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Previous work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers.Statewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles.Medicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage.In the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.

Treating chronic pruritus is challenging for dermatologists due to the lack of therapeutic options. We review the effects of κ-opioid receptor (KOR) and μ-opioid receptor (MOR) in the modulation of itch, summarize evidence supporting the efficacy and safety of opioid receptor-targeting agents in chronic pruritus, and address clinical considerations.Preclinical studies have found neural pathways underlying detection, transmission, and modulation of itch signaling and spotlighted the importance of neuronal KOR and MOR in itch perception. Clinical reports suggest that opioid axis modulation may be the basis for the successful treatment of chronic itch. Several agents (MOR antagonist naltrexone; KOR agonists nalfurafine and difelikefalin; dual-acting KOR agonists/MOR antagonists butorphanol and nalbuphine) have been evaluated for treating chronic pruritus in case series, small studies, and clinical trials; nalbuphine has progressed through preliminary (phase II/III) studies in uremic pruritus and prurigo nodularis. The antipruritic efficacy of these agents has been observed across multiple disorders with disparate etiologies, suggesting the potential utility of this class to provide a unified approach to chronic pruritus treatment.The relative safety of these agents, including a reduced potential for dependence versus MOR-agonist analgesics, should help overcome resistance to the use of opioid receptor-targeting agents in chronic pruritus treatment.

Purpose To examine receipt of formal sexual health education on Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) and receipt of HIV testing in adolescents and young adults (AYAs) residing in nonmetropolitan versus metropolitan areas. Methods A secondary data analysis of the 2015–2017 National Survey of Family Growth of AYAs ages 15–24 years (N = 3,114). Logistic regression models predicted associations between nonmetropolitan versus metropolitan status and outcomes of interest (formal sexual health education on HIV/AIDS and HIV testing). Results Most AYAs (85.3%) reported receiving formal sexual health education on HIV/AIDS, while less than half (46.9%) indicated receiving HIV testing. Residing in a nonmetropolitan area was associated with a lower odds of reporting formal sexual health education on HIV/AIDS (OR = .47, CI = [.29, .77]) but not with HIV testing (OR = 1.33, CI = [.89, 2.01]). Conclusions AYAs living in nonmetropolitan areas are less likely to receive formal sexual health education on HIV/AIDS.

Background Prolonged wear of facial protective equipment can lead to occupational dermatoses. Objective To identify important causes of occupational dermatoses from facial protective equipment. Methods A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed using PubMed and Embase databases. Articles were included if they reported occupational dermatoses caused by surgical/procedure masks or N95 respirators, or both. Results We identified 344 articles, and 16 were suitable for inclusion in this review. Selected articles focused on facial occupational dermatoses in health care workers. Allergic contact dermatitis to the elastic straps, glue, and formaldehyde released from the mask fabric was reported. Irritant contact dermatitis was common on the cheeks and nasal bridge due to pressure and friction. Irritant dermatitis was associated with personal history of atopic dermatitis and prolonged mask wear (>6 hours). Acneiform eruption was reported due to prolonged wear and occlusion. Contact urticaria was rare. Limitations Only publications listed in PubMed or Embase were included. Most publications were case reports and retrospective studies. Conclusion This systematic review from members of the American Contact Dermatitis Society highlights cases of occupational dermatitis to facial protective equipment, including potential offending allergens. This work may help in the diagnosis and treatment of health care workers with facial occupational dermatitis.

Background Racially disparate pain management affects both adult and pediatric patients, but is not well studied among pediatric surgical patients after discharge. The objectives were to evaluate racial disparities in pediatric postoperative opioid prescription filling. Methods This retrospective cohort study included black or white pediatric Medicaid patients who underwent tonsillectomy, supracondylar humeral fracture fixation, or appendectomy (2/2012–7/2016). Patients were followed for 14 days post-surgery to identify opioid prescription fills. Logistic regression models evaluated the association between race and the probability of filling an opioid prescription. Results Among 39,316 surgical patients, the proportions of patients with post-surgical opioid prescriptions were 66.0%, 83.9%, and 68.5%, among tonsillectomy, supracondylar fracture, and appendectomy patients, respectively. The proportion of black appendectomy patients with a postoperative opioid prescription was significantly lower compared to white patients (65.0% vs. 69.2% respectively, p = 0.03), but was no longer significant after adjusting for other patient and provider characteristics. There were no differences by race in opioid prescription filling among other surgical patient groups. Conclusions The present study did not identify racial disparities in opioid prescription filling in adjusted analyses. Racial differences in unadjusted postoperative opioid prescription filling among appendectomy patients may be explained in part by longer postoperative length-of-stay among black children. Type of Study Prognosis Study Level of Evidence Level II

INTRODUCTION: Pediatric postoperative opioid prescribing has come under scrutiny as a result of the ongoing opioid epidemic. Previous research has demonstrated that African American adults are less likely to receive analgesics, particularly opioids, after surgery, even after controlling for pain severity. We sought to examine racial disparities in the filling of opioid prescriptions by pediatric surgical patients after cholecystectomy. METHODS: We studied patients aged 1 to 18 years of age who were enrolled in Ohio Medicaid and underwent cholecystectomy. Procedures performed in January 2013 - July 2016 were included. The percentage of patients who filled a postoperative opioid prescription within 14 days of their procedure was compared between black and white patients using log binomial regression models fit using generalized estimating equations to account for patient clustering within hospitals. RESULTS: We identified 1277 patients who underwent a cholecystectomy. In unadjusted analyses, black children were significantly less likely than white children to fill an opioid prescription postoperatively (74.9% vs 85.7%, p

Palliative care is underutilized amongst patients with bladder cancer despite guideline recommendations and known benefits. In order to uncover potential access barriers, we sought to describe patient and caregiver knowledge, attitudes and experiences surrounding palliative care.We surveyed 272 patients with bladder cancer and their caregivers through the Bladder Cancer Advocacy Network Patient Survey Network. In addition to collecting demographic, socioeconomic, and clinical characteristics, previously studied and validated questionnaires on palliative care knowledge and beliefs were administered. Patients and caregivers were also queried regarding their experiences with palliative care consultation.Survey respondents demonstrated highly accurate knowledge of palliative care services. Attitudes and beliefs surrounding palliative care were overall positive. Caregivers demonstrated better knowledge and more positive beliefs of palliative care compared to patients. Despite an overall positive sentiment toward palliative care, only 9% of the cohort had palliative care consultation as part of their cancer treatment plan. Most patients with muscle-invasive or metastatic bladder cancer wished that palliative care had been discussed by their providers.A subset of bladder cancer patients possess accurate knowledge and positive beliefs of palliative care. Palliative care is infrequently discussed during the treatment of bladder cancer, with patients and their caregivers expressing desire for palliative care to be discussed more often. Provider education surrounding palliative care services is imperative to improving access for bladder cancer patients and caregivers.

Social media use is increasing in the United States. Because psychiatrists and physicians are becoming more active online, Twitter is emerging as a leading platform for professional development. Social media can enhance networking, serve as a tool for mentoring trainees and colleagues, introduce journal articles to new readers, and allow psychiatrists and physicians to advocate for health care issues. Psychiatrists and physicians should observe ethical standards for digital citizenship on Twitter and other social media platforms.

Introduction Children with disabilities have significant health care needs, and receipt of care coordinator services may reduce caregiver burdens. The present study assessed caregivers’ experience and satisfaction with care coordination. Method Caregivers of Medicaid-enrolled children with disabilities (n = 2,061) completed a survey (online or by telephone) collecting information on the caregivers’ experiences and satisfaction with care coordination using the Family Experiences with Coordination of Care questionnaire. Results Eighty percent of caregivers with a care coordinator reported receiving help making specialist appointments, and 71% reported help obtaining community services. Caregivers who reported that the care coordinator helped with specialist appointments or was knowledgeable, supportive, and advocating for children had increased odds of satisfaction (odds ratio = 3.46, 95% confidence interval = [1.01, 11.77] and odds ratio = 1.07, 95% confidence interval = [1.03, 1.11], respectively). Discussion Findings show opportunities for improving care coordination in Medicaid-enrolled children with disabilities and that some specific elements of care coordination may enhance caregiver satisfaction with care.

Human trafficking is a public health issue affecting homeless young adults across the United States; however, screening tools for trafficking specifically for this population are lengthy and onerous. The aim of this study was to develop a sensitive, brief, and user-friendly trafficking screening tool for homeless young adults. Five candidate items for the screening tool were identified from the Vera Institute's Trafficking Victim Identification Tool (TVIT). Study participants were asked the five candidate items, and then received a trafficking assessment using the Human Trafficking Identification and Measurement (HTIAM-14), which is validated for the homeless youth population. A multivariable logistic model was used to analyze the five candidate items in relation to a trafficking experience on the longer HTIAM-14. Homeless people, aged 18 to 22 years old, receiving support from Covenant House New Jersey were eligible to participate in the study. Over 15 months in 2015–2017, 340 trafficking assessments were performed for 307 participants; 8.8% (30) of the assessments revealed a human trafficking experience. Of assessments identifying a trafficking experience, 66.7% (20) found sex trafficking and 46.7% (14) labor trafficking, with 16.7% (5) demonstrating both forms of trafficking. We validated a new screening tool, Quick Youth Indicators for Trafficking (QYIT). QYIT allows providers to screen for trafficking among homeless young adults; an affirmative answer to at least one QYIT question is 86.7% sensitive and 76.5% specific in identifying a trafficking experience. QYIT is the first highly sensitive, comprehensive trafficking screening tool that is truly brief and does not require a trafficking expert to administer. Use of QYIT at appropriate agencies will enable social service providers to systematically detect and serve homeless young adults who have labor and/or sex trafficking experiences.

PURPOSE To determine if a more restrictive transfusion protocol results in increased rates of adverse flap outcomes in patients undergoing free tissue transfer. MATERIALS AND METHODS Mixed retrospective and prospective cohort study. Patients who underwent surgery before the protocol change were collected retrospectively. Patients who underwent surgery after the protocol change were collected prospectively. RESULTS Of the 460 patients who underwent free tissue transfer, 116 patients in the pre-change cohort (N = 211) underwent transfusion (54.98%) and 78 in the post-change cohort(N = 249) (31.33%) (p

Purpose To explore the factors that differentiate trafficked homeless youth from not-trafficked homeless youth. Methods From November 2015–February 2017, homeless youth served by Covenant House New Jersey, aged 18–22, received a trafficking assessment. Youth were stratified based upon trafficking experience, and their responses to demographic and social history questions were examined for association with trafficking occurrence. Results Of 344 participants, 9.6% had a trafficking experience. Having an Individualized Education Program/504 plan was, for the first time in anti-trafficking literature, associated with a trafficking experience in bivariable analysis. IEP/504 plans are developed for school-aged children whose ability to succeed in traditional educational formats is challenged by learning, social, or functional problems. In the multivariable analysis, a history of arrest was associated with being trafficked while the presence of a supportive adult was associated with not being trafficked. Gender was not associated with a trafficking experience. Conclusions This study is the largest to specifically assess homeless youth's demographic and social variables for association with trafficking experience. Homeless youth who are and are not trafficked share similar life experiences, but those with a supportive adult in their life had lower odds of being trafficked. Building upon our research, future investigations exploring order of occurrence will elucidate the risk factors for and protective factors against trafficking among homeless youth, contributing to evidence-based prevention efforts.

Background Caring for teens with special health care needs places physical and mental health burdens on parents, which can be exacerbated by the stresses of transitions to independence. Medical homes can improve teen transitions to greater self-management and reduce health care–related time and financial burdens for families. We examined the association between parent-reported teen medical home status and caregiver health-related quality of life (HRQOL). Methods The study sample included parents or caregivers of teens with special health care needs aged 15 to 18 recruited from a pediatric Medicaid accountable care organization who participated in a survey (response rate, 40.5%). The primary outcome was parent HRQOL scores (0–100 points) measured using the Pediatric Quality of Life Inventory Family Impact Module. Medical home status was based on parent report of teen's health care meeting medical home criteria. Linear regression models were used to estimate HRQOL scores, adjusted for demographic characteristics, health literacy, and teen functional limitation. Results Among 488 parents, 27% reported their teen received care consistent with a medical home. Adjusted parent HRQOL scores were significantly higher among those whose teens had a medical home (74.40; 95% confidence interval, 71.31–77.48), relative to those whose teens did not (65.78; 95% confidence interval, 63.92–67.65). Medical home subscale analyses showed HRQOL scores had significant positive associations with family-centered care and coordinated care, but not other subscales. Conclusions Teen medical home status was positively associated with caregiver HRQOL, suggesting that the medical home may benefit overall caregiver well-being. In particular, receiving care that was family centered and coordinated appeared to be the most beneficial.

The nutrient environment and metabolism play a dynamic role in cellular differentiation and research is elucidating the mechanisms that contribute to this process. Metabolites serve as an effective bridge that helps to translate information about nutrient states into specific interpretations of the genome. Part of this activity relates to the role for metabolites in regulating epigenetic processes as well as a newly appreciated role for metabolites in the regulation of genome organization. In this review, we will highlight recent research that has defined roles for metabolism in the organization and interpretation of the genome and how this influences cellular differentiation decisions. We will integrate information about how nutrients, such as glutamine, regulate metabolites, such as alpha-ketoglutarate, and highlight how these pathways influence epigenetic states as well as CTCF association and genome organization. We will also discuss mechanistic similarities and differences between normal differentiation states associated with embryonic stem (ES) cells and T cells and how this might relate to dysregulated states such as those associated with tumor infiltrating lymphocytes.

Background and Objectives Despite recommendations supporting human papillomavirus (HPV) vaccination, pediatric vaccination rates remain suboptimal in the United States; lack of tools to support provider counseling is one barrier. We sought to evaluate HPV-related counseling materials for readability, suitability, and content, and assess parent perceptions of materials, using a health literacy perspective. Methods A systematic search was conducted for written materials developed for HPV vaccination counseling by examining state Department of Health Web sites and associated links to local and national organizations. Materials were assessed for the following: 1) readability (Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Fry), 2) suitability (understandability and actionability) (Suitability Assessment of Materials; Patient Education Materials Assessment Tool for Printable Materials), and 3) coverage of 8 key content areas (recommended by Centers for Disease Control and Prevention). Semistructured interviews were conducted with English-speaking parents or caregivers of children 9 to 17 years of age from 3 pediatric clinics (New York, Ohio, Illinois) serving predominantly low-income families to assess perceptions and usefulness of 4 handouts selected for review. Results Thirty-eight documents were assessed. Mean ± standard deviation (SD) reading grade level was 9.4 ± 2; 10.5% (n = 4) had a reading level of 6th grade or below; 68.4% (n = 26) were considered not suitable. Mean understandability was 41.7% and mean actionability was 20.7%. Only 5.3% (n = 2) addressed all 8 content areas mean ± SD (number of areas = 6.7 ± 1.2). Brochure comprehensiveness and inclusion of a personal story were cited as factors that would be helpful in influencing parents to vaccinate against HPV. Conclusions Few written materials for HPV vaccination counseling were optimal from a health literacy best practices perspective. Content comprehensiveness was important for informed decision making.