Preventing Traumatic Causes of Maternal Death.

Despite medical advances, maternal deaths in the U.S. are more common than in nearly all other developed nations. In addition, racial disparities have continued to widen. Driving our rates are maternal deaths from trauma such as homicide, suicide, and drug overdose. Here we discuss limitations of existing practices in prenatal and postpartum care in preventing maternal deaths. We then outline three simple yet novel strategies for changing care to prevent traumatic cases of maternal mortality.

A Mobile Clinic Care Coordination Program: Enhancing Patient Care with Innovative Roles for Undergraduate Students.

The University of Florida Mobile Outreach Clinic's Care Coordination Program uses trained undergraduate volunteers to provide vital services; these include patient intake, recording vital signs, scribing first drafts of clinic notes, and making follow-up phone calls. The program and its benefits are replicable as demonstrated by our systematic implementation plan.

Continuous Rural-Urban Coding for Cancer Disparity Studies: Is It Appropriate for Statistical Analysis?

Background: The dichotomization or categorization of rural-urban codes, as nominal variables, is a prevailing paradigm in cancer disparity studies. The paradigm represents continuous rural-urban transition as discrete groups, which results in a loss of ordering information and landscape continuum, and thus may contribute to mixed findings in the literature. Few studies have examined the validity of using rural-urban codes as continuous variables in the same analysis. Methods: We geocoded cancer cases in north central Florida between 2005 and 2010 collected by Florida Cancer Data System. Using a linear hierarchical model, we regressed the occurrence of late stage cancer (including breast, colorectal, hematological, lung, and prostate cancer) on the rural-urban codes as continuous variables. To validate, the results were compared to those from using a truly continuous rurality data of the same study region. Results: In term of associations with late-stage cancer risk, the regression analysis showed that the use of rural-urban codes as continuous variables produces consistent outcomes with those from the truly continuous rurality for all types of cancer. Particularly, the rural-urban codes at the census tract level yield the closest estimation and are recommended to use when the continuous rurality data is not available. Conclusions: Methodologically, it is valid to treat rural-urban codes directly as continuous variables in cancer studies, in addition to converting them into categories. This proposed continuous-variable method offers researchers more flexibility in their choice of analytic methods and preserves the information in the ordering. It can better inform how cancer risk varies, degree by degree, over a finer spectrum of rural-urban landscape.

Animal cruelty as an indicator of family trauma: Using adverse childhood experiences to look beyond child abuse and domestic violence.

Youth who engage in animal cruelty are known to be at increased risk of perpetrating violence on other people in their lives including peers, loved ones, and elder family members. These youths have often been exposed to family violence, including animal cruelty perpetrated on their beloved pets by violent adults. The current study utilizes a data set of 81,000 juvenile offenders whose adverse childhood experiences are known and includes 466 youth who self-report engaging in animal cruelty. Compared to the larger group of juvenile offenders, the children admitting to engaging in animal cruelty are younger at time of first arrest, more likely to be male, and more likely to be White. When looking at their reports of adverse childhood experiences (ACEs), they are more likely than other juvenile offenders to have an array of adverse experiences beyond family violence and to have four or more ACEs. Although the youth who are cruel to animals are already troubled, the fact that they present to law enforcement at early ages provides early opportunities for intervention. Service providers outside the law enforcement field, such as teachers, physicians, veterinarians and animal control officers may be able to identify these vulnerable youth, and refer them to needed services before violence is visited on other humans.

Undergraduate Minor in Health Disparities in Society: a Magnet for Under-represented Pre-professional Students.

Increasing the diversity of tomorrow's healthcare work force remains a challenge despite many thoughtful published reports and recommendations. As part of an effort to grow a more diverse pre-professional health population, we created an undergraduate minor, Health Disparities in Society, at the University of Florida. Most courses for the minor were identified from existing offerings, and we created only two new courses, an introduction course and a capstone service-learning course. The new minor quickly became the most popular in the College of Liberal Arts and Sciences (which has approximately 12,000 total undergraduate students), and importantly, students selecting the minor were more likely to be under-represented minorities than would be expected given undergraduate demographics. Pre-professional students choosing this minor reflect the desired diversity of the healthcare workforce of tomorrow.

Factors that Influence Intake to One Municipal Animal Control Facility in Florida: A Qualitative Study.

This qualitative study identified a study area by visualizing one year of animal intake from a municipal animal shelter on geographic information systems (GIS) maps to select an area of high stray-dog intake to investigate. Researchers conducted semi-structured interviews with residents of the selected study area to elucidate why there were high numbers of stray dogs coming from this location. Using grounded theory, three themes emerged from the interviews: concerns, attitudes, and disparities. The residents expressed concerns about animal welfare, personal safety, money, and health. They held various attitudes toward domestic animals in the community, including viewing them as pets, pests, or useful commodities (products). Residents expressed acceptance as well as some anger and fear about the situation in their community. Interviewees revealed they faced multiple socioeconomic disparities related to poverty. Pet abandonment can result when pet owners must prioritize human needs over animal needs, leading to increased shelter intake of stray dogs. Community-specific strategies for reducing local animal shelter intake should address the issue of pet abandonment by simultaneously targeting veterinary needs of animals, socioeconomic needs of residents, and respecting attitude differences between residents and shelter professionals.

Youth Arrested for Trading Sex Have the Highest Rates of Childhood Adversity: A Statewide Study of Juvenile Offenders.

A history of childhood adversity is associated with high-risk behaviors and criminal activity in both adolescents and adults. Furthermore, individuals with histories of child maltreatment are at higher risk for engaging in risky sexual behavior, experiencing re-victimization, and in some cases, becoming sexual offenders. The purpose of the current study was to examine the prevalence of individual and cumulative adverse childhood experiences (ACEs) reported by 102 offending youth who were arrested for trading sex and 64,227 offending youth who were arrested for various other crimes, using Florida's Positive Achievement Change Tool. Youth with violations related to sex trafficking had higher rates for each ACE as well as number of ACEs, particularly sexual abuse and physical neglect. These findings have implications for identifying adverse experiences in both maltreated and offending youth as well as tailoring services to prevent re-victimization.

Evaluation of healthcare use trends of high-risk female intimate partner violence victims.

INTRODUCTION: Practitioners need more information about intimate partner violence (IPV) victims' healthcare use trends. We used a novel data-linkage method and complaint categorization allowing us to evaluate IPV victims healthcare use trends compared to the date of their victimization. METHODS: This was a retrospective case series using data-linking techniques cross-referencing databases of Medicaid-eligible women between the ages of 16 and 55 years, an IPV Case Database for 2007 and the Florida State Agency for Healthcare Administration, which tracks hospital inpatient, ambulatory and emergency department (ED) use within the State of Florida. We analyzed resulting healthcare visits 1.5 years before and 1.5 years after the women's reported IPV offense. Using all available claims data a 'complaint category' representing categories of presenting chief complaints was assigned to each healthcare visit. Analysis included descriptive statistics, correlation coefficients between time of offense and visits, and a logistic regression analysis. RESULTS: The 695 victims were linked with 4,344 healthcare visits in the four-year study period. The victims were young (46% in the 16-25 age group and 79% were younger than 35). Healthcare visits were in the ED (83%) rather than other healthcare sites. In the ED, IPV victims mostly had complaint categories of obstetrics and gynaecology-related visits (28.7%), infection-related visits (18.9%), and trauma-related visits (16.3%). ED use escalated approaching the victim's date of offense (r=0.59, p<0.0001) compared to use of non-ED sites of healthcare use (r=0.07, p=0.5817). ED use deescalated significantly after date of reported offense for ED visits (r=0.50, p<0.0001) versus non-ED use (r=0.00, p=0.9958). The victims' age group more likely to use the ED than any other age group was the 36-45 age group (OR 4.67, CI [3.26-6.68]). CONCLUSION: IPV victims use the ED increasingly approaching their date of offense. Presenting complaints were varied and did not reveal unique identifiers of IPV victims. This novel method of database matching between claims data and government records has been shown to be a valid way to evaluate healthcare utilization of at-risk populations.

Prevalence of prescription and illicit drugs in pregnancy-associated non-natural deaths of Florida mothers, 1999-2005.

Abuse of prescription and illicit drugs has been rapidly increasing. This study examines the prevalence of drug use in the non-natural deaths of pregnant or recently pregnant women. Records from Florida's Pregnancy Associated Mortality Review conducted between 1999 and 2005 (n = 415) were linked to 385 toxicology reports obtained from Florida medical examiners' offices. The final study sample consisted of 169 drug-positive, pregnancy-associated non-natural deaths. Of these, 86 were positive for both blood and urine, 64 were positive for blood only and five for urine only, and the remainder were positive for some other specimen. Among these deaths, 91 cases (54%) involved prescription drugs, 78 cases (46%) involved illicit drugs, and 69 cases (41%) involved alcohol. Opioids constituted the majority of deaths associated with prescription drugs. Substantial co-use of opioids and benzodiazepines was seen. Pregnant or recently pregnant women may have more interactions with healthcare providers, which may present more opportunities for intervention and prevention.

Use of a prenatal risk screen to predict maternal traumatic pregnancy-associated death: program and policy implications.

BACKGROUND: Motor vehicle crashes, homicide, suicide, and drug abuse are among the leading causes of pregnancy-associated deaths. To prevent such deaths, identifying women for intervention is required. The universally offered Florida Healthy Start Prenatal Risk Screen was evaluated to identify women at increased risk for traumatic pregnancy-associated death. METHODS: Florida's Enhanced Maternal Mortality Reporting Database for 1999 through 2005 was linked with Florida's Healthy Start Prenatal Risk Screen to identify traumatic pregnancy-associated death as the outcome. Distribution of Healthy Start risk scores among women who died were compared with the screened population. Traumatic death estimates per 100,000 births were drawn for each risk score, along with estimates of the relative risk (RR) of traumatic death for each score. The RR of women with scores greater than or equal to 4 were compared with the risk of women scoring 0 to 3. FINDINGS: Almost 20% of the 620,959 women who did not die of traumatic death had a risk score of 0, compared with only 3% of the 144 women who did die of traumatic death. As risk scores increased, the chance of traumatic deaths sharply increased. A woman with a score of 4 had 11.78 times (confidence interval [CI], 4.63-29.69) the risk of traumatic death compared with a woman with a risk score of 0. CONCLUSIONS: The implementation of prenatal risk screening to identify women at increased risk for traumatic pregnancy-associated death would help to ensure that policies to reduce infant risk factors also address maternal risk factors.

Neighborhood-level hot spot maps to inform delivery of primary care and allocation of social resources.

Challenges to health care access in the US are forcing local policymakers and service delivery systems to find novel ways to address the shortage of primary care clinicians. The uninsured and underinsured face the greatest obstacles in accessing services. Geographic information systems mapping software was used to illustrate health disparities in Alachua County, FL; galvanize a community response; and direct reallocation of resources. The University of Florida Family Data Center created "hot spot" density maps of important health and social indicators to highlight the location of disparities at the neighborhood level. Maps were produced for Medicaid births, teen births, low birth weight, domestic violence incidents, child maltreatment reports, unexcused school absences, and juvenile justice referrals. Maps were widely shared with community partners, including local elected officials, law enforcement, educators, child welfare agencies, health care providers, and service organizations. This data sharing resulted in advocacy efforts to bring resources to the greatest-need neighborhoods in the county. Novel public-private partnerships were forged between the local library district, children and family service providers, and university administrators. Two major changes are detailed: a family resource center built in the neighborhood of greatest need and a mobile clinic staffed by physicians, nurses, physician assistants, health educators, and student and faculty volunteers. Density maps have several advantages. They require minimal explanation. Anyone familiar with local geographic features can quickly identify locations displaying health disparities. Personalizing health disparities by locating them geographically allows a community to translate data to action to improve health care access.

Identifying indicators during pregnancy for child maltreatment.

To measure the effect of a short interpregnancy interval (IPI), along with other indicators routinely asked during pregnancy on later report of child maltreatment. We hypothesized that an IPI of <18 months was associated with increased risk of child maltreatment. This study was a secondary analysis of a linked population-based dataset from 2005 to 2007 in Florida. Data were derived from three sources: Birth Certificates, Healthy Start Prenatal Risk Screens, and the HomeSafeNet Database. Primary predictor variables were IPI, and mothers' evaluations of the timing of the pregnancy and perceptions of harm. Logistic regression analyses were used to estimate the odds of child maltreatment, adjusting for demographic and other known risk factors for maltreatment. The final study sample consisted of 85,258 multipara women-infant dyads with credible IPIs and with completed Healthy Start Prenatal Risk Screens. Seventeen percent of children had a report of child maltreatment in the first 5 years of life. An IPI of less than 18 months was associated with 18 % higher odds of maltreatment compared to an IPI of greater than 18 months (95 % CI 1.13, 1.23). Mothers' perception of harm and desire to be pregnant at a later time were also significantly associated with higher odds of maltreatment report (AOR = 2.43 95 % CI = 2.17, 2.71 and AOR = 1.18 95 % CI 1.13, 1.24, respectively). Ascertaining short IPI and asking pregnant and peripartum women about their perception of harm and desire for a longer birth spacing can alert obstetricians, family practitioners and pediatricians to potential child maltreatment.

Medical students' self-evaluations of their patient-centered cultural sensitivity: implications for cultural sensitivity/competence training.

The goals of this study were to (1) empirically assess the need for training in patient-centered culturally sensitive health care among medical students and (2) determine if training in such care needs to be customized to some degree based on individual or subgroup differences. Two hundred seventeen advanced (third- and fourth-year) medical students from 4 medical schools participated. Participants self-reported their current levels of engagement in patient-centered culturally sensitive health care using an online version of the Tucker-Culturally Sensitive Health Care Inventory Provider Form. Results indicated that participating advanced medical students gave self-ratings of engagement in patient-centered culturally sensitive health care that indicate high engagement in some but not all of the behaviors and attitudes that indicate this care. Additionally, their self-ratings differed in association with their gender, race/ethnicity, being fluent in a language other than English, and prior experience providing health care to racial/ethnic minority patients. Conclusions include that some medical students need training in patient-centered culturally sensitive health care, and this training ideally should be assessment-based and customized to address areas where there are low self-ratings of engagement in patient-centered culturally sensitive health care.

Women tipping the scale during pregnancy: a special population for obesity interventions, treatments and clinical trials.

New treatments for obesity are often focused on reducing appetite in otherwise healthy adults. Similarly, health guidelines and promotion programs are focused on healthy adults. We have become alarmed by the increasing prevalence of overweight and obesity in women of reproductive age. This issue has been equally overlooked in policy debates and clinical trials. The proportion of overweight or obese young women has overwhelmed the proportion of underweight and normal weight women. In order to prevent obesity in women and their offspring, clinical interventions and trials need to be developed for women before and in between pregnancies.

Histological characteristics and altered expression of interleukins (IL) IL-13 and IL-15 in endometria of levonorgestrel users with different uterine bleeding patterns.

OBJECTIVE: To determine the relationship between uterine bleeding patterns in levonorgestrel users with endometrial histology and expression of interleukins (IL) IL-13 and IL-15. DESIGN: Prospective observational study. SETTING: Academic research center. PATIENT(S): Questionnaires were sent to patients (n = 578) who had levonorgestrel implants concerning bleeding patterns; 35 of these patients were identified to have regular cycle (n = 13), amenorrhea (n = 8), or metrorrhagia (n = 14). INTERVENTION(S): Endometrial biopsies, serum, histology, and immunostaining. MAIN OUTCOME MEASURE(S): Endometrial histological assessment and immunostaining for IL-13 and IL-15 and for blood levonorgestrel, E2, and progesterone levels by ELISA or RIA. RESULT(S): No correlation was found between circulating levonorgestrel, E2, or progesterone levels with the bleeding patterns, although a trend toward a lower E2 level was observed in patients with amenorrhea who had inactive endometrium. There was a direct correlation between bleeding patterns and endometrial histology, as well as IL-13 and IL-15 expression in patients with regular cycles and metrorrhagia, demonstrating secretory and proliferative endometrium, respectively. Some patients in each group were also identified as demonstrating endometritis. CONCLUSION(S): Endometrial histology may assist directing therapy and subsequently increasing compliance in progestin-only contraceptive users with irregular bleeding who fail to respond to standard therapies. Altered endometrial expression of IL-13 and IL-15, key cytokines in inflammatory and immune cell trafficking, may influence events, leading to irregular bleeding.

Malignant melanoma associated with lichen sclerosus in the vulva of a 10-year-old.

Malignant melanoma of the vulva in childhood is a rare neoplasm. Lichen sclerosus of the vulva in childhood is also a rare disease. The association of these two rare lesions in the vulva of young girls is extremely rare. We present a 10-year-old white girl with malignant melanoma associated with lichen sclerosus of the vulva. She had dark pigmentation of both the labia minora and posterior fourchette. The inner labia majora and fourchette showed whitish, glistening areas of skin. Histologic examination found mostly an in situ lentiginous/mucosal melanoma with focal invasion to a depth of 0.44 mm in the left upper labium majus. All specimens showed evidence of lichen sclerosus. Partial vulvectomy was performed, and no metastases were detected at the time of treatment. The patient has been disease free for the 12 months after treatment. It is critical for physicians to realize that melanoma can occur in children, and although rare, can occur in the vulva. We feel that lichen sclerosus in this instance may represent a pattern of host immune response to melanoma.