(8):904-908. https://doi.org/10.2105/AJPH.2023.307325).

Developing an Assessment of Contraceptive Preferences in Botswana: Piloting a Novel Approach Using Best-Worst Scaling of Attributes.

Introduction: To develop an attribute-based method for assessing patient contraceptive preferences in Botswana and pilot its use to explore the relationship between patient contraceptive preferences and the contraceptive methods provided or recommended to patients by clinicians. Methods: A list of contraceptive attributes was developed with input from patients, clinicians, and other stakeholders. We assessed patient preferences for attributes of contraceptives using a discrete choice "best-worst scaling" approach and a multi-attribute decision-making method that linked patient attribute preferences to actual contraceptive method characteristics. Attribute-based patient method preferences and clinician recommendations were compared in 100 women seeking contraceptive services, and 19 clinicians who provided their care. For 41 of the patients, the short-term reliability of their preference scores was also examined. Results: For 57 patients who wanted more children in the future, the degree of concordance between patients and clinicians was 7% when comparing the top attribute-based contraceptive preference for each woman with the clinician-provided/recommended method. When the top two model-based preferred contraceptive methods were considered, concordance was 28%. For 43 women who did not want more children, concordance was 0% when using the patient's model-based "most-preferred" method, and 14% when considering the top two methods. Assessment of the short-term reliability of preference scores yielded an intraclass correlation coefficient of 0.93. Conclusions: A best-worst scaling assessment of attributes of contraceptives was designed and piloted in Botswana as a Contraceptive Preference Assessment Tool. The preference assessment was found to have high short-term reliability, which supports its potential use as a measurement tool. There was very low concordance between women's attribute-based contraceptive preferences and their clinician's provision/recommendations of contraceptive methods. Using such a preference assessment tool could encourage greater patient involvement and more tailored discussion in contraceptive consultations.

Public Health Actions to Control Measles Among Afghan Evacuees During Operation Allies Welcome - United States, September-November 2021.

On August 29, 2021, the United States government oversaw the emergent establishment of Operation Allies Welcome (OAW), led by the U.S. Department of Homeland Security (DHS) and implemented by the U.S. Department of Defense (DoD) and U.S. Department of State (DoS), to safely resettle U.S. citizens and Afghan nationals from Afghanistan to the United States. Evacuees were temporarily housed at several overseas locations in Europe and Asia* before being transported via military and charter flights through two U.S. international airports, and onward to eight U.S. military bases,† with hotel A used for isolation and quarantine of persons with or exposed to certain infectious diseases.§ On August 30, CDC issued an Epi-X notice encouraging public health officials to maintain vigilance for measles among Afghan evacuees because of an ongoing measles outbreak in Afghanistan (25,988 clinical cases reported nationwide during January-November 2021) (1) and low routine measles vaccination coverage (66% and 43% for the first and second doses, respectively, in 2020) (2).

Risk factors for death and illness in dogs imported into the United States, 2010-2018.

CDC estimates 1 million dogs are imported into the United States annually. With the movement of large numbers of animals into the United States the risk of disease importation, especially emerging diseases, and animal welfare issues are of concern. Dogs that arrive to the United States ill or dead are investigated by public health authorities to ensure dogs are not infected with diseases of concern (such as rabies). We identified factors associated with illness and death in imported dogs and estimated the initial investigation cost to public health authorities. Dog importation data from the CDC's Quarantine Activity Reporting System were reviewed from 2010 to 2018. The date of entry, country of origin, port of entry, transportation method and breed were extracted to examine factors associated with illness and death in dogs during international travel. Costs for public health investigations were estimated from data collected by the Bureau of Labor Statistics and Office of Personal Management. Death or illness was more likely to occur in brachycephalic breeds (aOR = 3.88, 95%CI 2.74-5.51). Transportation of dogs via cargo (aOR = 2.41, 95%CI 1.57-3.70) or as checked baggage (aOR = 5.74, 95%CI 3.65-9.03) were also associated with death or illness. On average, 19 dog illnesses or deaths were reported annually from 2010 to 2018. The estimated annual cost to public health authorities to conduct initial public health assessments ranged from $2,071 to $104,648. Current regulations do not provide adequate resources or mechanisms to monitor the rates of morbidity and mortality of imported dogs. There are growing attempts to assess animal welfare and communicable disease importation risks. However, because the responsibility for dogs' health and wellbeing is overseen by multiple agencies it is challenging to coordinate implementation and enforcement measures. A joint federal agency approach to identify interventions that reduce dog morbidity and mortality during flights while continuing to protect US borders from public health and foreign animal disease threats could be beneficial.

Trichosporon asahii Urinary Tract Infection in a Patient with Severe COVID-19.

Trichosporon asahii is a yeast-like basidiomycete that is an emerging opportunistic infection in immunocompromised patients. Urinary tract infections due to T. asahii are rarely reported in the literature and typically seen only in immunocompromised patients. In addition to being immunocompromised, critically ill COVID-19 patients often have prolonged exposure to antibiotics, corticosteroids, and Foley catheters, which further increases their susceptibility to infection with T. asahii. There are limited case reports documenting successful treatment of T. asahii among hospitalized patients, particularly among COVID-19 patients, in the literature. Therefore, it is important that successful treatment regimens be reported. Here, we report a case of T. asahii urinary tract infection successfully treated with fluconazole and voriconazole in a 73-year-old male recovering from COVID-19. Urinary tract infections with T. asahii should be considered in persistently febrile COVID-19 patients with fungal urinary tract infections since prompt recognition and treatment can reduce the risk of disseminated disease and early mortality.

Experiences of Accessing and Providing Contraceptive Implant Removal Services in Gaborone, Botswana: A Qualitative Study Among Implant Users and Healthcare Providers.

Introduction: This study explored implant user and healthcare provider experiences of accessing and providing contraceptive implant removal services in Gaborone, Botswana, following introduction of the implant in the public sector in 2016. We sought to understand reasons for satisfaction and dissatisfaction with services and their potential impact on wider perceptions of the implant, including influence on future uptake. Methods: Qualitative data were collected through in-depth interviews. Participants comprised ten women who had previously undergone implant removal, and ten providers whose work included provision of implant insertion and removal. Data were analyzed using thematic content analysis. Results: Seven of the ten users in this study had experienced a delay between initial request and undergoing implant removal. This interval ranged from <1 week to 3 months. Users identified the principal barriers to accessing implant removal services as lack of access to trained removal providers, inconvenient appointment times, and provider resistance to performing removal. Nine of the ten providers in this study had experienced barriers to providing implant removal, including insufficient training, lack of equipment, lack of time, and lack of a referral pathway for difficult removals. Despite experiencing barriers in accessing removal, users' perceptions of the implant remained generally positive. Providers were concerned that ongoing negative user experiences of removal services would damage wider perceptions of the implant. Conclusion: Introduction of the contraceptive implant in Botswana has been an important strategy in increasing contraceptive choice. Following an initial focus on provision of insertion services, the development of comparable, accessible removal services is critical to ensuring that the implant remains a desirable contraceptive option and is vital to upholding women's reproductive health rights. The experiences of users and providers in this study can inform the ongoing development of services for implant insertion and removal in Botswana and other lower-resource settings.

Integration of family planning services into health care for HIV-positive women in Botswana.

OBJECTIVE: To create and assess a clinic model to address the unmet need for effective contraception among women living with HIV in Botswana, where half of all pregnancies are unintended and 30% of women of reproductive age are living with HIV. METHODS: We introduced family planning services into an HIV clinic in Gaborone, Botswana. Our intervention gave HIV providers brief training on contraceptive counseling plus the option of immediate referral of interested patients to an on-site contraception provider. We administered a survey to patients and providers before and after intervention. Patients were female, aged 18-45 years and using antiretrovirals. RESULTS: At baseline, 6% of 141 patients discussed contraception with their HIV-care provider, compared with 61% of 107 post intervention (P < 0.001). At baseline, 6% of patients reported wanting to use long-acting reversible contraception (LARC). Post intervention, 45% of patients chose to meet with the contraception provider, and 29% wanted to use LARC (P < 0.001 versus baseline). All providers strongly agreed that they were better informed about contraception post intervention and were satisfied with their ability to counsel and refer women for contraception. CONCLUSIONS: Provision of on-site contraceptive services in this HIV clinic encouraged family planning discussions and increased interest in LARC.

Comparison of plasma etonogestrel concentrations sampled from the contralateral-to-implant and ipsilateral-to-implant arms of contraceptive implant users.

OBJECTIVE: To compare plasma etonogestrel concentrations sampled from the contralateral- versus ipsilateral-to-implant arm. STUDY DESIGN: Sub-analysis of a cross-sectional study in Botswana in 33 participants who provided contralateral and ipsilateral blood samples. RESULTS: Plasma etonogestrel concentrations in contralateral and ipsilateral specimens were highly correlated (correlation coefficient = 0.99; p < 0.0001). Bland-Altman analysis of agreement showed that etonogestrel levels were on average 5.9 pg/mL higher (2.1%) in ipsilateral compared to contralateral specimens (95% confidence interval: -4.1, 15.9 pg/mL). CONCLUSIONS: We found no meaningful differences in plasma etonogestrel concentrations between samples taken from the contralateral- versus ipsilateral-to-implant arm. IMPLICATIONS: Our data suggest that etonogestrel plasma concentrations are unlikely to be meaningfully different between samples drawn from the ipsilateral- versus the contralateral-to-implant arms in etonogestrel contraceptive implant users.

Etonogestrel concentrations among contraceptive implant users in Botswana using and not using dolutegravir-based antiretroviral therapy.

OBJECTIVES: To evaluate whether etonogestrel concentrations are reduced to a level that could potentially reduce contraceptive efficacy when the etonogestrel contraceptive implant is used concomitantly with dolutegravir-based antiretroviral therapy (ART). STUDY DESIGN: We conducted a non-randomized, open-label, cross-sectional pharmacokinetic study among women using single-rod etonogestrel contraceptive implants in Botswana. We compared plasma etonogestrel concentrations, sampled at a single time-point between 3 and 12 months from implant insertion, among implant users living with HIV and receiving dolutegravir-based ART with HIV-negative implant users. We also assessed concentrations among implant users living with HIV and receiving efavirenz-based ART. We compared geometric mean etonogestrel concentrations analyzing data from 142 participants: 97 HIV-negative, 30 using dolutegravir, and 15 using efavirenz. RESULTS: The groups were similar. Duration of implant use was between 3 and 12 months (median = 5). Geometric mean etonogestrel plasma concentrations and 90% confidence intervals of the mean were 227.5(212.4-243.8), 289.6(251.8-333.0) and 76.4(63.9-91.4) pg/mL among the HIV-negative, dolutegravir- and efavirenz-based ART groups, respectively. All women in the HIV-negative and dolutegravir-based ART groups had etonogestrel concentrations above 90 pg/mL; 9/15 women (60%) using efavirenz-based ART had concentrations below 90 pg/mL. On average, etonogestrel levels were lower among individuals who had implants inserted for longer durations. CONCLUSIONS: Implant users receiving dolutegravir-based ART had a higher mean etonogestrel concentration compared to HIV-negative women, and none had etonogestrel concentrations below the posited threshold for ovulation suppression. In contrast, women in the efavirenz-group had much lower etonogestrel concentrations. Overall, these data provide evidence that the etonogestrel implant may be effectively combined with dolutegravir-based ART regimens. IMPLICATIONS: The etonogestrel implant remains a highly effective contraceptive option for women living with HIV who use dolutegravir-based ART.

Difficult etonogestrel implant removals in South Africa: A review of 74 referred cases.

OBJECTIVES: To assess etonogestrel contraceptive implant location and outcomes among women referred for "difficult" removal to a specialist clinic in South Africa. STUDY DESIGN: We performed a retrospective review of cases referred to our clinic for removal of nonpalpable, deep, migrated, or damaged implants, or failed removals from March to August 2017. RESULTS: Most (n = 68, 92%) of the 74 referrals were nonpalpable in our clinic. We used ultrasound for localization and successfully removed 72 implants (97%) in the outpatient clinic. CONCLUSION: With proper protocols and equipment, localization and removal of nonpalpable implants can be safely and effectively achieved in an outpatient African setting. IMPLICATIONS: Access to providers specially trained in ultrasound localization should be available in all settings where implants are offered. Providing timely access to safe and effective implant removals in routine and difficult cases is essential to ensuring that implant programs are in alignment with rights-based, client-centered family planning principles.

Mortality from HIV-associated meningitis in sub-Saharan Africa: a systematic review and meta-analysis.

INTRODUCTION: HIV-associated cryptococcal, TB and pneumococcal meningitis are the leading causes of adult meningitis in sub-Saharan Africa (SSA). We performed a systematic review and meta-analysis with the primary aim of estimating mortality from major causes of adult meningitis in routine care settings, and to contrast this with outcomes from clinical trial settings. METHODS: We searched PubMed, EMBASE and the Cochrane Library for published clinical trials (defined as randomized-controlled trials (RCTs) or investigator-managed prospective cohorts) and observational studies that evaluated outcomes of adult meningitis in SSA from 1 January 1990 through 15 September 2019. We performed random effects modelling to estimate pooled mortality, both in clinical trial and routine care settings. Outcomes were stratified as short-term (in-hospital or two weeks), medium-term (up to 10 weeks) and long-term (up to six months). RESULTS AND DISCUSSION: Seventy-nine studies met inclusion criteria. In routine care settings, pooled short-term mortality from cryptococcal meningitis was 44% (95% confidence interval (95% CI):39% to 49%, 40 studies), which did not differ between amphotericin (either alone or with fluconazole) and fluconazole-based induction regimens, and was twofold higher than pooled mortality in clinical trials using amphotericin based treatment (21% (95% CI:17% to 25%), 17 studies). Pooled short-term mortality of TB meningitis was 46% (95% CI: 33% to 59%, 11 studies, all routine care). For pneumococcal meningitis, pooled short-term mortality was 54% in routine care settings (95% CI:44% to 64%, nine studies), with similar mortality reported in two included randomized-controlled trials. Few studies evaluated long-term outcomes. CONCLUSIONS: Mortality rates from HIV-associated meningitis in SSA are very high under routine care conditions. Better strategies are needed to reduce mortality from HIV-associated meningitis in the region.

Peripartum cardiomyopathy and HELLP syndrome in a previously healthy multiparous woman: A case report.

Peripartum cardiomyopathy is a type of dilated cardiomyopathy in which the exact etiology is uncertain. HELLP syndrome is characterized by a constellation of different clinical and laboratory findings, including hemolysis, elevated liver enzymes, and low platelets. Few case reports exist detailing successful diagnosis and management of postpartum HELLP syndrome, peripartum cardiomyopathy, and multisystem organ failure in a previously healthy woman. We herein report the case of a 39-year-old multiparous female with mild gestational hypertension, who presented in the third trimester with vaginal bleeding and was subsequently suspected to have intrapartum placental abruption leading to immediate Cesarean section, complicated by massive postpartum hemorrhage, necessitating care in the intensive care unit. HELLP syndrome, disseminated intravascular coagulation, and acute kidney injury requiring hemodialysis subsequently developed along with respiratory failure and peripartum cardiomyopathy. After diagnosis and proper management, the patient made a full recovery. Peripartum cardiomyopathy should remain on the differential for women with heart failure symptoms.

Closing the Gap: Ensuring Access to and Quality of Contraceptive Implant Removal Services is Essential to Rights-based Contraceptive Care.

The use of the subdermal contraceptive implant is increasing globally, and particularly so in lower- and middle-income countries in sub-Saharan Africa. For initiation or discontinuation of the implant, users need to have access to services for insertion and removal by healthcare providers. Providing access to safe and effective contraceptive implant removal services presents both clinical and programmatic challenges. The most challenging implant removal cases, termed -difficult removals‖, place additional demands upon removal services. In this commentary, we outline challenges for the provision of removal services. Based on our experience in this field, we make recommendations on how healthcare providers and health services can plan for these challenges. Through maximising the provision of comprehensive and accessible implant removal services, including those for difficult removals, implant users can be empowered to discontinue their use of this method of contraception if they choose, thus upholding the principles of rights-based contraceptive care.

Case Report: Traumatic Incomplete Fracture of an Implanon NXT® Contraceptive Implant.

The etonogestrel (ENG) subdermal contraceptive implant (Implanon NXT®) is a safe and highly effective method of contraception which is increasing in popularity globally. This case report describes a 26-year-old woman who requested removal of the Implanon NXT® contraceptive implant. She reported that her implant had bent following direct trauma. The implant was removed in accordance with her request and without complication, but was noted to be incompletely fractured. We compare this case with a summary of the existing literature on fractured or damaged contraceptive implants. Structural damage detected whilst the implant is in situ is one potential complication of contraceptive implant use. The incidence of this complication and the implications for contraceptive efficacy are unknown. Damaged implants may present healthcare providers with more technically challenging "difficult removals". With the scale-up of services for implant provision, consideration should be given to this issue in order to inform counselling and removal services.

Effectiveness and safety of patient activation interventions for adults with type 2 diabetes: systematic review, meta-analysis, and meta-regression.

BACKGROUND: Patient activation interventions (PAIs) engage patients in care by promoting increased knowledge, confidence, and/or skills for disease self-management. However, little is known about the impact of these interventions on a wide range of outcomes for adults with type 2 diabetes (DM2), or which of these interventions, if any, have the greatest impact on glycemic control. METHODS: Electronic databases were searched from inception through November 2011. Of 16,290 citations, two independent reviewers identified 138 randomized trials comparing PAIs to usual care/control groups in adults with DM2 that reported intermediate or long-term outcomes or harms. For meta-analyses of continuous outcomes, we used a random-effects model to derive pooled weighted mean differences (WMD). For all-cause mortality, we calculated the pooled odds ratio (OR) using Peto's method. We assessed statistical heterogeneity using the I (2) statistic and conducted meta-regression using a random-effects model when I (2) > 50 %. A priori meta-regression primary variables included: intervention strategies, intervention leader, baseline outcome value, quality, and study duration. RESULTS: PAIs modestly reduced intermediate outcomes [A1c: WMD 0.37 %, CI 0.28-0.45 %, I (2) 83 %; SBP: WMD 2.2 mmHg, CI 1.0-3.5 mmHg, I (2) 72 %; body weight: WMD 2.3 lbs, CI 1.3-3.2 lbs, I (2) 64 %; and LDL-c: WMD 4.2 mg/dL, CI 1.5-6.9 mg/dL, I (2) 64 %]. The evidence was moderate for A1c, low/very low for other intermediate outcomes, low for long-term mortality and very low for complications. Interventions had no effect on hypoglycemia (evidence: low) or short-term mortality (evidence: moderate). Higher baseline A1c, pharmacist-led interventions, and longer follow-up were associated with larger A1c improvements. No intervention strategy outperformed any other in adjusted meta-regression. CONCLUSIONS: PAIs modestly improve A1c in adults with DM2 without increasing short-term mortality. These results support integration of these interventions into primary care for adults with uncontrolled glycemia, and provide evidence to insurers who do not yet cover these programs.

Aging, cancer, and longevity: the uncertain road.

First, the latest scientific and clinical reports will be evaluated to separate the wheat from the chaff, that is, good data versus merely anecdotal evidence. Thus, the famous (infamous) Stromboli Cocktail will be brought up to date. Second, longevity statistics will be reviewed: Why do the most scientifically advanced countries have such low (comparatively) life expectancies? Scientific knowledge expands exponentially each decade, whereas there have been no significant advances in our knowledge, government, economics, politics, anti-corruption, and so forth since the dawn of history. What can we expect in the future? Will the human species outlive the cockroach? Can we expect to get closer to that theoretical asymptote of 120 years of human life? Will this ceiling ever be lifted? Finally, we offer two vital challenges to scientists of today.