Student Clinical Experiences in Cross-Cultural Education.

OBJECTIVES: Education in cultural competence is critical to training medical students to care for patients from all backgrounds, but it is unclear what experience students have in the clinical learning environment. We describe the medical student experience in directly observed cross-cultural encounters within two clinical clerkships, and we identify areas of need for further resident and faculty training in providing high-quality feedback following these encounters. METHODS: We collected direct observation feedback forms from third-year medical students in the Internal Medicine and Pediatrics clerkships. The observed cross-cultural skill was categorized, and the quality of feedback given to students was quantified using a standardized model. RESULTS: Students were observed using an interpreter more frequently than any other skill. Positive feedback received the highest quality scores, averaging 3.34 out of 4 coded elements. Corrective feedback quality only averaged 2.3 out of 4 coded elements, and quality correlated with the frequency of cross-cultural skill observation. CONCLUSIONS: Significant variability exists in the quality of feedback provided to students following the direct observation of cross-cultural clinical skills. Faculty and resident training to improve feedback should focus on corrective feedback in less commonly observed cross-cultural skills.

Meningovascular Neurosyphilis Presenting as Multiple Ischemic Infarcts in a Young Adult.

Neurosyphilis occurs when the spirochete Treponema pallidum invades the cerebrospinal fluid (CSF). Clinical presentation depends on an individual's immune response and invasion location, with all possible involvement of meningeal, vascular, and/or parenchymatous tissues. Meningovascular neurosyphilis occurs when both the meninges and vasculature are affected and can lead to headaches, photophobia, neck stiffness, cranial nerve palsies, and/or ischemic brain infarctions due to infectious arteritis. The following report describes the rare case of a 32-year-old male patient presenting with multiple ischemic brain infarctions of varying ages. The stepwise diagnostic approach as described allowed the medical team to reach the final diagnosis of meningovascular neurosyphilis with concomitant acquired immunodeficiency syndrome (AIDS). This case emphasizes the importance of maintaining high clinical suspicion in all young adult patients who present with acute neurological deficits.

Assessing Health and Human Services Needs to Support an Integrated Health in All Policies Plan for Prince George's County, Maryland.

With evolving demographics and a changing health system landscape, the Prince George's County Council, acting as the County Board of Health, is considering its future policy approaches and resource allocations related to health and well-being. To inform this path forward, the authors of this study used primary and secondary data to describe both the health needs of county residents and drivers of health within the county, inclusive of the social, economic, built, natural, and health service environments. This study integrates these findings, an analysis of budget documents, and a review of promising practices from other communities to situate recommendations in a Health in All Policies framework to foster aligned and integrated planning and budgeting across the county to promote health and well-being. Findings from the assessment indicate a shared interest among leaders and residents to embrace a holistic strategy for health and well-being in the county. Inefficient uses of the health care system are identified, highlighting a need to rebalance investments in health care use and drivers of health. Additionally, challenges in navigating health and human services and inequities in drivers of health across communities are noted, signaling broader concerns related to residents' access to health and human services that influence health and well-being outcomes. Recommendations are provided for several paths forward for the county to pursue a more integrated policy approach to influence health and well-being outcomes.

Race, Place, And Structural Racism: A Review Of Health And History In Washington, D.C.

Recent events have amplified the debilitating effects of systemic racism on the health of the United States. In an effort to improve population health and dismantle more than 400 years of racial injustice, retrospective examinations of policies, practices, and events that have sustained and continue to undergird racial hierarchy are necessary. In this historical review we feature Washington, D.C.-a city with a legacy of Black plurality. We begin with an overview of contemporary place-based health and socioeconomic disparities. To express the etiology of the trends and uncover opportunities to undo the damage, we reflect on the national landscape as well as on policies and events that socially, economically, and politically disenfranchised Black residents, yielding stark differences in health outcomes among Washington, D.C., populations. In the spirit of atonement in policy and practice, we hope that this approach will inspire policy makers and practitioners in communities across the nation to conduct similar examinations.

Relationship of Hospital Star Ratings to Race, Education, and Community Income.

INTRODUCTION: The Centers for Medicare & Medicaid Services (CMS) publishes hospital quality ratings to provide more transparent and useable quality information to patients and stakeholders. However, there is a gap in the literature regarding the geographic distribution of the hospitals with higher star ratings. In this paper, we focus on the associations between star ratings and community characteristics, including racial/ethnic mix, household income, educational attainment, and regional difference. METHODS: A retrospective study and cross-sectional logistic and multinomial logistic regression analyses. RESULTS: According to the multivariate regression results, hospitals in areas with lower income, lower educational attainment, and higher minority population shares have lower quality ratings (lower income: odds ratio [OR] 0.67; 95% CI, 0.49-0.91; lower education: OR 0.66; 95% CI, 0.51-0.85; higher minority: OR 0.52; 95% CI, 0.40-0.69). Compared with hospitals in the Midwest, hospitals in Northeast, South, and West regions have lower quality ratings (Northeast: OR 0.37; 95% CI, 0.25-0.56; South: OR 0.68; 95% CI, 0.51-0.91; West: OR 0.69; 95% CI, 0.49-0.97). DISCUSSION AND CONCLUSION: Overall, our results show that hospitals with higher star ratings are less likely to be located in communities with higher minority populations, lower income, and lower levels of educational attainment. Findings contribute to the discussion of integrating social factors in hospital quality star rating calculation methodologies.

Diabetes mortality rates among African Americans: A descriptive analysis pre and post Medicaid expansion.

BACKGROUND: Compared with other racial and ethnic groups, African Americans are disproportionately burdened by high rates of deaths due to diabetes. Insurance coverage and access to primary care are critical for prevention and chronic disease management. PURPOSE: To examine the difference in age-adjusted diabetes mortality rates in African Americans before and after Medicaid expansion. METHODS: Using ICD-10 Cause List E10-E14, age-adjusted diabetes mortality rates among African Americans were extracted from the Centers for Disease Control and Prevention's Compressed Mortality File. Sufficient and reliable data were available for 36 states and the District of Columbia. With a 95% confidence interval, two periods were analyzed: pre-Medicaid expansion - years 2008, 2009, 2010 and post-Medicaid expansion - years 2014, 2015, 2016. Three-year means for both periods were calculated for each state. Differences for each state are presented and contextualized as a state that opted in or out of expanding Medicaid coverage. RESULTS: There was a slight reduction in diabetes mortality in African Americans (41.14/100,000 pre-expansion and 38.94/100,000 post-expansion). We found variability across states - regardless of expansion status. Differences in rates ranged from a decrease of 15.43/100,000 to an increase of 9.53/100,000. Out of all states that met our criteria, 24 states expanded coverage; age-adjusted diabetes death rates declined in 16 of those states. There were also reductions in eight states that did not expand coverage. CONCLUSION: Future research is needed to explore if Medicaid expansion is associated with reductions in diabetes mortality in the African American community.

Defining Medical Student Patient Care Responsibilities Before Intern Year: Results of a National Survey.

OBJECTIVES: Program directors have noted that first-year residents struggle with many of the patient care responsibilities they assume as they enter the US graduate medical education system. A national description of medical students' patient care experience in advance of graduation has not been published. We sought to describe the experience of US medical students during their clinical training by surveying the student representatives of each school. METHODS: We developed a mixed-methods survey that was delivered to representatives of 82 schools via an e-mail link to an online survey. RESULTS: Our response rate was 54% (44/82). Of those responding, 28% reported that students do not write any patient care orders at their institution and 34% reported not receiving pages related to patient care. Only 26% of institutions provide an increased patient load to students during their final year of training. Students identified many areas to improve the role of fourth-year medical students, including writing patient care orders, answering pages, increasing autonomy, defining their role better, and providing them with a longer subinternship experience. CONCLUSIONS: Our survey suggests that students are graduating from the undergraduate medical education system and moving to the graduate medical education system in the United States without a guarantee of having answered a page related to patient care or having placed a patient care order. Further studies of students' experiences should be conducted to explore whether exposure to these skills improves first-year resident performance.

The Health Care Institution, Population Health and Black Lives.

The ongoing existence of institutionalized racism and discriminatory practices in various systems (education, criminal justice, housing, employment) serve as root causes of poor health in Blacks Lives. Furthermore, these unjust social structures and their complex interplay result in inefficient utilization of health services and reactive or futile interactions with medical providers. Collectively, these factors contribute to racial disparities in health and treatment represents a significant portion of the nation's health care expenditures. In order for health care systems to optimize population health goals, racism must be recognized as a determinant of health. As anchor institutions in their respective communities, we offer hospitals and health systems a conceptual framework to address the issue within internal and external constructs.

Decomposing differences in medical care access among cancer survivors by race and ethnicity.

More research is needed to identify factors that explain why minority cancer survivors ages 18 to 64 are more likely to delay or forgo care when compared with whites. Data were merged from the 2000-2011 National Health Interview Survey to identify 12 125 adult survivors who delayed medical care. The Fairlie decomposition technique was applied to explore contributing factors that explain the differences. Compared with whites, Hispanics were more likely to delay care because of organizational barriers (odds ratio = 1.38; P < .05), and African Americans were more likely to delay medical care or treatment because of transportation barriers (odds ratio = 1.54; P < .001). The predicted probability of not receiving timely care because of each barrier was lowest among minorities. Age, insurance, perceived health, comorbidity, nativity, and year were significant factors that contributed to the disparities. Although expanded insurance coverage through the Affordable Care Act is expected to increase access, organizational factors and transportation play a major role.

Breast and cervical screening by race/ethnicity: comparative analyses before and during the Great Recession.

BACKGROUND: Traditionally, economic recessions have resulted in decreased utilization of preventive health services. PURPOSE: To explore racial and ethnic differences in breast and cervical cancer screening rates before and during the Great Recession. METHODS: The Medical Expenditure Panel was the source for identifying 10,894 women, ages 50-74 for breast screening and 19,957 women, ages 21-65 for cervical screening. Survey years included 2004-2005 and 2009-2010. Dependent variables were as follows: 1) receipt of mammogram within the past 2 years; and 2) receipt of a Pap smear within the past 3 years. The interaction of the recession and the likelihood of screening between whites and minorities was analyzed. Multivariate regressions were applied to estimate the likelihood of screening for the two time periods while controlling for a recession variable. RESULTS: Nationally, breast and cervical cancer screening rates dropped during the recession period; white women contributed most to the decline. However, there were significant improvements in timely screening for both cancers among Hispanics during the recession period. After controlling for the recession, African American women were more likely to have timely screenings compared to white women. Screening rates during the recession were lowest in the South, Midwest and West. CONCLUSION: There was a national reduction in the percentages of women who obtained timely breast and cervical screenings during the Great Recession. Outreach efforts are needed to ensure that women who were not screened during the recession are screened. Widespread education about the Affordable Care Act may be helpful.

Post-extubation dysphagia is associated with longer hospitalization in survivors of critical illness with neurologic impairment.

INTRODUCTION: Critically ill patients can develop acute respiratory failure requiring endotracheal intubation. Swallowing dysfunction after liberation from mechanical ventilation, also known as post-extubation dysphagia, is common and deleterious among patients without neurologic disease. However, the risk factors associated with the development of post-extubation dysphagia and its effect on hospital lengthofstay in critically ill patients with neurologic disorders remains relatively unexplored. METHODS: We conducted a retrospective, observational cohort study from 2008 to 2010 of patients with neurologic impairment who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech-language pathologist. RESULTS: A BSE was performed after mechanical ventilation in 25% (630/2,484) of all patients. In the 184 patients with neurologic impairment, post-extubation dysphagia was present in 93% (171/184), and was classified as mild, moderate, or severe in 34% (62/184), 26% (48/184), and 33% (61/184), respectively. In univariate analyses, statistically significant risk factors for moderate/severe dysphagia included longer durations of mechanical ventilation and the presence of a tracheostomy. In multivariate analysis, adjusting for age, tracheostomy, cerebrovascular disease, and severity of illness, mechanical ventilation for >7 days remained independently associated with moderate/severe dysphagia (adjusted odds ratio=4.48 (95%confidence interval=2.14 to 9.81), P<0.01). The presence of moderate/severe dysphagia was also significantly associated with prolonged hospital lengthofstay, discharge status, and surgical placement of feeding tubes. When adjusting for age, severity of illness, and tracheostomy, patients with moderate/severe dysphagia stayed in the hospital 4.32 days longer after their initial BSE than patients with none/mild dysphagia (95% confidence interval=3.04 to 5.60 days, P<0.01). CONCLUSION: In a cohort of critically ill patients with neurologic impairment, longer duration of mechanical ventilation is independently associated with post-extubation dysphagia, and the development of post-extubation dysphagia is independently associated with a longer hospital length of stay after the initial BSE.

Biological evaluation of 99mTc labelled cis-platinum containing benzyliminodiacetic acids as potential tumour imaging agents.

The synthesis of three new potential tumour-imaging radiopharmaceuticals in which a cis-platin derivative is attached to benzyl iminodiacetic acid, a ligand capable of forming a stable complex with 99mTc, has previously been reported by us [Awaluddin et al. Appl. Radiat. Isot. 38, 671-674 (1987)]. We have now carried out extensive biodistribution studies on these compounds as well as on two fragments of their structures which do not contain platinum. The results suggest that the presence of platinum is not essential for the tumour-localizing properties of the radiopharmaceuticals.