Predictors of Secondhand Smoke Exposure During Pregnancy in Costa Rica, the Dominican Republic, and Honduras.

INTRODUCTION: Secondhand smoke (SHS) exposure poses risks to pregnant women and children. Though smoking among pregnant women in many low- and middle-income countries is low, exposure to SHS might be higher. We examined the prevalence and predictors of SHS among pregnant women from Costa Rica, the Dominican Republic, and Honduras. METHODS: Postpartum women 18+ years old who completed pregnancy in past 5 years were surveyed in health care and community settings. RESULTS: Data for 1,081 women indicated low tobacco use (1.0%-3.7%), frequent exposure to active smokers (29.0%-34.0%), often being close enough to breathe others' smoke (49.4%-66.5%), and most having smoke-free home policies (70.8%-76.2%). Women reporting unintended pregnancy (adjusted odds ratio [aOR]: 1.44, 95% confidence interval [CI] 1.03, 2.00) and alcohol consumption (aOR: 1.92, 95% CI 1.34, 2.77) were more likely to be close enough to breathe others' smoke. Women with health problems during pregnancy (aOR: 1.48 95% CI 1.07, 2.06) were more likely to have home smoking policies. Tobacco use was associated with all SHS exposure outcomes. CONCLUSIONS: SHS exposure was high during pregnancy; women with higher risk variables, that is, tobacco use, alcohol consumption, and unintended pregnancy were more likely to be exposed. Addressing SHS exposure in pregnancy in low- and middle-income countries can improve maternal health outcomes in vulnerable populations. IMPLICATIONS: The study results suggest a cluster of multiple risk factors associated with a high prevalence of exposure to SHS among pregnant women in LIMCs from Latin America and Caribbean Region. Interventions, regulations, and policies need to address specific high-risk factors to change behaviors and improve maternal and child health outcomes especially in vulnerable populations.

Attitudes Toward the Environment and Use of Information and Communication Technologies to Address Environmental Health Risks in Marginalized Communities: Prospective Cohort Study.

BACKGROUND: Information and communication technologies, including mobile health (mHealth), can help isolated communities address environmental health challenges. The Puerto Rican island of Culebra has faced multiple sociopolitical and economic factors that have distressed the island's environment and health. Culebrenses are technologically engaged and have demonstrated a use of technology that transcends socioeconomic barriers. As a result, technological interventions could potentially help manage environmental risks on the island. OBJECTIVE: This study aims to test and evaluate the potential benefits of an mHealth tool, termed ¡mZAP! (Zonas, Acción y Protección), for engaging communities with environmental risks through technology. METHODS: Participants using ¡mZAP! (N=111) were surveyed. Bivariate analyses were used to examine associations of mHealth use with sociodemographics, technology use, an adapted environmental attitudes inventory, and the multidimensional health locus of control. Logistic regression was used to examine associations between attitudes toward environmental health risks and mHealth use. RESULTS: Higher positive attitudes toward the environment were significantly associated with the use of ¡mZAP! (odds ratio 5.3, 95% CI 1.6-17.0). Environmental attitudes were also associated with the multidimensional health locus of control powerful others subscale (P=.02), indicating that attitudes toward the environment become more negative as feelings controlled by others increase. Participants felt that the authorities would resolve the challenges (63/111, 56.7%). CONCLUSIONS: Perceived lack of control could present barriers to collective actions to address salient environmental health challenges in communities. The ongoing dependency on government-based solutions to community problems is worrisome, especially after the hurricane experiences of 2017 (which may potentially continue to be an issue subsequent to the more recent 2020 earthquakes).

Evaluating the implementation of cervical cancer screening programs in low-resource settings globally: a systematized review.

PURPOSE: Cervical cancer disproportionately burdens low-resource populations where access to quality screening services is limited. A greater understanding of sustainable approaches to implement cervical cancer screening services is needed. METHODS: We conducted a systematized literature review of evaluations from cervical cancer screening programs implemented in resource-limited settings globally that included a formal evaluation and intention of program sustainment over time. We categorized the included studies using the continuum of implementation research framework which categorizes studies progressively from "implementation light" to more implementation intensive. RESULTS: Fifty-one of 13,330 initially identified papers were reviewed with most study sites in low-resource settings of middle-income countries (94.1%) ,while 9.8% were in low-income countries. Across all studies, visual inspection of the cervix with acetic acid (58.8%) was the most prevalent screening method followed by cytology testing (39.2%). Demand-side (client and community) considerations were reported in 86.3% of the articles, while 68.6% focused scientific inquiry on the supply side (health service). Eighteen articles (35.3%) were categorized as "Informing Scale-up" along the continuum of implementation research. CONCLUSIONS: The number of cervical cancer screening implementation reports is limited globally, especially in low-income countries. The 18 papers we classified as Informing Scale-up provide critical insights for developing programs relevant to implementation outcomes. We recommend that program managers report lessons learnt to build collective implementation knowledge for cervical cancer screening services, globally.

Qualitative Assessment of Environmental Health Risk Perceptions and Community Challenges in a Puerto Rican Community: Change and Continuity in Response to Hurricanes Irma and María.

Culebra, a geographically isolated island located 17 miles from the eastern coast of Puerto Rico's main island, suffers from an amalgam of significant environmental health risk and associated social determinants of health that are affecting the community. In 2017, two major Hurricanes (Irma and María) impacted Culebra, resulting in an increase of preexisting environmental health risk. The present study's primary aim was to explore community attitudes, beliefs, and perceptions of environmental health risk, and to describe the social priorities of Culebrenses in relation to these risks and challenges. Semi-structured interview guide and Rapid Qualitative Inquiry (RQI) focused on topics of environmental health risk was followed. Qualitative focus groups and individual interviews were conducted among community members in Culebra before and shortly after Hurricanes Irma and María affected the island. Environmental health factors identified included: presence of mosquitoes, trash disposal, water quality and tourism. Additionally, a strong sentiment of island pride was found potentially generating a sense of community that could facilitate solutions to the existing environmental health challenges. Preexisting environmental health risk magnified after the pass of Hurricanes Irma and María. Sustainable and community engagement approaches are needed to develop strategies that can assist in the mitigation and resolution of the identified environmental health risk and challenges, including factors associated with threats such as disasters and pollution.

A woman's worth: an access framework for integrating emergency medicine with maternal health to reduce the burden of maternal mortality in sub-Saharan Africa.

BACKGROUND: Within each of the Sustainable Development Goals (SDGs), the World Health Organization (WHO) has identified key emergency care (EC) interventions that, if implemented effectively, could ensure that the SDG targets are met. The proposed EC intervention for reaching the maternal mortality benchmark calls for "timely access to emergency obstetric care." This intervention, the WHO estimates, can avert up to 98% of maternal deaths across the African region. Access, however, is a complicated notion and is part of a larger framework of care delivery that constitutes the approachability of the proposed service, its acceptability by the target user, the perceived availability and accommodating nature of the service, its affordability, and its overall appropriateness. Without contextualizing each of these aspects of access to healthcare services within communities, utilization and sustainability of any EC intervention-be it ambulances or simple toll-free numbers to dial and activate EMS-will be futile. MAIN TEXT: In this article, we propose an access framework that integrates the Three Delays Model in maternal health, with emergency care interventions. Within each of the three critical time points, we provide reasons why intended interventions should be contextualized to the needs of the community. We also propose measurable benchmarks in each of the phases, to evaluate the successes and failures of the proposed EC interventions within the framework. At the center of the framework is the pregnant woman, whose life hangs in a delicate balance in the hands of personal and health system factors that may or may not be within her control. CONCLUSIONS: The targeted SDGs for reducing maternal mortality in sub-Saharan Africa are unlikely to be met without a tailored integration of maternal health service delivery with emergency medicine. Our proposed framework integrates the fields of maternal health with emergency medicine by juxtaposing the three critical phases of emergency obstetric care with various aspects of healthcare access. The framework should be adopted in its entirety, with measureable benchmarks set to track the successes and failures of the various EC intervention programs being developed across the African continent.

Attitudes, practices, and priority of HIV screening and testing among clinical providers in Transylvania and Moldavia, Romania.

Screening and linkage to care are core, foundational strategies for HIV transmission prevention and for identifying People Living with HIV (PLHIV). In Romania - with an atypical experience in the HIV/AIDS epidemic - providing care for HIV+ patients identified early is a priority, though screening and testing can pose a challenge in some areas. METHODS: A survey of 125 clinical providers to explore important dimensions of HIV/ AIDS clinical care was conducted in Transylvania and Moldavia, where clinicians identified poor/ latent screening as a major problem in providing timely care and in preventing the spread of disease. We analyzed determinants of offering HIV screening/testing to patients using Pearson Chi-square analysis and logistic regression. Logistic regression generated Odds Ratios (OR) to reflect the magnitude of association between the relevant variables, with 95% confidence interval (95% CI) indicating statistical range. RESULTS: In total, 40.8% of providers did not provide HIV screening/testing to at least one segment of the population. Hospital-based providers were significantly more likely to offer HIV screening/testing to all segments than were non-hospital-based providers (58.1% v. 35.5%, respectively; p < .05). Providers located within institutions with screening/testing policies were more likely to offer such services to their patients (p < .05). Overall, 94.4% of providers indicated interest in more training around HIV screening/testing. DISCUSSION: Reaching Romanian and global goals for reducing HIV require more timely screening and action based on positive status. Romanian clinicians are interested in expanding HIV screening/testing and are interested in participating in training that helps them feel more prepared to undertake this work.

Behind the Scenes: Publishing in the Maternal and Child Health Journal.

The Editors of the Maternal and Child Health Journal offer an inside look at publishing in the journal, including advice for potential authors and reviewers.

Antepartum Contraceptive Counseling in Women with Preterm Birth.

OBJECTIVE: To compare rates of antepartum contraceptive counseling among women with preterm birth (PTB) and term birth. STUDY DESIGN: This is a retrospective cohort study of patients with completed delivery records in New York from January 1, 2004, to December 31, 2014. Exposure was determined based on the timing of delivery. Exposed women delivered at <37 weeks, and nonexposed women delivered at ≥37 weeks. Primary outcome was patient response to questions regarding receipt of prenatal contraceptive counseling (PCC) by a health care provider. Secondary outcome was receipt of interpregnancy interval counseling. Chi-square tests and multivariate logistic regression were used for analysis. RESULTS: Of 724,723 delivery records, PTB rate was 7.9%. Women with PTB < 37 weeks were significantly less likely to receive PCC (odds ratio [OR]: 0.9; 95% confidence interval [CI]: 0.89-0.93) or interpregnancy interval counseling (OR: 0.95; 95% CI: 0.94-0.97). The primary outcome remained significant after adjusting for confounders (adjusted OR: 0.91; 95% CI: 0.89-0.93). PTB < 34 weeks was associated with even lower odds of receiving contraceptive counseling (OR: 0.79; 95% CI: 0.76-0.83). CONCLUSION: Postpartum contraception is an important tool for the prevention of recurrent PTB. Antepartum contraception counseling increases postpartum contraceptive uptake. Women with PTB have less exposure to antepartum contraceptive counseling. Lack of adequate counseling and decreased uptake of postpartum contraception may impact future pregnancy outcomes.

Influence of Hearing Loss on Child Behavioral and Home Experiences.

OBJECTIVES: To assess the influence of hearing loss on child behavioral diagnoses, and socioemotional and behavior status. METHODS: We analyzed US National Health Interview Survey (NHIS) child data, years 2011 to 2015, for associations between reported hearing loss and relevant NHIS items. RESULTS: Compared with hearing children, NHIS respondents with a deaf child were more likely to report developmental delays (adjusted odds ratio [AOR] = 11.1; 95% confidence interval [CI] = 3.8, 32.4), attention-deficit disorder (AOR = 3.1; 95% CI = 2.5, 3.9), autism diagnoses (AOR = 2.9; 95% CI = 1.8, 4.9), and minor to severe socioemotional difficulties (AOR = 3.9; 95% CI = 3.2, 4.7). When asked if their child was well behaved, respondents were more likely to reply "somewhat true" or "not true" (AOR = 2.7; 95% CI = 2.2, 3.4). CONCLUSIONS: Hearing loss increases likelihood of reporting child behavioral diagnoses, behavior issues, and socioemotional difficulties. Although etiology and professional misdiagnoses likely contribute to elevated prevalence, lack of attention toward language deprivation as a public health issue prevents any further epidemiological insights. Public Health Implications. Despite widespread use of cochlear implants, concerns about deaf children's well-being remain significant. Language deprivation requires investigation and awareness as a social determinant of health.

Bon-EV: an improved multiple testing procedure for controlling false discovery rates.

BACKGROUND: Stability of multiple testing procedures, defined as the standard deviation of total number of discoveries, can be used as an indicator of variability of multiple testing procedures. Improving stability of multiple testing procedures can help to increase the consistency of findings from replicated experiments. Benjamini-Hochberg's and Storey's q-value procedures are two commonly used multiple testing procedures for controlling false discoveries in genomic studies. Storey's q-value procedure has higher power and lower stability than Benjamini-Hochberg's procedure. To improve upon the stability of Storey's q-value procedure and maintain its high power in genomic data analysis, we propose a new multiple testing procedure, named Bon-EV, to control false discovery rate (FDR) based on Bonferroni's approach. RESULTS: Simulation studies show that our proposed Bon-EV procedure can maintain the high power of the Storey's q-value procedure and also result in better FDR control and higher stability than Storey's q-value procedure for samples of large size(30 in each group) and medium size (15 in each group) for either independent, somewhat correlated, or highly correlated test statistics. When sample size is small (5 in each group), our proposed Bon-EV procedure has performance between the Benjamini-Hochberg procedure and the Storey's q-value procedure. Examples using RNA-Seq data show that the Bon-EV procedure has higher stability than the Storey's q-value procedure while maintaining equivalent power, and higher power than the Benjamini-Hochberg's procedure. CONCLUSIONS: For medium or large sample sizes, the Bon-EV procedure has improved FDR control and stability compared with the Storey's q-value procedure and improved power compared with the Benjamini-Hochberg procedure. The Bon-EV multiple testing procedure is available as the BonEV package in R for download at https://CRAN.R-project.org/package=BonEV .

Reporting studies on time to diagnosis: proposal of a guideline by an international panel (REST).

BACKGROUND: Studies on time to diagnosis are an increasing field of clinical research that may help to plan corrective actions and identify inequities in access to healthcare. Specific features of time to diagnosis studies, such as how participants were selected and how time to diagnosis was defined and measured, are poorly reported. The present study aims to derive a reporting guideline for studies on time to diagnosis. METHODS: Each item of a list previously used to evaluate the completeness of reporting of studies on time to diagnosis was independently evaluated by a core panel of international experts (n = 11) for relevance and readability before an open electronic discussion allowed consensus to be reached on a refined list. The list was then submitted with an explanatory document to first, last and/or corresponding authors (n = 98) of published systematic reviews on time to diagnosis (n = 45) for relevance and readability, and finally approved by the core expert panel. RESULTS: The refined reporting guideline consists of a 19-item checklist: six items are about the process of participant selection (with a suggested flowchart), six about the definition and measurement of time to diagnosis, and three about optional analyses of associations between time to diagnosis and participant characteristics and health outcomes. Of 24 responding authors of systematic reviews, more than 21 (≥88 %) rated the items as relevant, and more than 17 (≥70 %) as readable; 19 of 22 (86 %) authors stated that they would potentially use the reporting guideline in the future. CONCLUSIONS: We propose a reporting guideline (REST) that could help authors, reviewers, and editors of time to diagnosis study reports to improve the completeness and the accuracy of their reporting.

An evaluation of statistical methods for DNA methylation microarray data analysis.

BACKGROUND: DNA methylation offers an excellent example for elucidating how epigenetic information affects gene expression. ß values and M values are commonly used to quantify DNA methylation. Statistical methods applicable to DNA methylation data analysis span a number of approaches such as Wilcoxon rank sum test, t-test, Kolmogorov-Smirnov test, permutation test, empirical Bayes method, and bump hunting method. Nonetheless, selection of an optimal statistical method can be challenging when different methods generate inconsistent results from the same data set. RESULTS: We compared six statistical approaches relevant to DNA methylation microarray analysis in terms of false discovery rate control, statistical power, and stability through simulation studies and real data examples. Observable differences were noticed between ß values and M values only when methylation levels were correlated across CpG loci. For small sample size (n=3 or 6 in each group), both the empirical Bayes and bump hunting methods showed appropriate FDR control and the highest power when methylation levels across CpG loci were independent. Only the bump hunting method showed appropriate FDR control and the highest power when methylation levels across CpG sites were correlated. For medium (n=12 in each group) and large sample sizes (n=24 in each group), all methods compared had similar power, except for the permutation test whenever the proportion of differentially methylated loci was low. For all sample sizes, the bump hunting method had the lowest stability in terms of standard deviation of total discoveries whenever the proportion of differentially methylated loci was large. The apparent test power comparisons based on raw p-values from DNA methylation studies on ovarian cancer and rheumatoid arthritis provided results as consistent as those obtained in the simulation studies. Overall, these results provide guidance for optimal statistical methods selection under different scenarios. CONCLUSIONS: For DNA methylation studies with small sample size, the bump hunting method and the empirical Bayes method are recommended when DNA methylation levels across CpG loci are independent, while only the bump hunting method is recommended when DNA methylation levels are correlated across CpG loci. All methods are acceptable for medium or large sample sizes.

Can we really diagnose diabetes during pregnancy?

OBJECTIVE: To identify the accuracy of diagnosing postpartum diabetes and glucose intolerance using antepartum glycosylated hemoglobin (HbA1c) and fasting glucose values. STUDY DESIGN: A retrospective Hawaiian cohort of women with gestational diabetes during 2004-2011 were evaluated. Antepartum HbA1c and postpartum 75-g glucose tolerance tests were obtained. RESULTS: An antepartum HbA1c value of ≥6.5% had a 45.7% sensitivity, a 96% specificity and a 40% positive predictive value (PPV) for predicting postpartum diabetes. An antepartum HbA1c value of ≥6.5% had a 6.6% sensitivity, a 94.2% specificity and a 27% PPV for predicting postpartum impaired glucose tolerance. An antepartum HbA1c value of ≥6.5% had a 10.3% sensitivity, a 95.7% specificity and a 33.3% PPV for predicting postpartum impaired fasting glucoses. CONCLUSION: We could not demonstrate a clinically useful PPV for diagnosing postpartum diabetes or glucose intolerance using an antepartum elevated HbA1c value of ≥6.5% or a fasting glucose level of ≥90 mg/dL.

Seafood consumption and umbilical cord blood mercury concentrations in a multiethnic maternal and child health cohort.

BACKGROUND: Fish consumption is common among the cultures of Hawaii, and given public health attention to mercury exposure in pregnancy, it is important to better understand patterns of fish consumption and mercury in pregnancy. This study examined the influence of maternal fish consumption during pregnancy on umbilical cord mercury (Hg) concentrations in a multiethnic cohort of women in Hawaii. METHODS: This secondary analysis of a prospective cohort pilot study examined antenatal seafood consumption and neonatal outcomes in Hawaii. The first 100 eligible women who consented were enrolled. After delivery, umbilical cord blood and a dietary survey were obtained. RESULTS: Most women (86%) consumed seafood during the month prior to delivery. Overall, 9% of women consumed more than the recommended limit of 12 ounces/week. Seafood consumption varied significantly by ethnicity and income, with 30% of poor women consuming more than the recommended limit. Seafood consumption did not vary by age or education.Umbilical cord blood Hg levels were 5 µg/L or more in 44% of women. Filipina were significantly less likely to have elevated Hg levels compared with non- Filipina (p < .05). Mercury levels did not vary by other demographic characteristics.Women reporting consumption exceeding 12 ounces fish per week were significantly more likely to have cord blood Hg levels of 5 µg/L or more, but mean Hg concentrations were not significantly higher (6.1 ± 3.3 v 5.0 ± 3.7). The odds ratio for elevated Hg, however, was significant among seafood-consumers compared with non-consumers (5.7; 95% confidence interval: 1.2, 27.1). CONCLUSIONS: Despite Environmental Protection Agency (EPA) guidelines, a significant portion of pregnant women consumed more than the recommended amount of seafood, which was associated with race and income. Further, almost half of study participants had cord blood Hg concentrations at or exceeding 5 µg/L.

Improved abnormal Pap smear triage using cervical cancer biomarkers.

OBJECTIVE: The current system of Pap smear screening and management of abnormal cytology has resulted in a marked reduction in invasive cervical cancer. Many women, however, are not found to have significant precursor lesions. This is due to the poor specificity of high-risk human papillomavirus (HPV) triage. More specific cervical cancer biomarkers may be more effective triage tools than hr-HPV. We evaluated whether a dual stain for p16 and Ki-67 might improve the triage of abnormal Pap smears. MATERIALS AND METHODS: p16/Ki-67 immunostaining was performed on additional slides prepared from 515 women with abnormal Pap smears (301 atypical squamous cells of undetermined significance [ASCUS], 169 low-grade squamous intraepithelial lesion [LSIL], 29 atypical squamous cells-cannot exclude high-grade lesion [ASC-H], 16 high-grade squamous intraepithelial lesion [HSIL]). High-risk HPV typing was performed on all cases. Immunostaining and hr-HPV were compared in relation to their diagnostic accuracy for the detection of biopsy-proven cervical intraepithelial neoplasia (CIN) 2/3. A cost analysis comparing hr-HPV versus immunostaining as the initial triage tool used for abnormal Pap smears was also performed. RESULTS: High-risk HPV was positive in 127 (42.2%) ASCUS, 129 (76.3%) LSIL, 20 (69.0%) ASC-H, and 15 (93.8%) HSIL. p16/Ki-67 was positive in 54 (17.9%) ASCUS, 73 (43.2%) LSIL, 19 (65.5%) ASC-H, and 15 (93.8%) HSIL. For detection of CIN 2/3, sensitivity/specificity of hr-HPV and p16/Ki-67 was 89.29%/14.94% and 96.43%/60.92%, respectively. Overall, diagnostic accuracy was statistically significantly higher for p16/Ki-67 compared with hr-HPV. Compared to HPV, immunostain triage could have generated approximately $46,000 savings in the study population. CONCLUSIONS: The triage of abnormal Pap smears by p16/Ki-67 immunostaining shows comparable sensitivity, improved specificity, and significantly improved diagnostic performance when compared to hr-HPV. Immunostaining is of value in triaging LSIL and ASC-H Pap smears in addition to ASCUS. The widespread utilization of biomarker triage could result in significant health care cost savings without compromising the detection of significant cervical cancer precursors.

Associations of childhood hearing loss and adverse childhood experiences in deaf adults.

Childhood trauma and adverse childhood experiences have a strong relationship with health disparities across the lifespan. Despite experiencing approximately doubled rates of trauma, Adverse Childhood Experiences (ACEs) are poorly characterized in deaf populations. We sought to characterize deaf-specific demographic factors and their association with multiple experiences of ACEs before the age of 18 years old. An analytical cross-sectional approach was used to ascertain associations of deaf-specific demographic factors and experiences with ACEs. The complete dataset included 520 participants for a total response rate of 56%. After adjusting for confounding effects, less severe hearing loss of 16-55 dB (2+ OR: 5.2, 4+ OR: 4.7), having a cochlear implant (2+ OR: 2.1, 4+ OR: 2.6), and not attending at least one school with signing access (2+ OR: 2.4, 4+ OR: 3.7) were significantly and independently associated with reported experiences of multiple ACEs. We conclude that factors associated with childhood hearing loss and language experiences increase risk of experiencing ACEs. Given the strong relationship between ACEs and poor social outcomes, early intervention clinical practice and health policies should consider interventions to support healthy home environments for deaf children.

Attitudes and experiences regarding preventive strategies for the deaf population in Western New York.

People for whom English is a second language, such as the deaf population, often have unequal access to health information and low health literacy. In the context of a wider study on risk of tick-borne illness in deaf communities, we explored barriers, opportunities, and nuances to accessible health information and communication among deaf people. Semi-structured qualitative individual and group interviews were conducted with 40 deaf people in upstate New York, to explore factors associated with health literacy and health information accessibility. Interviews were conducted in American Sign Language (ASL) by a deaf researcher fluent in ASL. Data analysis included the translation of ASL signs into English words, systematic coding, and generation of themes. A total of 21 interview events (mean time per interview = 41 minutes) were conducted. Two main themes and multiple sub-themes emerged from the data: 1) Layers of obstacles faced by deaf people confirms (or reinforces) exclusion; and 2) preventive information is unavailable or inaccessible to deaf people. Sub- themes identified in the results were perceptions of the deaf community and deaf culture, complex layers of obstacles faced by deaf individuals, the digital divide, the culture of communication, awareness of tick and tick-borne disease (TBD) diseases, importance of using certified deaf interpreters (CDI), health information dissemination strategies and collaborations with the education system, and physical/virtual community engagement. The data suggested several challenges to health literacy in the deaf population, including healthcare and education inequalities and negative perceptions of deaf people by both deaf and hearing people. Improving health literacy in the deaf population requires more interpreters who themselves are deaf ("certified deaf interpreters"), provision of health information in ASL, and a greater engagement with the deaf population by education and healthcare systems.

An evaluation of statistical differential analysis methods in single-cell RNA-seq data.

Background: Single-cell RNA Sequencing is gaining popularity in recent years. Compared to bulk RNA-Seq, single-cell RNA Sequencing allows the gene expression being measured within individual cells instead of mean gene expression levels across all cells in the sample. Thus, cell-to-cell variation of gene expressions could be examined. Gene differential expression analysis remains the major purpose in most single-cell RNA sequencing experiments and many methods have been developed in recent years to conduct gene differential expression analysis for single-cell RNA sequencing data. Results: Through simulation studies and real data examples, we evaluated the performance of five open-source popular methods used for gene differential expression analysis in single-cell RNA sequencing data. The five methods included DEsingle (Zero-inflated negative binomial model), Linnorm (Empirical Bayes method on transformed count data using the limma package), monocle (An approximate Chi-Square likelihood ratio test), MAST (A generalized linear hurdle model), and DESeq2 (A generalized linear model with empirical Bayes approach and also commonly used for bulk RNA sequencing differential express analyses). We assessed the false discovery rate (FDR) control, sensitivity, specificity, accuracy, and area under the receiver operating characteristics (AUROC) curve for all five methods under different sample sizes, distribution assumptions, and proportions of zeros in the data. Conclusions: We found the MAST method performed the best among the five methods compared with the largest AUROC values across all tested sample sizes and different proportion of truly differential expressed genes, when the data followed negative binomial distributions. When the sample size increased to 100 in each group, the MAST method showed the best performance with the highest AUROC regardless of the data distributions. If the excess zeros were first filtered out before the gene differential analyses, the DESingle, Linnorm, and DESeq2 performed relatively better than the MAST and the monocle methods with higher AUROC values.

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.