Faculty Bibliography

ABSTRACT:Pre-exposure prophylaxis (PrEP) stigma is an understudied barrier to PrEP uptake among Black and Latinx adolescents. U.S. Black and Latinx adolescents (13-17 years) completed an online survey or participated in focus groups/interviews. Associations between PrEP stigma, PrEP disclosure, and provider-initiated PrEP discussion preferences were examined using logistic-regression models. Qualitative data provided further context to quantitative findings. The survey sample included 208 adolescents (53% female; 58% Latinx; M = 15 years), with 98% endorsing PrEP stigma. The qualitative sample included 26 adolescents (54% female; 34% Latinx; M = 15 years). PrEP stigma was associated with lower odds of PrEP disclosure to parents/guardians, and preference for health care providers to initiate PrEP-related discussions only with patients the provider judged to be at high risk for HIV. Qualitative data supported quantitative results: Adolescents endorsed multiple negative stereotypes about PrEP users. Mitigating PrEP stigma among Black and Latinx adolescents is an important step in overcoming challenges related to PrEP uptake.

In the United States, Black and Latinx youth remain disproportionately affected by HIV. Oral antiretroviral pre-exposure prophylaxis (PrEP) is a proven effective HIV prevention strategy. PrEP is approved for use in people younger than the age of 18 years, but little is known about provider comfort and preparedness with prescribing it to adolescents. In this study, physicians provide their perspectives on the facilitators and barriers to PrEP access among adolescents. Focus groups (n = 23) were conducted with pediatric and family practitioners practicing in an urban community hospital setting to assess PrEP awareness and receptivity to use among adolescents. Most providers were unfamiliar with clinical guidelines for PrEP use, especially in determining adolescent candidates for PrEP use, including appropriate dosing regimen and follow-up procedures. Overall, providers had low intent on prescribing PrEP, citing concerns about consent, medication adherence, and appropriateness of primary care providers in prescribing and managing adolescent PrEP use. Strategies that will address provider education and comfort in prescribing PrEP to adolescents are required to increase PrEP access and uptake among communities disproportionally affected by HIV.

BACKGROUND:In contrast to the current broad dissemination of telemedicine across medical specialties, previous research focused on the effectiveness of telemedicine in special populations and for behavioral health encounters; demonstrating that both physician and patient factors impact the efficacious use of telemedicine. OBJECTIVE:We evaluated physician perceptions of the appropriateness of telemedicine for patients attending the primary care practices of a federally qualified health center in New York City. METHODS:Anonymous cross-sectional survey including closed and open-ended questions. We used chi-square to test whether providers from certain specialties were more likely to state they would use telemedicine in the future. We used t-test to compare age between those who would vs. would not use telemedicine. Then, we used logistic regression to test whether age and specialty were both correlated with desire to use telemedicine in the future. We used thematic content analysis to describe the reasons providers felt they would not want to use telemedicine in the future, and to describe the situations for which they felt telemedicine would be appropriate. RESULTS:Of 272 FHC providers who were sent the electronic survey, 159(58%) responded within the 2-week survey time frame. Mean age of providers was 45 years (range 28-75). Overall, 81% stated they would use telemedicine in the future. Compared to the Family Medicine, Internal Medicine, Behavioral Health, Dental, and OB/GYN specialties, providers from Pediatrics, Med-Peds, Subspecialties and Surgery [Pro-telemedicine specialties] were more likely to believe telemedicine would be useful post pandemic (94% vs. 72%, p<0.05). Providers who reported they would use telemedicine in the future were younger [mean age 44(42-46) vs. 50(46-55), p<0.01). In regression analysis, both pro-telemedicine specialties and age were significantly associated with odds of reporting they would use telemedicine in the future [pro-specialties: 5.2(1.7-16.2); younger age: 1.05(1.01-1.08)]. Providers who did not want to use telemedicine in the future cited concerns about inadequate patient care, lack of physical patient interaction, technology issues, and lack of necessity. Providers who felt telemedicine would be useful cited the following situations: follow up visits, medication refills, urgent care, patient convenience, and specific conditions such has behavioral health, dermatology visits, and chronic care management. CONCLUSIONS:The majority of health providers in this resource poor setting in a federally qualified health center believed that telemedicine would be useful for providing care after the pandemic is over. CLINICALTRIAL/UNASSIGNED/:

Introduction:Poor health literacy has a negative impact on various health care outcomes. Medical schools are not consistently providing health literacy training; when they do, they overly rely on didactics. Methods:Our curriculum for third-year pediatric clerkship students taught principles of health literacy and evidence-supported clear communication strategies. Communication skills were structured on a novel mnemonic: CTEP (clear language, teach-back, effectively encouraging questions, and pictures). The curriculum included a 30-minute didactic, followed 1-2 weeks later by a 90-minute interactive workshop. All 188 clerkship students attended the didactic lecture; approximately half (90) attended the follow-up workshop. All students completed a formative objective structured clinical encounter. Standardized patients then evaluated students' use of the four clear communication skills. Students completed a survey to assess confidence, knowledge, and use of the skills. Results:< .01). In addition, the didactic + workshop group had improved recall, self-reported use, and comfort with the skills. The didactic + workshop group solicited questions from the standardized patient less often, and there was no difference in use of clear language between the two groups. Discussion:An interactive curriculum in health literacy and clear communication for pediatric clerkship students was superior to a didactic alone. Optimizing instructional methods for health literacy skills can help future physicians properly communicate with their patients to improve health outcomes.

BACKGROUND: Patient Portals(PP) allow access to medical records and interaction with providers; however activation(PPA) and use (PPU) are limited by language barriers, low health/computer literacy, and poor internet access which are prevalent issues in Federally Qualified Health Centers(FQHC). Little is known of the drivers and patterns of PPA in such settings. We aimed to describe the prevalence of PPA and PPU in adult patients of an FQHC; describe PPU activity, and test demographic, condition, and utilization-related correlates of PPA and PPU.
METHOD(S):We conducted a retrospective chart review in an FQHC that launched a PP in September 2016. We extracted demographics, PPA status(active/not) at data pull, PPU activities, presence of a chronic condition on the problem list, # emergency department, inpatient, subspecialty visits over past year (utilization summed, dichotomized >1 vs. 0-1 visit). Missing values for homelessness were coded to majority category( 0). Analyses included descriptive statistics, bivariate analyses, then logistic regression to test odds of PPA and PPU by. demographics, chronic conditions, and utilization. We report [adjusted odds ratios(confidence interval)].
RESULT(S): Data were analyzed for 62,610 adults [mean age 45(SD 17), 21% Black, 47% Hispanic, 46% Medicaid, 25% Selfpay, speaking English( 60%), Spanish (31%), Chinese(6%), Other(3%), with: hypertension( 19%), diabetes(11%), depression(8%), asthma(6%), CVD(5%); 21% had utilization>1. Overall 23,104(37%) activated the PP. PPU included viewing test results(69%), medications(62% ), immunizations( 51%), billing (38%), asking advice (29%), and scheduling appointments( 16%). PPA and PPU varied by demographics, chronic condition, and utilization, but were consistently higher for females, those who were not Medicaid recipients or Self-pay, English speakers and those with asthma, hypertension, and depression.
CONCLUSION(S): PPA was lower for non-whites and poorer patients, but higher for patients speaking the predominant languages of this FQHC, suggesting that language concordance helps engage patients. Patients with chronic conditions and more healthcare utilization had greater odds of PPA and PPU. On the other hand, Spanish-speakers were less likely to actively use the portal for functions such as scheduling appointments, suggesting that improvements in language capabilities of the platform are needed

This mixed-methods study examined awareness of and willingness to use pre-exposure prophylaxis (PrEP) among sexually active Black and Latinx adolescents (13-17 years) residing in five cities in the United States with some of the highest burden of HIV. Data are from adolescents who participated in a cross-sectional survey (n = 208) and one-on-one interviews and focus groups (n = 26) conducted from September 2017-August 2019. Approximately 50% of the sample were recruited through community efforts, and the other half through a panel. Logistic regression with covariates including sexual orientation, relationship status, socioeconomic status, and race/ethnicity were used to assess factors associated with PrEP awareness and willingness. For the qualitative data, thematic analysis was used to develop a codebook of a-priori and inductive codes while analytic memos were written to identify key themes. PrEP awareness was reported by 38% of the sample and was associated with Black race (AOR = 0.49; 95% CI = 0.27, 0.90) and prior HIV testing (AOR = 3.89, 95% CI = 1.25, 12.08). PrEP willingness (defined as "definitely would use PrEP") was reported by 22% of the sample and was associated with higher age, more education, having had condomless sex in the past 6 months (AOR = 0.23; 95% CI = 0.10, 0.56), perceived likelihood of acquiring HIV (AOR = 3.59; 95% CI = 1.06, 12.21), and PrEP awareness (AOR = 0.41; 95% CI = 0.19, 0.89). Qualitative data showed that misconceptions about PrEP persist and PrEP stigma, fear of being punished, provider attitudes and recommendations, and empowerment were related to adolescents' willingness to use PrEP. Study findings reveal important strategies for improving PrEP delivery and scale-up to Black and Latinx adolescents. These strategies include using sociodemographic and health behavior data to target adolescents who may be more or less willing to use PrEP, improving provider communication about PrEP, and creating culturally and developmentally appropriate PrEP education materials that address common misconceptions held by adolescents.

OBJECTIVE:Functional gastrointestinal (GI) disorders (FGIDs), such as irritable bowel syndrome, functional abdominal pain and dyspepsia, are common causes of chronic GI symptoms in children. Prior studies found high comorbidity of FGID and asthma. This study aimed to assess the prevalence and comorbidities of FGID among pediatric patients with asthma at a university-affiliated urban community hospital. METHODS:This prospective, cross-sectional study assessed FGID prevalence, asthma control and symptoms of anxiety among pediatric patients with persistent asthma. The pediatric ROME III questionnaire was used to assess FGID. The Asthma Control Test assessed asthma control. The Beck Anxiety Inventory assessed symptoms of anxiety. RESULTS:Of the 110 enrolled patients, 18 (16.4%) met the diagnostic criteria for FGID, of which 10 were consistent with the diagnosis of functional abdominal pain disorder. Patients with FGID had a significantly lower mean asthma control score than patients without FGID (11.5 ± 4.9 vs 14.8 ± 5.3, P = 0.03; Cohen's d = 0.6) and higher mean anxiety scores than those without FGID (P < 0.01). Asthma control predicted the presence of FGID (OR 0.90, 95% CI 0.80-0.99, P = 0.03). However, after adjusted for anxiety, asthma control no longer predicted FGID presence (adjusted OR 0.90, 95% CI 0.83-1.05, P = 0.23). CONCLUSIONS:This study suggests a high prevalence of FGID among patients with persistent asthma. Moreover, patients with FGID had poor asthma control and increased anxiety. Clinicians should consider FGID in patients with poor asthma control and assess them for anxiety.

BACKGROUND:Childhood obesity is a growing health challenge. Recent studies show that children with late bedtime and late awakening are more obese independent of total sleep time. In adolescents and adults, a delayed sleep phase has been associated with higher caloric intake. Furthermore, an adult study showed a positive correlation between REM sleep and energy balance. This relationship has not been demonstrated in children. However, it may be important as a delayed sleep phase would increase the proportion of REM sleep. OBJECTIVES:This study investigated the relationship between hunger score and sleep physiology in a paediatric population. METHODS:Thirty-six patients referred for a polysomnogram for suspected obstructive sleep apnoea were enrolled in the study. Sleep stages were recorded as part of the polysomnogram. Hunger scores were obtained using a visual analogue scale. Mean age was 9.6 ± 3.5 years. RESULTS:Mean hunger scores were 2.07 ± 2.78. Hunger scores were positively correlated with percentage of total rapid eye movement (REM) sleep (r = 0.438, P < 0.01) and REM sleep duration in minutes (r = 0.471, P < 0.05). Percentage slow wave sleep (SWS) was negatively correlated with hunger score (r = -0.360, P < 0.05). There were no correlations between age, sex, body mass index percentiles, apnoea-hypopnoea index, total sleep time, sleep efficiency, sleep onset latency, stage 2 sleep duration and hunger scores. CONCLUSIONS:These findings suggest that delayed bedtime, which increases the proportion of REM sleep and decreases the proportion of SWS, results in higher hunger levels in children.