Importance Emergency department (ED) boarding times have increased rapidly, but their health equity outcomes are unknown. Objective To investigate whether prolonged ED boarding is associated with increased perceived racial discrimination and dissatisfaction and whether associations vary between patients from marginalized racial and ethnic groups vs non-Hispanic White patients. Design, Setting, and Participants This is a cross-sectional study of hospitalized adults who boarded in the ED during internal medicine admissions at a large, urban hospital in Boston, Massachusetts, from June 2023 to January 2024. Equal proportions of non-Hispanic White patients and patients from marginalized racial and ethnic groups (American Indian or Alaska Native, Hispanic, non-Hispanic Black and/or African American, and multiracial) were selected randomly. Exposure The duration of ED boarding was categorized as less than 4 hours (reference), 4 to less than 24 hours, and 24 or more hours. Main Outcomes and Measures Primary outcomes were odds of reporting (1) discrimination via the Discrimination in Medical Settings scale, and (2) dissatisfaction via the adapted Picker Patient Experience-15 questionnaire. Marginalized race and ethnicity was tested as an effect modifier. Multivariable logistic regression models adjusted for patient age, sex, language, and insurance payer. Results Of 598 patients approached, 527 were enrolled, and 525 completed the surveys (response rate, 87.8%). The mean age (SD) was 60.6 (18.7) years, 300 patients (57.1%) were female, 246 patients (47.3%) identified as non-Hispanic White, and 274 (52.7%) were from a marginalized racial or ethnic group. In total, 135 (25.7%) boarded less than 4 hours (reference), 202 (38.5%) boarded 4 to less than 24 hours, and 188 (35.8%) boarded 24 hours or longer. Compared with less than 4 hours, boarding 24 hours or longer was associated with increased perceived discrimination (odds ratio [OR], 1.84; 95% CI, 1.14-2.99; P = .01). An increased association was observed in the subgroup of patients from racial and ethnic marginalized groups (OR, 2.36; 95% CI, 1.20-4.65; P = .01); effect modification was not significant (P for interaction, .10). For all patients, boarding 24 hours or longer was associated with increased dissatisfaction with care (OR, 1.77; 95% CI, 1.03-3.06; P = .04); effect modification was not significant (P for interaction, .80). Conclusions and Relevance In this cross-sectional study, hospitalized patients who boarded in the ED 24 hours or longer reported more discrimination and dissatisfaction with care, which may disproportionately affect patients from marginalized racial and ethnic groups. As ED boarding times increase nationally, it is critical to recognize their potential to exacerbate health inequities and to respond with equity-focused solutions.

Purpose: To identify intimate partner violence (IPV)-related injury patterns of U.S. patients of three age groups: <18 years (adolescents), 18-25 years (emerging adults), and >25 years (adults). Methods: We performed a nationally representative retrospective review of all patients presenting to U.S. Emergency Department for IPV-related injuries from 2005 through 2020. Demographics and injury patterns were calculated using statistical methods accounting for the weighted stratified data. Main outcomes were injury morphology, mechanism, severity, location, and temporal associations of IPV-related injuries among the three age groups. Results: There was a higher proportion of female victims, sexual assault cases, and lower trunk injuries among adolescents compared to emerging adults and adults. There was increasing injury severity, fractures, and hospital admissions with increasing age. Adolescents experienced a greater prevalence of fractures of the head, neck, hands, fingers, and distal lower extremity, while trunk fractures increased with age. The peak prevalence of violence -related Emergency Department visits among adolescents was in June and September, with the peak day as Tuesday. Discussion: Injurious forms of IPV are prevalent across all age groups, with sexual assault cases demonstrably higher among adolescents and increasing severity of injuries as victims age. Identi fication of age -speci fic injury patterns will aid health-care professionals and policymakers in developing targeted interventions for adolescents who experience IPV. (c) 2024 Society for Adolescent Health and Medicine. All rights reserved.

As the world's attention and resources continue to focus on the war in Ukraine, other devastating conflicts persist in many countries with less public scrutiny and far fewer demands for accountability or justice for survivors. Consider the conflict in Tigray, where the Ethiopian Government and the Tigray People's Liberation Front (TPLF), alongside the Eritrean army and regional military groups, have engaged in intense fighting since 2020. This has resulted in the killing of thousands of civilians, life-altering injuries, and the collapse of the region's health-care system; Ethiopia's war was described as the world's “bloodiest conflict” in 2022. 1 Knight B Global conflicts: death toll at highest in 21st century. DW. https://www.dw.com/en/global-conflicts-death-toll-at-highest-in-21st-century/a-66047287Date: June 28, 2023 Date accessed: August 7, 2023 Google Scholar , 2 Gesesew H Berhane K Siraj ES et al. The impact of war on the health system of the Tigray region in Ethiopia: an assessment. BMJ Glob Health. 2021; 6e007328 Crossref Scopus (56) Google Scholar

Objectives. To quantify the prevalence of diabetes and barriers to care in U.S. migrant farmworkers (i.e., who travel from their permanent residence for seasonal farmwork). Research Design and Methods. Age-adjusted prevalence of self-reported diabetes and barriers to care were calculated in adult U.S. farmworkers from 2008-2017 National Agricultural Workers Surveys. Results. Among 16,913 farmworkers, 30.7% reported one or more barriers to care, most often cost. Age-adjusted self-reported prevalence of diabetes was 13.51% (95% CI 10.0 – 17.1) amongst migrants and 10.8% (95% CI 9.0 – 12.6) amongst non-migrants with access to healthcare. Migrants without recent access had 83% lower odds of reporting diabetes (aOR 0.17, 95% CI 0.06 – 0.54) compared to non-migrants, likely due to poor healthcare access and/or a healthy worker effect. Conclusion. Many migrant farmworkers face barriers to care which may lead to significant underdiagnosis of diabetes in this vulnerable population.

In this narrative medicine essay, a physician recounts her family’s experience with critical illness and death and how she came to appreciate both the health care team’s perspective and the family’s perspective regarding when to have hope and when to let go.

Background:To describe factors that influence interprofessional staff decisions and ability to implement trauma-informed care (TIC) in a level-one emergency department (ED) trauma center. Methods:This qualitative research study consisted of semi-structured interviews and quantitative surveys that were conducted between March and December 2020 at an urban trauma center. Eligible participants were staff working in the ED. Interview questions were developed using the Theoretical Domains Framework (TDF), which is designed to identify influences on health professional behavior related to implementation of evidence-based recommendations. Interview responses were transcribed, coded using Atlas software, and analyzed using thematic analysis. Results:Key themes identified included awareness of TIC principles, impact of TIC on staff and patients, and experiences of bias. Participants identified opportunities to improve care for patients with a trauma history, including staff training, more time with patients, and efforts to decrease bias toward patients. Most participants (85.7%) felt that a TIC plan, tiered trauma inquiry, and warm handovers would be easy or very easy to implement. Conclusion:We identified key interprofessional staff beliefs and attitudes that influence implementation of TIC in the ED. These factors represent potential individual, team-based, and organizational targets for behavior change interventions to improve staff response to patient trauma and to address secondary trauma experienced by ED staff.

ImportanceAn estimated 27% of ever-partnered women aged 15 to 49 years have experienced intimate partner violence (IPV) in their lifetimes, which has been associated with a wide range of both acute and chronic illness. Poverty is thought to be a major driver of IPV, and economic empowerment programs may reduce violence.ObjectiveTo evaluate whether microfinance interventions are associated with reductions in various forms of IPV.Data SourcesOn August 3, 2022, PubMed, CINAHL, Embase, Web of Science, EconLit, and 5 global health databases were searched from inception.Study SelectionIncluded studies were randomized clinical trials evaluating the effect of microfinance interventions vs control on exposure to IPV. This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline.Data Extraction and SynthesisAuthors independently assessed study eligibility, extracted prespecified data, and evaluated risk of bias using the Cochrane Risk of Bias tool.Main Outcomes and MeasuresOutcome measures of interest were exposure to overall IPV and 4 World Health Organization–designated IPV domains: physical, psychological and emotional, sexual, and controlling behaviors. Univariate meta-analyses using a random effects model were used to calculate the standardized mean differences (SMDs) and 95% CIs for each IPV outcome. The Grading of Recommendations Assessment, Development, and Evaluation method was used to rate the certainty of findings.ResultsOverall, 10 randomized clinical trials met inclusion criteria, with a total of 16 136 participants, of whom 98% identified as women, with a mean age of 28.9 years. Compared with no intervention, participation in microfinance was associated with lower rates of psychological and emotional violence (SMD, 0.87; 95% CI, 0.80-0.95; I2 = 46%; high certainty), sexual violence (SMD, 0.76; 95% CI, 0.63-0.90; I2 = 44%; low certainty), and controlling behaviors (SMD, 0.82; 95% CI, 0.74-0.92; I2 = 54%; high certainty). There was no significant association with physical violence (SMD, 0.89; 95% CI, 0.76-1.04; very-low certainty).Conclusions and RelevanceThis systematic review and meta-analysis of microfinance interventions found a reduction in exposure to psychological and emotional IPV as well as controlling behaviors among participants receiving microfinance interventions, with high certainty evidence. Further work is needed to evaluate which types of microfinance interventions are most effective at reducing the various forms of IPV.

Importance An estimated 27% of ever-partnered women aged 15 to 49 years have experienced intimate partner violence (IPV) in their lifetimes, which has been associated with a wide range of both acute and chronic illness. Poverty is thought to be a major driver of IPV, and economic empowerment programs may reduce violence. Objective To evaluate whether microfinance interventions are associated with reductions in various forms of IPV. Data Sources On August 3, 2022, PubMed, CINAHL, Embase, Web of Science, EconLit, and 5 global health databases were searched from inception. Study Selection Included studies were randomized clinical trials evaluating the effect of microfinance interventions vs control on exposure to IPV. This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Data Extraction and Synthesis Authors independently assessed study eligibility, extracted prespecified data, and evaluated risk of bias using the Cochrane Risk of Bias tool. Main Outcomes and Measures Outcome measures of interest were exposure to overall IPV and 4 World Health Organization-designated IPV domains: physical, psychological and emotional, sexual, and controlling behaviors. Univariate meta-analyses using a random effects model were used to calculate the standardized mean differences (SMDs) and 95% CIs for each IPV outcome. The Grading of Recommendations Assessment, Development, and Evaluation method was used to rate the certainty of findings. Results Overall, 10 randomized clinical trials met inclusion criteria, with a total of 16 136 participants, of whom 98% identified as women, with a mean age of 28.9 years. Compared with no intervention, participation in microfinance was associated with lower rates of psychological and emotional violence (SMD, 0.87; 95% CI, 0.80-0.95; I2 = 46%; high certainty), sexual violence (SMD, 0.76; 95% CI, 0.63-0.90; I2 = 44%; low certainty), and controlling behaviors (SMD, 0.82; 95% CI, 0.74-0.92; I2 = 54%; high certainty). There was no significant association with physical violence (SMD, 0.89; 95% CI, 0.76-1.04; very-low certainty). Conclusions and Relevance This systematic review and meta-analysis of microfinance interventions found a reduction in exposure to psychological and emotional IPV as well as controlling behaviors among participants receiving microfinance interventions, with high certainty evidence. Further work is needed to evaluate which types of microfinance interventions are most effective at reducing the various forms of IPV.

Conflict-related sexual and gender-based violence is common in the eastern Democratic Republic of Congo, but there are few evaluations of multisectoral training interventions in conflict settings. We conducted high-quality, trauma-informed medicolegal trainings amongst multisectoral professionals and sought to describe changes in knowledge after training and perceived training acceptability. Participants were health, law enforcement, and legal professionals who completed training at one of four sites from January 2012 to December 2018. Twelve trainings were randomly selected for evaluation. We conducted pre-and post-training assessments and semi-structured interviews of participants within 12 months of index training. Forty-six trainings of 1,060 individuals were conducted during the study period. Of the randomly selected trainings, 368 questionnaires were included in the analysis (36% health, 31% legal, 12% law enforcement, 21% other). The mean knowledge scores (standard deviation) significantly improved after training: 77.9 (22.9) vs. 70.4 (20.8) (p <0.001). Four key benefits were identified: 1) improved cross-sector coordination; 2) enhanced survivor-centered care; 3) increased standardization of forensic practices; and 4) higher quality evidence collection. Participants completing the training had improved knowledge scores and perceived several key benefits, suggesting the multi-sectoral training was acceptable in this under-resourced, conflict region.

Sexual and gender-based violence (SGBV) leads to severe sequelae for individuals and communities. Lack of cross-sector coordination inhibits effective medical–legal support and justice for survivors. Multisectoral trainings for health, legal, and law enforcement professionals on survivor-centered SGBV care were conducted in Kenya during 2012–2018. Evaluation utilized objective structured clinical examinations, standardized patients, knowledge assessments, and interviews. A total of 446 professionals participated in 18 trainings. Mean knowledge scores increased from 75.6% to 84.7% ( p < .001). Thirty interviews revealed improved survivor confidentiality, increased specialized hospital care, more comprehensive forensic care, and greater cross-sector collaboration. Participants reported survivors feeling more comfortable pursuing legal action and increased perpetrator convictions.

OBJECTIVE:To assess how race has been incorporated into rheumatology practice guidelines, including how race is defined and used in diagnostic and treatment recommendations. METHODS:We searched race and ethnicity terms in all clinical practice guidelines from the American College of Rheumatology (ACR) and European Alliance of Associations for Rheumatology (EULAR) that were published between 2010 and 2020 and publicly available on professional society websites. Findings were summarized and assessed through standardized data abstraction forms. Key themes were identified through a thematic analysis approach. RESULTS:A total of 23 ACR clinical practice guidelines and 42 EULAR recommendations were reviewed. In total, 16 of 65 (25%) of the guidelines used race terms in their text. No guideline clearly defined race, and race was often conflated with ethnicity and/or genetic ancestry. Reported racial categories varied substantially by guideline and often used classifications that oversimplified and excluded non-White races. Research with insufficient racial diversity was used to make race-based recommendations for Black patients that may not be generalizable. Additionally, recommendations using research on predominantly White populations reinforced data of White populations as normative and perpetuated race-based stereotypes, especially for rare diseases. Structural causes of identified racial disparities were not discussed in clinical guidelines. CONCLUSION:There is an urgent need for standardized race reporting in rheumatology. Recommendations are provided to enhance consistency and accuracy of race and ethnicity terms, mitigate conflation of race with ethnicity or genetic ancestry, encourage a critical reanalysis of race-based diagnostic tools and treatment options, and better address the structural causes of racial disparities.

Introduction High-quality forensic documentation can improve justice outcomes for survivors of sexual and gender-based violence, but there are limited tools to assess documentation data quality. This study aimed to develop and validate a data quality assessment index to objectively assess clinician documentation across the 26 key elements of the standardized forensic evidence forms used in Kenya. Methods Informed by prior quality assessment tools, an initial draft of the index was developed. Feedback from Kenya- and U.S.-based clinicians and human rights experts was solicited and incorporated into the draft index in an iterative fashion. Two raters independently employed the finalized Physicians for Human Rights Data Quality Index to assess and score the quality of documentation across 31 clinician-completed forms. Inter-rater reliability was determined using Cohen kappa (к) coefficients. Results The Index was found to have substantial overall reliability. Of the 26 documentation items, the Index had a perfect (к = 1.0) and almost perfect (к = 0.81–0.99) level of inter-rater agreement across 17 (65.4%) and 5 (19.2%) items, respectively. On a low-to-high documentation quality scale of 0 to 2, the majority of items (n = 19, 73.1%) had a mean documentation quality score >1.5–2. Conclusion Quality assurance of forensic documentation is an essential component of post-sexual assault care. To our knowledge, this is the first validated quality-assessment tool in the peer-reviewed literature for sexual assault documentation and may be a promising strategy to enhance the quality of sexual assault documentation in other settings, locally, regionally, and internationally.

Understanding the spread of SARS-CoV-2, how and when evidence emerged, and the timing of local, national, regional, and global responses is essential to establish how an outbreak became a pandemic and to prepare for future health threats. With that aim, the Independent Panel for Pandemic Preparedness and Response has developed a chronology of events, actions, and recommendations, from December, 2019, when the first cases of COVID-19 were identified in China, to the end of March, 2020, by which time the outbreak had spread extensively worldwide and had been characterised as a pandemic. Datapoints are based on two literature reviews, WHO documents and correspondence, submissions to the Panel, and an expert verification process. The retrospective analysis of the chronology shows a dedicated initial response by WHO and some national governments, but also aspects of the response that could have been quicker, including outbreak notifications under the International Health Regulations (IHR), presumption and confirmation of human-to-human transmission of SARS-CoV-2, declaration of a Public Health Emergency of International Concern, and, most importantly, the public health response of many national governments. The chronology also shows that some countries, largely those with previous experience with similar outbreaks, reacted quickly, even ahead of WHO alerts, and were more successful in initially containing the virus. Mapping actions against IHR obligations, the chronology shows where efficiency and accountability could be improved at local, national, and international levels to more quickly alert and contain health threats in the future. In particular, these improvements include necessary reforms to international law and governance for pandemic preparedness and response, including the IHR and a potential framework convention on pandemic preparedness and response.

Over years of rigorous medical training, from cold cadaver labs to physically demanding, gruesome codes, it gets easier to stop giving love so freely, to cover a dying person's face, to put on your mask. Yet there are moments in medicine that crack our thick exteriors.

Introduction Many low- and middle-income countries have implemented health-system based one stop centres to respond to intimate partner violence (IPV) and sexual violence. Despite its growing popularity in low- and middle-income countries and among donors, no studies have systematically reviewed the one stop centre. Using a thematic synthesis approach, this systematic review aims to identify enablers and barriers to implementation of the one stop centre (OSC) model and to achieving its intended results for women survivors of violence in low- and middle-income countries. Methods We searched PubMed, CINAHL and Embase databases and grey literature using a predetermined search strategy to identify all relevant qualitative, quantitative and mixed methods studies. Overall, 42 studies were included from 24 low- and middle-income countries. We used a three-stage thematic synthesis methodology to synthesise the qualitative evidence, and we used the CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach to assess confidence in the qualitative research. Meta-analysis could not be performed due heterogeneity in results and outcome measures. Quantitative data are presented by individual study characteristics and outcomes, and key findings are incorporated into the qualitative thematic framework. Results The review found 15 barriers with high-confidence evidence and identified seven enablers with moderate-confidence evidence. These include barriers to implementation such as lack of multisectoral staff and private consultation space as well as barriers to achieving the intended result of multisectoral coordination due to fragmented services and unclear responsibilities of implementing partners. There were also differences between enablers and barriers of various OSC models such as the hospital-based OSC, the stand-alone OSC and the NGO-run OSC. Conclusion This review demonstrates that there are several barriers that have often prevented the OSC model from being implemented as designed and achieving the intended result of providing high quality, accessible, acceptable, multisectoral care. Existing OSCs will likely require strategic investment to address these specific barriers before they can achieve their ultimate goal of reducing survivor retraumatisation when seeking care. More rigorous and systematic evaluation of the OSC model is needed to better understand whether the OSC model of care is improving support for survivors of IPV and sexual violence. The systematic review protocol was registered and is available online (PROSPERO: CRD42018083988).

This article highlights the timely situation that resident physicians, faculty, and staff are facing after the recent highly publicized murders of Black Americans and its impact on our healthcare communities. We discuss our experiences of how the hospital can serve as a meeting place for anti-racism, as well as how anti-racist events at the hospital can raise public consciousness and be catalysts for creating a more inclusive, diverse, and welcoming environment for all members of hospital communities.

Background: So-called virginity testing, also referred to as hymen, two-finger, or per vaginal examination, is the inspection of the female genitalia to assess if the examinee has had or has been habituated to sexual intercourse. This paper is the first systematic review of available evidence on the medical utility of virginity testing by hymen examination and its potential impacts on the examinee.Methods: Ten electronic databases and other sources for articles published in English were systematically searched from database inception until January 2017. Studies reporting on the medical utility or impact on the examinee of virginity testing were included. Evidence was summarized and assessed via a predesigned data abstraction form. Meta-analysis was not possible.Main Results: Seventeen of 1269 identified studies were included. Summary measures could not be computed due to study heterogeneity. Included studies found that hymen examination does not accurately or reliably predict virginity status. In addition, included studies reported that virginity testing could cause physical, psychological, and social harms to the examinee.Conclusions: Despite the lack of evidence of medical utility and the potential harms, health professionals in multiple settings continue to practice virginity testing, including when assessing for sexual assault. health professionals must be better informed and medical and other textbooks updated to reflect current medical knowledge. Countries should review their policies and move towards a banning of virginity testing.

A 15-year-old girl at 18 weeks gestation by the last menstrual period presented to a rural Ugandan healthcare facility for termination of her pregnancy as a result of rape by her uncle. Skilled healthcare workers at the facility refused to provide the abortion due to fear of legal repercussions. The patient subsequently obtained an unsafe abortion by vaginal insertion of local herbs and sharp objects. She developed profuse vaginal bleeding and haemorrhagic shock. She was found to have uterine rupture and emergent hysterectomy was performed. Young and poor women are at high risk of unplanned pregnancy and subsequent mortality during pregnancy and childbirth. Unsafe abortion is a leading and entirely preventable cause of maternal mortality worldwide. Multiple barriers restrict access to safe abortions including social and moral stigma, gender-based power imbalances, inadequate contraceptive use and sexual education, high cost and poor availability, and restrictive abortion laws.

We aim to elucidate the role of eicosanoids in cellular immunity in the squash bug, Anasa tristis. Squash bugs are significant pest insects that cause major crop damage throughout the Midwest each year. Currently we are assaying the immune response of squash bugs to bacterial challenge by the pathogen Serratia marcescens by documenting hemocyte proliferation, microaggreagate formation, and nodulation in comparison to control insects. In addition to a bacterial challenge, we inject the eicosanoid biosynthesis inhibitor indomethacin to observe the potential effects on the immune response. Assays were also performed on the spined soldier bug, Podisus maculiventris, during periods when squash bugs were unavailable due to diapause. Eleven of 31 challenged squash bugs (35.5%) showed nodulation. The average count per challenged bug was 190 hemocytes and 2.56 microaggregates. This compared to 1 out of the 11 insects with nodulation (9.09%), and an average count of 145 hemocytes and 0.33 microaggregates in the control squash bugs. Of 14 challenged spined soldier bugs, 1 showed nodulation (7.14%) whereas two of 17 control insects showed nodules (11.8%). The hemocyte count was 2820 for challenged spined soldier bugs compared to 1210 in controls. Preliminary experiments with indomethacin showed reduced nodulation, microaggregate formation and hemocytes numbers in spined soldier bugs. More experiments are warranted to determine the overall effect. The bacteria, S. marcenscens, induced an immune response in both types of insects. The challenged squash bugs generally showed higher levels of the indicators of immunity that we chose. These results may establish a baseline for subsequent studies. Abstract