Fluorescence lateral flow competitive protein binding assay for the assessment of serum folate concentrations.

Folate is a micronutrient required for the production of new cells, making it a key factor in early fetal development and ensuring normal growth and maintenance of health. The increase in consumption of folate due to increased periconceptional supplementation and fortification of grains in many countries has led to a decrease in occurrence of folate deficiency and a class of birth defects called neural tube defects. However, an opportunity remains to further improve folate status of populations in areas with limited access to fortified foods and supplementation. Screening of women of reproductive age and other vulnerable populations for folate status would increase our understanding of the magnitude of the burden of folate deficiency and inform monitoring of public health programs. Current gold standard methods for folate assessment are time-intensive and require cold chain, sophisticated laboratory infrastructure, and highly-trained personnel. Our lateral flow assay is low-cost, easy to use, and allows a user to assess folate insufficiency at the point of care in less than 40 minutes. We evaluated the sensitivity and specificity of our assay in 24 human serum samples, including 8 samples with folate concentrations less than 10.0 nmol/L and 14 samples less than 13.4 nmol/L using the Immulite 2000 commercial assay as a reference standard. The sensitivity and specificity were found to be 93% (95% CI: 54.7-100.0) and 91% (95% CI: 80.0-100.0), respectively, when using our test to determine folate insufficiency based on a cutoff of 13.4 nmol/L. Our point-of-care diagnostic test for folate concentrations could inform screening and public health programs in at-risk populations.

High-yield paper-based quantitative blood separation system.

Interest in developing paper-based devices for point-of-care diagnostics in resource-limited settings has risen remarkably in recent decades. In this paper, we demonstrate what we refer to as "high yield passive rrythrocyte removal" (HYPER) technology, which utilizes capillary forces in a unique cross-flow filtration for the separation of whole blood with performance comparable to centrifuges. As we will demonstrate, state-of-the-art passive blood separation methods implemented in paper-based systems exhibit rapid blood cell clogging on the filtration media or serum outlet and yield only about 10-30% of the total serum present in the sample. Our innovation results from the inclusion of a differentiation pad, which exploits hydrodynamic effects to reduce the formation of a fouling layer on the blood filtration membrane resulting in more than 60% serum yield with undiluted whole blood as direct input. To demonstrate the effectiveness of the HYPER technology we implement it in a lateral flow system and demonstrate the accurate quantification of vitamin A and iron levels in whole blood samples in 15 minutes.

Rapid diagnostic testing platform for iron and vitamin A deficiency.

Micronutrient deficiencies such as those of vitamin A and iron affect a third of the world's population with consequences such as night blindness, higher child mortality, anemia, poor pregnancy outcomes, and reduced work capacity. Many efforts to prevent or treat these deficiencies are hampered by the lack of adequate, accessible, and affordable diagnostic methods that can enable better targeting of interventions. In this work, we demonstrate a rapid diagnostic test and mobile enabled platform for simultaneously quantifying iron (ferritin), vitamin A (retinol-binding protein), and inflammation (C-reactive protein) status. Our approach, enabled by combining multiple florescent markers and immunoassay approaches on a single test, allows us to provide accurate quantification in 15 min even though the physiological range of the markers of interest varies over five orders of magnitude. We report sensitivities of 88%, 100%, and 80% and specificities of 97%, 100%, and 97% for iron deficiency (ferritin <15 ng/mL or 32 pmol/L), vitamin A deficiency (retinol-binding protein <14.7 µg/mL or 0.70 µmol/L) and inflammation status (C-reactive protein >3.0 µg/mL or 120 nmol/L), respectively. This technology is suitable for point-of-care use in both resource-rich and resource-limited settings and can be read either by a standard laptop computer or through our previously developed NutriPhone technology. If implemented as either a population-level screening or clinical diagnostic tool, we believe this platform can transform nutritional status assessment and monitoring globally.

Mitigating the Hook Effect in Lateral Flow Sandwich Immunoassays Using Real-Time Reaction Kinetics.

The quantification of analyte concentrations using lateral flow assays is a low-cost and user-friendly alternative to traditional lab-based assays. However, sandwich-type immunoassays are often limited by the high-dose hook effect, which causes falsely low results when analytes are present at very high concentrations. In this paper, we present a reaction kinetics-based technique that solves this problem, significantly increasing the dynamic range of these devices. With the use of a traditional sandwich lateral flow immunoassay, a portable imaging device, and a mobile interface, we demonstrate the technique by quantifying C-reactive protein concentrations in human serum over a large portion of the physiological range. The technique could be applied to any hook effect-limited sandwich lateral flow assay and has a high level of accuracy even in the hook effect range.

Depression, anxiety, antidepressant use, and cardiovascular disease among Hispanic men and women of different national backgrounds: results from the Hispanic Community Health Study/Study of Latinos.

PURPOSE: To describe prevalence and relationships to cardiovascular morbidity of depression, anxiety, and medication use among Hispanic/Latinos of different ethnic backgrounds. METHODS: Cross-sectional analysis of 15,864 men and women aged 18 to 74 years in the population-based Hispanic Community Health Study/Study of Latinos. Depressive and anxiety symptoms were assessed with shortened Center for Epidemiological Studies Depression Scale and Spielberger Trait Anxiety Scale. RESULTS: Prevalence of high depressive symptoms ranged from low of 22.3% (95% confidence interval [CI], 20.4-24.3) to high of 38.0% (95% CI, 35.2-41.0) among those of Mexican or Puerto Rican background, respectively. Adjusted odds ratios for depression rose monotonically with number of cardiovascular disease (CVD) risk factor from 1.46 (95% CI, 1.18-1.75) for those with one risk factors to 4.36 (95% CI, 2.47-7.70) for those with five risk factors. Antidepressant medication was used by 5% with striking differences between those with and without history of CVD (15.4% and 4.6%, respectively) and between insured (8.2%) and uninsured (1.8%). CONCLUSIONS: Among US Hispanics/Latinos, high depression and anxiety symptoms varied nearly twofold by Hispanic background and sex, history of CVD, and increasing number of CVD risk factors. Antidepressant medication use was lower than in the general population, suggesting under treatment especially among those who had no health insurance.

Racial and ethnic minority medical students' perceptions of and interest in careers in academic medicine.

PURPOSE: To describe diverse medical students' perceptions of and interest in careers in academic medicine. METHOD: In 2010, the authors invited students attending three national medical student conferences to respond to a survey and participate in six focus groups. The authors identified trends in data through bivariate analyses of the quantitative dataset and using a grounded theory approach in their analysis of focus group transcripts. RESULTS: The 601 survey respondents represented 103 U.S. medical schools. The majority (72%) were in their first or second year; 34% were black and 17% were Hispanic. Many respondents (64%) expressed interest in careers in academic medicine; teaching and research were viewed as positive influences on that interest. However, black and Hispanic respondents felt they would have a harder time succeeding in academia. The 73 focus group participants (25% black, 29% Hispanic) described individual- and institutional-level challenges to academic medicine careers and offered recommendations. They desired deliberate and coordinated exposure to academic career paths, research training, clarification of the promotion process, mentorship, protected time for faculty to provide teaching and research training, and an enhanced infrastructure to support diversity and inclusion. CONCLUSIONS: Medical students expressed an early interest in academic medicine but lacked clarity about the career path. Black and Hispanic students' perceptions of having greater difficulty succeeding in academia may be an obstacle to engaging them in the prospective pool of academicians. Strategic and dedicated institutional resources are needed to encourage racial and ethnic minority medical students to explore careers in academic medicine.

Commentary: the building the next generation of academic physicians initiative: engaging medical students and residents.

Data from the 2010 U.S. Census are a reminder of the diverse patient population in the United States and the growing health care needs of Americans. Academic health centers are tasked with reforming the system to expand its capacity for care and with cultivating innovation to generate the teaching, training, and research prowess needed to eliminate health disparities. At the center of this reform is enhancing the system that produces the human capital, including the physicians who care for the patients and the educators who train those physicians. Institutions and foundations have committed to the development of pipeline programs, from kindergarten through college, to create a diverse clinical workforce, but they have limited their direct promotion of diversity in the academic medicine workforce to faculty development programs. Despite faculty efforts, shortcomings in diversity persist, including a paucity of female full professors and deans, an insignificant increase in the proportion of underrepresented racial and ethnic minority faculty, and a lack of knowledge on the cultivation of the lesbian and gay faculty perspective. Furthermore, underrepresented racial and ethnic minority students in particular lose interest in academic medicine careers during medical school, and overall students lose interest in academic medicine careers during residency. The Building the Next Generation of Academic Physicians Initiative is designed to develop interest and promote achievement in pursuing academic medicine careers. This initiative is needed to increase the pool of diverse faculty down the road and elicit their perspectives to more effectively address health care disparities.

Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research.

BACKGROUND: Cultural competency training has been proposed as a way to improve patient outcomes. There is a need for evidence showing that these interventions reduce health disparities. OBJECTIVE: The objective was to conduct a systematic review addressing the effects of cultural competency training on patient-centered outcomes; assess quality of studies and strength of effect; and propose a framework for future research. DESIGN: The authors performed electronic searches in the MEDLINE/PubMed, ERIC, PsycINFO, CINAHL and Web of Science databases for original articles published in English between 1990 and 2010, and a bibliographic hand search. Studies that reported cultural competence educational interventions for health professionals and measured impact on patients and/or health care utilization as primary or secondary outcomes were included. MEASUREMENTS: Four authors independently rated studies for quality using validated criteria and assessed the training effect on patient outcomes. Due to study heterogeneity, data were not pooled; instead, qualitative synthesis and analysis were conducted. RESULTS: Seven studies met inclusion criteria. Three involved physicians, two involved mental health professionals and two involved multiple health professionals and students. Two were quasi-randomized, two were cluster randomized, and three were pre/post field studies. Study quality was low to moderate with none of high quality; most studies did not adequately control for potentially confounding variables. Effect size ranged from no effect to moderately beneficial (unable to assess in two studies). Three studies reported positive (beneficial) effects; none demonstrated a negative (harmful) effect. CONCLUSION: There is limited research showing a positive relationship between cultural competency training and improved patient outcomes, but there remains a paucity of high quality research. Future work should address challenges limiting quality. We propose an algorithm to guide educators in designing and evaluating curricula, to rigorously demonstrate the impact on patient outcomes and health disparities.

Diversity in academic medicine no. 6 successful programs in minority faculty development: ingredients of success.

This article describes the ingredients of successful programs for the development of minority faculty in academic medicine. Although stung by recent cuts in federal funding, minority faculty development programs now stand as models for medical schools that are eager to join the 140-year-old quest for diversity in academic medicine. In this article, the ingredients of these successful faculty development programs are discussed by experts in minority faculty development and illustrated by institutional examples. Included are descriptions of program goals and content, mentoring and coaching, selecting participants, providing a conducive environment, managing the program, and sustaining support. This article is a companion to another article, "Successful Programs in Minority Faculty Development: Overview," in this issue of the Mount Sinai Journal of Medicine.

Diversity in academic medicine no. 4 Northeast Consortium: innovation in minority faculty development.

In fiscal year 2006, the US Government abruptly and drastically reduced its funding for programs to increase the racial and ethnic diversity of academic medicine, including programs to increase the development of minority medical faculty. Anticipating this reduction, 4 such programs-the Albert Einstein College of Medicine, Mount Sinai School of Medicine, University of Medicine and Dentistry in New Jersey-New Jersey Medical School, and University of Pennsylvania School of Medicine-decided to pool their resources, forming the Northeast Consortium of Minority Faculty Development. An innovation in minority faculty development, the Northeast Consortium of Minority Faculty Development has succeeded in exposing faculty trainees to research and teaching that they might not have considered otherwise, expanding the number and diversity of their mentors and role models, providing them potential access to larger and different populations and databases for purposes of research, and expanding their peer contacts. After introducing the Northeast Consortium of Minority Faculty Development, this article describes the origins and goals of each member program.

Diversity in academic medicine no. 2 history of battles lost and won.

Spurred by its rapidly changing demographics, the United States is striving to reduce and eliminate racial and ethnic health disparities. To do so, it must overcome the legacy of individual, institutional, and structural racism and resolve conflicts in related political and social ideologies. This has moved the struggle over diversity in the health professions outside the laboratories and ivy-covered walls of academic medicine into the halls of Congress and chambers of the US Supreme Court. Although equal employment opportunity and affirmative action programs began as legal remedies for distinct histories of legally sanctioned racial and gender discrimination, they also became effective means for increasing the representation of underrepresented minorities in higher education and the health professions. Beginning in the 1970s and continuing today, legal challenges to measures for realizing equal opportunity and leveling the playing field have reached the US Supreme Court and state-wide ballot initiatives. These historical challenges and successes are the subject of this article. Although the history is not exhaustive, it aims to provide an important context for the struggles of advocates to improve the representation of underrepresented minorities in medicine and reduce racial and ethnic health disparities.

Diversity in academic medicine no. 3 struggle for survival among leading diversity programs.

Since efforts to increase the diversity of academic medicine began shortly after the Civil War, the efforts have been characterized by a ceaseless struggle of old and new programs to survive. In the 40 years after the Civil War, the number of minority-serving institutions grew from 2 to 9, and then the number fell again to 2 in response to an adverse evaluation by the Carnegie Foundation for the Advancement of Teaching. For 50 years, the programs grew slowly, picking up speed only after the passage of landmark civil rights legislation in the 1960s. From 1987 through 2005, they expanded rapidly, fueled by such new federal programs as the Centers of Excellence and Health Careers Opportunity Programs. Encompassing majority-white institutions as well as minority-serving institutions, the number of Centers of Excellence grew to 34, and the number of Health Careers Opportunity Programs grew to 74. Then, in 2006, the federal government cut its funding abruptly and drastically, reducing the number of Centers of Excellence and Health Careers Opportunity Programs to 4 each. Several advocacy groups, supported by think tanks, have striven to restore federal funding to previous levels, so far to no avail. Meanwhile, the struggle to increase the representation of underrepresented minorities in the health professions is carried on by the surviving programs, including the remaining Centers of Excellence and Health Careers Opportunity Programs and new programs that, funded by state, local, and private agencies, have arisen from the ashes.

Health disparities between island and mainland Puerto Ricans.

OBJECTIVE: To detect health disparities among three populations--Puerto Ricans living in Puerto Rico as well as Puerto Ricans and non-Hispanic whites living on the United States (U.S.) mainland. METHODS: Data from two similarly designed surveys conducted in 1999-2000 were analyzed. The Behavioral Risk Factor Surveillance System (BRFSS) provided data on Puerto Ricans living on the island and on non-Hispanic whites in the U.S. Another survey of Puerto Ricans living in New York City provided data on mainland Puerto Ricans. The age- and sex-standardized weighted prevalences of various health parameters (e.g., obesity, diabetes, smoking, and physical illness) and indicators of access to health care (e.g., frequencies of routine checkups and diabetes care) were compared between populations by means of standardized rate ratios (SRR). RESULTS: Puerto Ricans living on the mainland and those living on the island had a similar prevalence of obesity (21% to 22%). Compared with islanders, mainland Puerto Ricans had a higher prevalence of diabetes (SRR = 1.4; 95% confidence interval [95% CI] = 1.01 to 2.0); those with diabetes also showed higher prevalences of smoking (SRR = 4.2; 95% CI = 2.3 to 7.7) and physical illness (SRR = 1.5; 95% CI = 1.1 to 2.0) than Puerto Ricans living on the island. While mainland Puerto Ricans were similar to non-Hispanic whites in terms of their utilization of primary prevention and diabetes care, island Puerto Ricans trailed behind significantly. CONCLUSIONS: Puerto Ricans living on the U.S. mainland and those living in Puerto Rico both need to target lowering their prevalence of obesity and diabetes. For island Puerto Ricans, improved education about the significance of primary prevention and diabetes care is needed. For mainland Puerto Ricans, the accessibility of the primary health care system renders it a potentially effective venue for interventions, particularly for smoking cessation. More studies are warranted to identify factors associated with the poor health status observed in mainland Puerto Ricans.

Health disparities between island and mainland Puerto Ricans

OBJETIVO: Detectar disparidades de salud entre tres poblaciones: puertorriqueños que viven en Puerto Rico, así como puertorriqueños y personas no hispanas de raza blanca que viven en tierra firme estadounidense. MÉTODOS: Se analizaron los datos obtenidos mediante dos encuestas de similar diseño que se realizaron en 1999–2000. El Sistema de Vigilancia de Factores de Riesgo Conductuales proporcionó datos acerca de los puertorriqueños radicados en la isla y de residentes de Estados Unidos de raza blanca que no son hispanos. Otra encuesta de puertorriqueños radicados en la Ciudad de Nueva York aportó datos acerca de los puertorriqueños que residían en tierra firme estadounidense. Se usaron las razones de las tasas estandarizadas (standardized rate ratios, SRR) para hacer las comparaciones interpoblacionales de las prevalencias ponderadas, estandarizadas por edad y sexo, de varios parámetros (obesidad, diabetes, tabaquismo y dolencias físicas) y de indicadores de acceso a la atención sanitaria (frecuencia de los exámenes de rutina y de la atención de la diabetes). RESULTADOS: Los puertorriqueños que vivían en tierra firme estadounidense y los que vivían en la isla tuvieron una prevalencia de obesidad parecida (21% a 22%). Comparados con los habitantes de la isla, los puertorriqueños radicados en tierra firme tuvieron una prevalencia de diabetes más alta (SRR = 1,4; intervalo de confianza de 95% [IC95%]: 1,01 a 2,0); los que tenían diabetes también mostraron una mayor prevalencia de tabaquismo (SRR = 4,2; IC 95%: 2,3 a 7,7) y de dolencias físicas (SRR = 1,5%; IC95%: 1,1 a 2,0) que los puertorriqueños que vivían en la isla. Mientras que los puertorriqueños en tierra firme se asemejaron a los blancos que no eran hispanos en cuanto a la utilización de servicios de prevención primaria y de atención de la diabetes, los puertorriqueños en la isla tenían cifras de utilización mucho más bajas...