Community-based Clinical Settings Research Articles

Caregiver-child agreement in posttraumatic symptoms and outcomes in the child and family traumatic stress intervention

BackgroundAgreement between caregiver and child reports of posttraumatic stress symptoms is often quite poor. Lack of agreement about symptoms, as well as failure of mutual recognition and understanding of symptoms, can impact treatment outcomes. ObjectiveThis study examines change in caregiver and child agreement about child posttraumatic stress symptoms (PTSS) before and after a brief and early intervention for children exposed to a traumatic event. MethodThe Child and Family Traumatic Stress Intervention (CFTSI) is a brief (5–8 session) trauma-focused mental health treatment designed to reduce trauma symptoms in the aftermath of recent traumatic experiences that involves a focus on caregiver and child recognition of and communication about the child’s PTSS. We report on results of a naturalistic treatment study of CFTSI implementation without a comparison group that includes 1,190 child-caregiver dyads from 13 community-based clinical settings. Pre- and post-treatment reports of child PTSS were assessed using caregiver and child reports on the Child Posttraumatic Symptom Scale. A mixed effects analysis was conducted to examine change in caregiver and child discrepancy from pre to post CFTSI intervention. ResultsThere was a significant discrepancy between caregiver and youth agreement in PTSS at baseline that was significantly reduced post-CFTSI treatment. Change in discrepancy was similar regardless of child age and gender. Higher caregiver PTSS at pretreatment was associated with less change in discrepancy. ConclusionThis study suggests CFTSI may reduce the discrepancy between caregiver and child reports of the child’s PTSS. Reduced discrepancy implies an increased recognition of, and communication about, children’s PTSS, which may be a mechanism through which CFTSI reduces child PTSS following a recent traumatic event.

From Calculation to Communication: Using Risk Score Calculators to Inform Clinical Decision Making and Facilitate Patient Engagement.

Risk score calculators are a widely developed tool to support clinicians in identifying and managing risk for certain diseases. However, little is known about physicians' applied experiences with risk score calculators and the role of risk score estimates in clinical decision making and patient communication. Physicians providing care in outpatient community-based clinical settings (N = 20) were recruited to participate in semi-structured individual interviews to assess their use of risk score calculators in practice. Two study team members conducted an inductive thematic analysis using a consensus-based coding approach. Participants referenced at least 20 risk score calculators, the most common being the Atherosclerotic Cardiovascular Disease Risk Calculator. Ecological factors related to the clinical system (e.g., time), patient (e.g., receptivity), and physician (e.g., experience) influenced conditions and patterns of risk score calculator use. For example, compared with attending physicians, residents tended to use a greater variety of risk score calculators and with higher frequency. Risk score estimates were generally used in clinical decision making to improve or validate clinical judgment and in patient communication to serve as a motivational tool. The degree to which risk score estimates influenced physician decision making and whether and how these scores were communicated to patients varied, reflecting a nuanced role of risk score calculator use in clinical practice. The theory of planned behavior can help explain how attitudes, beliefs, and norms shape the use of risk score estimates in clinical decision making and patient communication. Additional research is needed to evaluate best practices in the use of risk score calculators and risk score estimates. The risk score calculators and estimates that participants referenced in this study represented a range of conditions (e.g., heart disease, anxiety), levels of model complexity (e.g., probability calculations, scales of severity), and output formats (e.g., point estimates, risk intervals).Risk score calculators that are easily accessed, have simple inputs, and are trusted by physicians appear more likely to be used.Risk score estimates were generally used in clinical decision making to improve or validate clinical judgment and in patient communication to serve as a motivational tool.Risk score estimates helped participants manage the uncertainty and complexity of various clinical situations, yet consideration of the limitations of these estimates was relatively minimal.Developers of risk score calculators should consider the patient- (e.g., response to risk score estimates) and physician- (e.g., training status) related characteristics that influence risk score calculator use in addition that of the clinical system.

Deep Learning Models for the Screening of Cognitive Impairment Using Multimodal Fundus Images

ObjectiveWe aimed to develop a deep learning system capable of identifying subjects with cognitive impairment quickly and easily based on multimodal ocular images. DesignCross-sectional study SubjectsParticipants of Beijing Eye Study 2011 and patients attending Beijing Tongren Eye Center and Beijing Tongren Hospital Physical Examination Center. MethodsWe trained and validated a deep learning algorithm to assess cognitive impairment using retrospectively collected data from the Beijing Eye Study 2011. Cognitive impairment was defined as a Mini–Mental State Examination (MMSE) score <24. Based on fundus photographs and optical coherence tomography (OCT) images, we developed five models based on the following sets of images: macula-centered fundus photographs, optic disc-centered fundus photographs, fundus photographs of both fields, optical coherence tomography (OCT) images, and fundus photographs of both fields with OCT (multi-modal). The performance of the models was evaluated and compared in an external validation dataset, which was collected from patients attending Beijing Tongren Eye Center and Beijing Tongren Hospital Physical Examination Center. Main Outcome MeasuresArea under the curve (AUC). ResultsA total of 9,424 retinal photographs and 4,712 OCT images were used to develop the model. The external validation sets from each center included 1,180 fundus photographs and 590 OCT images. Model comparison revealed that the multi-modal performed best, achieving an AUC of 0.820 in the internal validation set, 0.786 in external validation set 1 and 0.784 in external validation set 2. We evaluated the performance of the multi-model in different sexes and different age groups; there were no significant differences. The heatmap analysis showed that signals around the optic disc in fundus photographs and the retina and choroid around the macular and optic disc regions in OCT images were used by the multi-modal to identify participants with cognitive impairment. ConclusionsFundus photographs and OCT can provide valuable information on cognitive function. Multi-modal models provide richer information compared to single-mode models. Deep learning algorithms based on multimodal retinal images may be capable of screening cognitive impairment. This technique has potential value for broader implementation in community-based screening or clinic settings.

US Medical-Legal Partnerships to Address Health-Harming Legal Needs: Closing the Health Injustice Gap.

The medical-legal partnership (MLP) model is emerging across the USA as a powerful tool to address the adverse social conditions underlying health injustice. MLPs embed legal experts into healthcare teams to address health-harming legal needs with civil legal remedies. We conducted a narrative review of peer-reviewed articles published between 2007 and 2022 to characterize the structure and impacts of US MLPs on patients, providers, and healthcare systems. We found that MLPs largely serve vulnerable patient populations by integrating legal experts into community-based clinical settings or children's hospitals, although patient populations and settings varied widely. In most models, healthcare providers were trained to screen patients for legal needs and refer them to legal experts. MLPs provided a wide range of services, such as assistance accessing public benefits (e.g., Social Security, Medicaid, cash assistance) and legal representation for immigration and family law matters. Patients and their families also benefited from increased knowledge about legal rights and systems. Though the evidence base remains nascent, available studies show MLPs to be associated with greater access to care, fewer hospitalizations, and improved physical and mental health outcomes. Medical and legal providers who were engaged in MLPs reported interdisciplinary learning, and healthcare systems often experienced high returns on investment through cost savings and increased Medicaid reimbursement. Many MLPs also conducted advocacy and education to effect broader policy changes related to population health and social needs. To optimize the MLP model, more rigorous research, systematic implementation practices, evaluation metrics, and sustainable funding mechanisms are recommended. Broader integration of MLPs into healthcare systems could help address root causes of health inequity among historically marginalized populations in the USA.

"Here, I am More than Just Symptoms Combined": Mental Health Services from the Perspective of Community Rehabilitation Groups.

In response to the rise in mental disorders, psychosocial and community approaches have been proposed, complementing traditional clinical services. The present research aimed to understand the perception of individuals attending community-based strategies regarding mental health services as part of the approach to mental disorders in Colombia. Two workshops were conducted with 30 individuals with mental disorders (depression, anxiety and bipolar disorder), who were members of community strategies. A thematic analysis was conducted. The theme resulting from the analysis shows Community mental health within the healthcare system, which consisted of categories such as Group Amplifying Actions for Health and Groups as Complementary to Other Forms of Care. It is emphasized that the healthcare system should establish bridges with community mental health strategies and actively engage in their strengthening processes to enhance the outcomes of pharmacological interventions and even psychotherapeutic interventions. Bidirectional learning approach is proposed between community-based mental health services and clinical settings within the healthcare system. Community strategies can make an important contribution to complex processes in the health system.

Community and Systems Contributors and Strategies to Reduce Racial Inequities in Maternal Health in the Deep South: Provider Perspectives.

Black pregnant individuals in Alabama are disproportionately affected by severe maternal morbidity and mortality (SMM). To understand why racial disparities in maternal health outcomes persist and identify potential strategies to reduce these inequities, we sought perspectives from obstetric health care providers, health administrators, and members of local organizations who provide pregnancy, delivery, and postpartum care services in Alabama. We conducted qualitative in-depth interviews with stakeholders (n=20), purposively recruited from community-based organizations, clinical settings, government organizations, and academic institutions. Interview guides were based on Howell's conceptual model of pathways to racial disparities in maternal mortality. Data were coded using a modified framework theory approach and analyzed thematically. Racism, unjust laws and policies, and poverty/lack of infrastructure in communities emerged as major themes contributing to racial disparities in maternal health at the community and systems levels. Inadequate health insurance coverage was described as a strong driver of the disparities. Service providers suggested strategies for Alabama should be community focused, evidence based, and culturally sensitive. These should include Medicaid expansion, expanded parental leave, and removal of laws restricting choice. Community- and systems-level interventions should include community infrastructure improvements, choice in maternity services, and provision of digital communication options. Providers shared perspectives on community and structural areas of intervention to reduce racial inequities in SMM. These results can inform discussions with health system and community partners about Alabama and other Deep South initiatives to improve maternal health outcomes in black communities.

A community-based participatory protocol to improving communication with Black men about oral and pharyngeal cancers: Research protocol.

Black men are disproportionately impacted by oral and pharyngeal cancer (OPC) mortality. This is in part due to a lack of information received about OPCs and their associated risk factors during health encounters. Discussions between dentists and Black men may improve Black men's knowledge, screening, and treatment uptake. Yet, dentists do not commonly communicate with Black men about OPCs due to their own discomfort. This paper describes the protocol for our research project, which proposes an initiative, grounded in community-based participatory research, to adapt a culturally-specific OPC communication tool. This tool will be adapted using a mixed-methods approach to assess the knowledge, attitudes, and experiences of Black men discussing OPCs and associated risk factors with dental providers. The tool will then be assessed for feasibility and acceptability among Black men, as well as dental students and dental providers in community-based clinical settings.

Violence, Discrimination, Psychological Distress, and HIV Vulnerability Among Men Who Have Sex With Men in Memphis, Tennessee.

Gay, bisexual, and other men who have sex with men (MSM) are disproportionally impacted by HIV. Discrimination, violence, and psychological distress (PD) may influence engagement with HIV prevention services and amplify HIV vulnerability among this priority population. These dynamics are understudied in the Southern United States. Understanding how these relationships interact is critical to designing effective HIV programs. We examined associations between MSM-related discrimination, MSM-related violence, and severe PD with HIV status among 2017 National HIV Behavioral Surveillance study participants in Memphis, Tennessee. Eligible participants were aged ≥18 years, born and identified as male, and reported having sex with another man in their lifetime. Participants completed a Centers for Disease Control and Prevention-designed anonymous survey and self-reported discrimination and violence across their lifetime, and PD symptoms within the past month, scored on the Kessler-6 Scale. Optional HIV rapid tests were performed on-site. Logistic regressions examined the associations between the exposure variables and HIV antibody-positive results. Among 356 respondents, 66.9% were aged <35 years and 79.5% identified as non-Hispanic Black; 13.2% reported experiencing violence, 47.8% reported discrimination, and 10.7% experienced PD. Of the 297 participants who tested, 33.33% were living with HIV. Discrimination, violence, and PD were significantly associated with each other (p < .0001). HIV antibody-positive test results were associated with violence (p < .01). Memphis-based MSM face a complex array of social experiences, which may increase vulnerability to HIV. On-site testing at community-based organizations and clinical settings among MSM may be an opportunity to screen for violence and incorporate strategies when designing HIV programs.

235. Tracking Invasive Extraintestinal Pathogenic Escherichia coli Disease in Older Adults in a Community-Based Clinical Trial Setting

Abstract Background A vaccine developed to prevent invasive extraintestinal pathogenic Escherichia coli disease (IED) is being evaluated in a phase 3 clinical trial (NCT04899336). However, historical performance of similar clinical trials has been challenged by inefficient endpoint catchment. Here we report the EXPECT-1 (NCT04087681) study findings on the capture techniques for IED and hospital admissions in a community-based setting. Methods EXPECT-1 was a prospective, observational study conducted in networks of 8 hospitals with surrounding primary care centers in North America, Europe, and Asia. Participants were followed for 1 year to track hospital admissions and occurrence of IED as reported by the primary care physician (PCP) or the participant. In 151 US participants, a geofence technology was used to track admissions to hospital areas. Participants were eligible if aged ≥ 60 years and if they did not have severe chronic conditions. Data were collected from October 24, 2019 until January 28, 2021. Study outcomes included incidence of IED and the rate of hospital admission. Results In total, 4470 participants were enrolled: 68% were female, 74.4% were white, median age was 70 years, and 59.4% had a urinary tract infection (UTI) in the past 10 years. Four IED events were captured with a cumulative incidence (95% CI) of 0.09% (0.024–0.229%) and an incidence rate of 98.6 cases (25.6–248.4) per 100,000 person-years. The incidence increased to 0.15% (0.041–0.385%) and 164.4 (43.8–420) per 100,000 person-years among participants with a history of UTI. Of the 4 IED events, 2 were participant self-reports, 1 PCP report, and 1 report via follow-up phone call. Of all hospital admissions, 56.6% were captured by PCPs and 48.7% by participants’ self-reports. The Kappa statistic varied from 0.31–0.65, indicating fair to moderate agreement between PCP reports and participant self-reports. Geofencing captured 99% of &amp;gt; 800 entries and exits from hospital areas. Conclusion The findings suggest that older adults with a history of UTI in the past 10 years may be a good target population for an efficacy clinical investigation on IED. PCP reports, participant self-reports, and geofencing can be promoted to track study endpoints in a community-based clinical trial setting. Disclosures Joachim Doua, MD, MPH, Janssen: Employee|Janssen: Stocks/Bonds Stephen Ruhmel, MPH, Janssen: Employee Oscar Go, PhD, Janssen: Employee of Janssen Research &amp; Development LLC. Ranee Chatterjee, MD, MPH, Bristol Myers Squibb: Grant/Research Support|Epigenomics: Grant/Research Support|Verily: Grant/Research Support Michal Sarnecki, MD, Janssen: Employee|Janssen: Stocks/Bonds Jan Poolman, PhD, Janssen: Janssen Vaccines &amp; Prevention B.V.|Janssen: Stocks/Bonds Marc Bonten, MD, PhD, Astra-Zeneca: Advisor/Consultant|Janssen: Advisor/Consultant|Merck: Advisor/Consultant|Novartis: Advisor/Consultant.

The child and family traumatic stress intervention: Factors associated with symptom reduction for children receiving treatment

ObjectiveWe examine factors associated with changes in posttraumatic stress symptoms for children following completion of an early and brief, trauma-focused mental health treatment that engages children together with their caregivers, with the child as the identified patient. MethodThe Child and Family Traumatic Stress Intervention (CFTSI), a brief (5–8 session) trauma-focused mental health treatment designed to reduce trauma symptoms in the aftermath of traumatic experiences in children aged 7 years and older. CFTSI has been widely disseminated in Child Advocacy Centers (CAC) and community treatment clinics nationally. We report on results of a naturalistic treatment study of CFTSI implementation without a comparison group that includes 1190 child caregiver dyads from 13 community-based clinical settings. ResultsMixed modeling revealed a significant reduction in child reported posttraumatic stress scores from pre to post-CFTSI. Scores on the Child Posttraumatic Checklist (CPSS) declined an average of 8.74 points from pre to post-CFTSI (p < .0001). There were no statistically significant differences in CPSS score changes based on age, gender, ethnicity, race, number of prior trauma types the child had experienced, caregiver posttraumatic stress symptoms, child relationship to the perpetrator, nature of event or length of time to begin treatment. ConclusionThis study provides further evidence that CFTSI can reduce child posttraumatic stress symptoms when implemented by community-based providers.

Passion, commitment, and burnout: Experiences of Black gay men working in HIV/AIDS treatment and prevention in Atlanta, GA

HIV-focused organizations, care providers and research programs often hire Black gay, bisexual and other men who have sex with men (GBMSM) in their efforts to reach highly affected communities. Due to their unique social position within and outside of organizations, Black GBMSM are ideally situated to contribute to HIV care and prevention programming targeting their own communities, but may also be at risk for stress and burnout in these settings. Despite this critical role for Black GBMSM in efforts to end the epidemic, little is known about subjective experiences of Black GBMSM who work in the HIV field. We conducted qualitative interviews with 19 Black GBMSM who were identified as key informants. All were working in community-based organizations, clinical or academic settings in the area of HIV prevention and treatment in Atlanta, Georgia. We used a thematic analysis approach to identify salient themes with respect to the workplace experiences of Black GBMSM as well as the role of their identities in their work in the field. Participants discussed: (1) Shared experiences and growth; (2) Work-related stressors; (3) Worker burnout; and (4) Commitment to continue working in the HIV field. On the whole, Black GBMSM derived meaning from their work, and found their intersectional identities to be a strength in fulfilling job duties. At the same time, Black GBMSM described multiple stresses faced as they balanced their personal and professional connections to this work, while also dealing with their own challenges related to discrimination, socioeconomic status, and health. Participants repeatedly described sacrificing their own well-being for the greater good of their communities, highlighting contributors to burnout within and outside of the workplace. Our participants derived meaning from their work in the HIV field and were affirmed by professional interactions with other Black GBMSM. At the same time, they also faced work-related and other psychosocial stressors that predisposed them to frustration and burnout. To promote workplace equity and wellness for Black GBMSM, we share recommendations for HIV-focused organizations that employ and serve men in this demographic.

Examining the Effects of Adverse Childhood Experiences and Gender on Trauma-Informed Intervention Outcomes.

The prevalence of Adverse Childhood Experiences (ACEs) and their link to negative behavioral and health outcomes is well documented, but very few studies have empirically examined the effect of ACEs on intervention outcomes. There is also emerging evidence of gender differences in vulnerability to developing traumatic symptoms, which relates to intervention outcomes. The current study examined the effects of ACEs and gender on trauma-informed intervention outcomes in a community-based clinical setting. The study includes data from children who were treated with trauma-informed intervention services grounded in the Attachment, Self-Regulation, and Competency (ARC) framework from 2017 to 2019. ACE scores are measured as a total across 10 items and different types, maltreatment versus family dysfunction, at intake. Children's trauma-related symptoms are assessed at intake and every 90 days under the ARC framework. In order to examine the changes of traumatic symptoms over time, a total of 362 children with three time points are included for the current analyses using Multilevel modeling with SAS PROC MIXED. The study found that a trauma-informed intervention based on the ARC framework was effective in reducing children's trauma related symptoms until they experienced 6 or more ACEs. The intervention effect, however, did not hold when children's ACEs were cumulated to 7 or more. The study also revealed gender differences in intervention outcomes. The finding has significant implications for early detection and preventative intervention efforts with children's ACEs before their ACEs further cumulate to a higher number. Gender difference should be considered in intervention planning and monitored during the intervention process.

Predictors of Service Utilization of Young Children and Families Enrolled in a Pediatric Primary Care Mental Health Promotion and Prevention Program.

Understanding early childhood mental health service utilization in community-based clinical settings is important. Project Linking Actions for Unmet Needs in Children's Health (Project LAUNCH) provided mental health-related services for young children and families within pediatric medical homes. Using data from the Project LAUNCH evaluation (n = 106), we implemented negative binomial regression models to determine if baseline variables were associated with service utilization, defined as the number of encounters between the family and the team. Past-year homelessness emerged as a significant predictor of service utilization. Encounters for families with children who experienced homelessness within the last 12months occurred at a rate 34.5% lower than those who had not experienced homelessness. Results highlight the importance of addressing homelessness as a barrier to mental health service utilization for families. Screening for recent housing insecurity and developing interventions that integrate housing support services into mental health programs may inform strategies to increase attendance for families with young children.

Body Mass Index and Blood Pressure Improvements With a Pediatric Weight Management Intervention at Federally Qualified Health Centers.

The Mind, Exercise, Nutrition, Do It! 7-13 (MEND 7-13) program was adapted in 2016 by 5 Denver Health federally qualified health centers (DH FQHC) into MEND+, integrating clinician medical visits into the curriculum and tracking health measures within an electronic health record (EHR). We examined trajectories of body mass index (BMI, kg/m2) percentile, and systolic and diastolic blood pressures (SBP and DBP) among MEND+ attendees in an expanded age range of 4 to 17 years, and comparable nonattendees. Data from April 2015 to May 2018 were extracted from DH FQHC EHR for children eligible for MEND+ referral (BMI ≥85th percentile). The sample included 347 MEND+ attendees and 21,061 nonattendees. Mixed-effects models examined average rate of change for BMI percent of the 95th percentile (%BMIp95), SBP and DBP (mm Hg), after completion of the study period. Most children were ages 7 to 13 years, half were male, and most were Hispanic. An average of 4.2 MEND+ clinical sessions were attended. Before MEND+, %BMIp95 increased by 0.247 units/month among MEND+ attendees. After attending, %BMIp95 decreased by 0.087 units/month (P < .001). Eligible nonattendees had an increase of 0.084/month in %BMIp95. Before MEND+ attendance, SBP and DBP increased by 0.041 and 0.022/month, respectively. After MEND+ attendance, SBP and DBP decreased by 0.254/month (P < .001) and 0.114/month (P < .01), respectively. SBP and DBP increased by 0.033 and 0.032/month in eligible nonattendees, respectively. %BMIp95, SBP, and DBP significantly decreased among MEND+ attendees when implemented in community-based clinical practice settings at DH FQHC.

Jail and Emergency Department Utilization in the Context of Harm Reduction Treatment for People Experiencing Homelessness and Alcohol Use Disorder.

People experiencing homelessness are disproportionately affected by alcohol use disorder (AUD). Abstinence-based treatment, however, does not optimally engage or treat this population. Thus, Harm Reduction Treatment for Alcohol (HaRT-A) was developed together with people with the lived experience of homelessness and AUD and community-based agencies that serve them. HaRT-A is a compassionate and pragmatic approach that aims to help people reduce alcohol-related harm and improve quality of life (QoL) without requiring abstinence or use reduction. The parent RCT showed that HaRT-A precipitated statistically significant reductions in alcohol use, alcohol-related harm, AUD symptoms, and positive urine toxicology tests. This secondary study tested HaRT-A effects on more distal, 6-month pre-to-posttreatment changes on jail and emergency department (ED) utilization. People experiencing homelessness and AUD (N = 168; 24% women) were recruited in community-based clinical and social services settings. Participants were randomized to receive HaRT-A or services as usual. Over four sessions, HaRT-A interventionists delivered three components: (a) collaborative tracking of participant-preferred alcohol metrics, (b) elicitation of harm-reduction and QoL goals, and (c) discussion of safer-drinking strategies. Administrative data on jail and ED utilization were extracted for 6 months pre- and posttreatment.Findings indicated no statistically significant treatment group differences on 6-month changes in jail or ED utilization (ps > .23). Exploratory analyses showed that 2-week frequency of alcohol use was positively correlated with number of jail bookings in the 12months surrounding their study participation. Additionally, self-reported alcohol-related harm, importance of reducing alcohol-related harm, and perceived physical functioning predicted more ED visits. Future studies are needed to further assess how harm-reduction treatment may be enhanced to move the needle in criminal justice and healthcare utilization in the context of larger samples, longer follow-up timeframes, and more intensive interventions.

Decídetexto: Mobile cessation support for Latino smokers. Study protocol for a randomized clinical trial

IntroductionLatinos, the largest minority group in the U.S., experience tobacco-related disparities, including limited access to cessation resources. Evidence supports the efficacy of mobile interventions for smoking cessation, which may be greater among Latinos, the highest users of text messaging. ObjectivesTo describe the methodology of a randomized clinical trial to evaluate the impact of Decídetexto, a culturally appropriate mobile smoking cessation intervention versus standard care on smoking abstinence (cotinine-verified 7-day point prevalence abstinence) at Month 6 among Latino smokers. MethodsLatino smokers (N = 618) will be randomized to one of two conditions: 1) Decídetexto or 2) standard of care. Decídetexto is a mobile smoking cessation intervention (available in English and Spanish) that incorporates three integrated components: 1) a tablet-based software that collects smoking-related information to develop an individualized quit plan, 2) a 24-week text messaging counseling program with interactive capabilities, and 3) pharmacotherapy support. Decídetexto follows the Social Cognitive Theory as theoretical framework. Standard of care consists of printed smoking cessation materials along with referral to telephone quitline. Participants in both groups are given access to free pharmacotherapy (nicotine patches or gum) by calling study phone number. Promotores de Salud will rely on community-based approaches and clinical settings to recruit smokers into the study. All participants will complete follow-up assessments at Week 12 and Month 6. DiscussionIf successful, Decídetexto will be ready to be implemented in different community- and clinic-based settings to reduce tobacco-related disparities.

Meeting the Rehabilitation and Support Needs of Patients With Breast Cancer During COVID-19: Opening New Frontiers in Models of Care

Background: COVID-19 presents a significant challenge to providing specialized rehabilitation and exercise for patients with breast cancer. Objective: The purpose of this report is to describe the implementation of telerehabilitation for one-on-one patient care and interactive, live, Web-based formats for group patient education, exercise, and support programs during the COVID-19 pandemic. Design: This report describes the concept, materials, and methods used in a community-based clinical setting to serve patients' needs during COVID-19. Results: Telerehabilitation and interactive Web-based strategies may be useful in meeting the physical and emotional needs of patients with breast cancer. Brief patient cases summarize the process of one-on-one telerehabilitation implementation and provide patient and family perspectives. Challenges and benefits of telerehabilitation are described. Interactive Web-based strategies substantially increased the numbers of patients reached with survivorship education and support groups during the first 2 months of COVID-19. Limitations: This report is descriptive and does not include group outcomes. Further research is needed to compare outcomes of telerehabilitation versus in-person delivery of breast cancer rehabilitation care. Conclusion: Telerehabilitation and interactive Web-based education formats provide an alternative to in-person breast cancer rehabilitation care during COVID-19 and have potential application for improving delivery of care to underserved populations and in other types of cancer.

University of Missouri-Columbia School of Medicine.

University of Missouri-Columbia School of Medicine.

Assessing the Effect of Middle Ear Effusions on Wideband Acoustic Immittance Using Optical Coherence Tomography.

Objectives:Wideband acoustic immittance (WAI) noninvasively assesses middle ear function by measuring the sound conduction over a range of audible frequencies. Although several studies have shown the potential of WAI for detecting the presence of middle ear effusions (MEEs), determining the effects of MEE type and amount on WAI in vivo has been challenging due to the anatomical location of middle ear cavity. The purpose of this study is to correlate WAI measurements with physical characteristics of the middle ear and MEEs determined by optical coherence tomography (OCT), a noninvasive optical imaging technique.Design:Sixteen pediatric subjects (average age of 7 ± 4 years) were recruited from the primary care clinic at Carle Foundation Hospital (Urbana, IL). A total of 22 ears (normal: 15 ears, otitis media with effusion: 6 ears, and acute otitis media: 1 ear, based on physician’s diagnosis) were examined via standard otoscopy, tympanometry, OCT imaging, and WAI measurements in a busy, community-based clinical setting. Cross-sectional OCT images were analyzed to quantitatively assess the presence, type (relative turbidity based on the amount of scattering), and amount (relative fluid level) of MEEs. These OCT metrics were utilized to categorize subject ears into no MEE (control), biofilm without a MEE, serous-scant, serous-severe, mucoid-scant, and mucoid-severe MEE groups. The absorbance levels in each group were statistically evaluated at α = 0.05.Results:The absorbance of the control group showed a similar trend when compared with a pediatric normative dataset, and the presence of an MEE generally decreased the power absorbance. The mucoid MEE group showed significantly less power absorbance from 2.74 to 4.73 kHz (p < 0.05) when compared with the serous MEE group, possibly due to the greater mass impeding the middle ear system. Similarly, the greater amount of middle ear fluid contributed to the lower power absorbance from 1.92 to 2.37 kHz (p< 0.05), when compared with smaller amounts of fluid. As expected, the MEEs with scant fluid only significantly affected the power absorbance at frequencies greater than 4.85 kHz. A large variance in the power absorbance was observed between 2 and 5 kHz, suggesting the dependence on both the type and amount of MEE.Conclusions:Physical characteristics of the middle ear and MEEs quantified from noninvasive OCT images can be helpful to understand abnormal WAI measurements. Mucoid MEEs decrease the power absorbance more than serous MEEs, and the greater amounts of MEE decreases the power absorbance, especially at higher (>2 kHz) frequencies. As both the type and amount of MEE can significantly affect WAI measurements, further investigations to correlate acoustic measurements with physical characteristics of middle ear conditions in vivo is needed.

Transformative medical education: must community-based traineeship experiences be part of the curriculum? A qualitative study

BackgroundThere are shortcomings in medical practitioners’ capacity to adapt to the particular needs of people experiencing circumstances of social vulnerability. Clinical traineeships create opportunities for the acquisition of knowledge, competencies, attitudes, and behaviors. However, some authors question the learnings to be made through classical clinical training pathways. This article explores the learnings gained from a traineeship experience within a community-based clinical setting intended for patients experiencing social vulnerability and operating under an alternative paradigm of care. To our knowledge, there is little research intended to identify and understand what medical trainees gain from their experience in such contexts.MethodsThis exploratory qualitative study is based on twelve interviews with practicing physicians who completed a traineeship at La Maison Bleue (Montreal, Canada) and three interviews conducted with key informants involved in traineeship management. Based on Mezirow’s theory of transformational learning, data were analyzed according to L’Écuyer’s principles of qualitative content analysis. NVivo software was used.ResultsThe main learnings gained through the traineeship are related to (1) greater awareness of beliefs, assumptions and biases through prejudice deconstruction, cultural humility and critical reflection on own limitations, power and privileges; (2) the development of critical perspectives regarding the health care system; (3) a renewed vision of medical practice involving a less stigmatizing approach, advocacy, empowerment, interdisciplinarity and intersectorality; and (4) strengthened professional identity and future practice orientation including confirmation of interest for community-based practice, the identification of criteria for choosing a future practice setting, and commitment to becoming an actor of social change. Certain characteristics of the setting, the patients and the learner’s individual profile are shown to be factors that promote these learnings.ConclusionsThis article highlights how a traineeship experience within a clinical setting intended for a clientele experiencing circumstances of social vulnerability and operating under an alternative paradigm presents an opportunity for transformative learning and health practice transformation toward renewed values of health equity and social justice. Our findings suggest medical traineeships in community-based clinical settings are a promising lead to foster the development of fundamental learnings that are conducive to acceptable and equitable care for people experiencing social vulnerability.