Unmet Needs of Unaccompanied Minors from Central America: Perceptions of Professionals from Multiple Sectors

Background: In recent years, there has been a significant influx of Central American youth who cross the U.S.-Mexico border without a parent or legal guardian. While federal procedures are established to oversee the treatment and placement of unaccompanied minors, less is known about the needs of unaccompanied minors and available services afterthey are placed in appropriate custody. Methods: Purposive and strategic sampling of professionals from medical, social work, education and legal fields was conducted. Fourteen informants were recruited across the U.S. for confidential semi-structured interviews, which were audio recorded and transcribed in 2016 to 2017. Standard anthropological methods were employed, including immersion and crystallization techniques that incorporated within-case and across-case analytic strategies. Results: Recruited informants had previous or current direct experience working with immigrant minors for three or more years in addition to extensive public health experience. Unaccompanied minors were described as predominantly adolescent boys, ranging from 2 to 18 years old. Children faced unmet mental, medical and psychosocial needs that are interconnected and largely unmet due to children’s legal status and ineligibility to access services in most jurisdictions. The most pressing challenge affecting the health of youth was their immigration status. Across sectors,informants revealed an imbalance between the growing demand for services, including legal counsel, and the limited supply of professionals and well-funded services to meet children’s complex needs. Informants emphasized the value of trauma-informed practice, Spanish language proficiency, child-informed practice and intercultural awareness and humility towards their clients as key features of equipped professionals working with this vulnerable population. Regardless of sector, professionals emphasized the importance of culturally-informed care to immigrant youth. Building these skills is associated with greater confidence to provide services to unaccompanied minors, many of whom have experienced as significant burden of childhood trauma. Conclusions: The health needs of unaccompanied minors are complex and span across medical, social work, education, and legal fields. Interdisciplinary collaboration is needed to address the challenges faced by unaccompanied minors in their efforts to integrate themselves into their new communities and promote their resilience. Promising initiatives include co-location of inter-sector services for increased access and efficiency of services and development of professional trainings and resources for professionals in sectors that serve this population

Healthcare Reform in Latino Rhode Island: Perspectives of Spanish speakers and Insurance Navigators

Latinos have the highest uninsurance rates of any ethnic or racial group in the US despite recent health insurance expansion reform. In addition to immigration and language barriers, health literacy and attitudes may impact coverage disparities. Focus groups with Spanish-speaking community members and semi-structured interviews with health insurance navigators were conducted to explore knowledge, awareness, and attitudes towards healthcare reform among Latinos in Rhode Island. Sessions were audio recorded, transcribed, and analyzed employing standard qualitative methods. Thirty-two focus group participants and six navigators were enrolled in the study. Spanish-speaking participants demonstrated limited knowledge of the cost implications of the Medicaid Expansion and of the role of health insurance exchanges. Common misconceptions included that insurance costs would increase regardless of income, that enrollment would compromise green card and citizenship applications, that documented non-permanent residents would be ineligible for subsidies, and that reform benefits would apply to undocumented workers. Our findings suggest that local initiatives and providers should target Latinos in a culturally sensitive manner to increase literacy regarding insurance eligibility, affordability, points of access as well as to address misconceptions related to insurance eligibility for documented immigrants

An analysis of spelling errors in written recall, grades four and six

Thesis (Ed.M.)--Boston Universit

Getting Started in Your Neighborhood: Piloting Community Health Teams through a Multi-Payer Approach

The Care Transformation Collaborative of Rhode Island (CTC), a patient-centered medical home initiative managed by UMass Medical School, explains how primary care practices can build a medical neighborhood by creating a community health team to provide behavioral health and social support services to patients with high-cost, complex care needs. CTC used a multi-payer approach to pilot and evaluate two community health teams in two diverse areas of Rhode Island

Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms

Objective: To describe the development of evidence-based electronic prescribing (e-prescribing) triggers and treatment algorithms for potentially inappropriate medications (PIMs) for older adults. Design: Literature review, expert panel and focus group. Setting: Primary care with access to e-prescribing systems. Participants: Primary care physicians using e-prescribing systems receiving medication history. Interventions: Standardised treatment algorithms for clinicians attempting to prescribe PIMs for older patients. Main outcome measure: Development of 15 treatment algorithms suggesting alternative therapies. Results: Evidence-based treatment algorithms were well received by primary care physicians. Providing alternatives to PIMs would make it easier for physicians to change decisions at the point of prescribing. Conclusion: Prospectively identifying older persons receiving PIMs or with adherence issues and providing feasible interventions may prevent adverse drug events

Complement Activation in Patients With Probable Systemic Lupus Erythematosus and Ability to Predict Progression to American College of Rheumatology-Classified Systemic Lupus Erythematosus.

ObjectiveTo evaluate the frequency of cell-bound complement activation products (CB-CAPs) as a marker of complement activation in patients with suspected systemic lupus erythematosus (SLE) and the usefulness of this biomarker as a predictor of the evolution of probable SLE into SLE as classified by the American College of Rheumatology (ACR) criteria.MethodsPatients in whom SLE was suspected by lupus experts and who fulfilled 3 ACR classification criteria for SLE (probable SLE) were enrolled, along with patients with established SLE as classified by both the ACR and the Systemic Lupus International Collaborating Clinics (SLICC) criteria, patients with primary Sjögren's syndrome (SS), and patients with other rheumatic diseases. Individual CB-CAPs were measured by flow cytometry, and positivity rates were compared to those of commonly assessed biomarkers, including serum complement proteins (C3 and C4) and autoantibodies. The frequency of a positive multianalyte assay panel (MAP), which includes CB-CAPs, was also evaluated. Probable SLE cases were followed up prospectively.ResultsThe 92 patients with probable SLE were diagnosed more recently than the 53 patients with established SLE, and their use of antirheumatic medications was lower. At the enrollment visit, more patients with probable SLE were positive for CB-CAPs (28%) or MAP (40%) than had low complement levels (9%) (P = 0.0001 for each). In probable SLE, MAP scores of >0.8 at enrollment predicted fulfillment of a fourth ACR criterion within 18 months (hazard ratio 3.11, P < 0.01).ConclusionComplement activation occurs in some patients with probable SLE and can be detected with higher frequency by evaluating CB-CAPs and MAP than by assessing traditional serum complement protein levels. A MAP score above 0.8 predicts transition to classifiable SLE according to ACR criteria

DR.SGX: Hardening SGX Enclaves against Cache Attacks with Data Location Randomization

Recent research has demonstrated that Intel's SGX is vulnerable to various software-based side-channel attacks. In particular, attacks that monitor CPU caches shared between the victim enclave and untrusted software enable accurate leakage of secret enclave data. Known defenses assume developer assistance, require hardware changes, impose high overhead, or prevent only some of the known attacks. In this paper we propose data location randomization as a novel defensive approach to address the threat of side-channel attacks. Our main goal is to break the link between the cache observations by the privileged adversary and the actual data accesses by the victim. We design and implement a compiler-based tool called DR.SGX that instruments enclave code such that data locations are permuted at the granularity of cache lines. We realize the permutation with the CPU's cryptographic hardware-acceleration units providing secure randomization. To prevent correlation of repeated memory accesses we continuously re-randomize all enclave data during execution. Our solution effectively protects many (but not all) enclaves from cache attacks and provides a complementary enclave hardening technique that is especially useful against unpredictable information leakage

The study design and rationale of the randomized controlled trial: translating COPD guidelines into primary care practice

Background: Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating disease associated with significant clinical burden and is estimated to affect 15 million individuals in the US. Although a large number of individuals are diagnosed with COPD, many individuals still remain undiagnosed due to the slow progression of the disorder and lack of recognition of early symptoms. Not only is there under-diagnosis but there is also evidence of sub-optimal evidence-based treatment of those who have COPD. Despite the development of international COPD guidelines, many primary care physicians who care for the majority of patients with COPD are not translating this evidence into effective clinical practice. Method/Design This paper describes the design and rationale for a randomized, cluster design trial (RCT) aimed at translating the COPD evidence-based guidelines into clinical care in primary care practices. During Phase 1, a needs assessment evaluated barriers and facilitators to implementation of COPD guidelines into clinical practice through focus groups of primary care patients and providers. Using formative evaluation and feedback from focus groups, three tools were developed. These include a computerized patient activation tool (an interactive iPad with wireless data transfer to the spirometer); a web-based COPD guideline tool to be used by primary care providers as a decision support tool; and a COPD patient education toolkit to be used by the practice team. During phase II, an RCT will be performed with one year of intervention within 30 primary care practices. The effectiveness of the materials developed in Phase I are being tested in Phase II regarding physician performance of COPD guideline implementation and the improvement in the clinically relevant outcomes (appropriate diagnosis and management of COPD) compared to usual care. We will also examine the use of a patient activation tool - ‘MyLungAge’ - to prompt patients at risk for or who have COPD to request spirometry confirmation and to request support for smoking cessation if a smoker. Discussion Using a multi-modal intervention of patient activation and a technology-supported health care provider team, we are testing the effectiveness of this intervention in activating patients and improving physician performance around COPD guideline implementation. Trial registration ClinicalTrials.gov, NCT0123756

Effects of adding a new PCMH block rotation and resident team to existing longitudinal training within a certified PCMH: primary care residents’ attitudes, knowledge, and experience

Background: Although the patient-centered medical home (PCMH) model is considered important for the future of primary care in the USA, it remains unclear how best to prepare trainees for PCMH practice and leadership. Following a baseline study, the authors added a new required PCMH block rotation and resident team to an existing longitudinal PCMH immersion and didactic curriculum within a Level 3-certified PCMH, aiming for “enhanced situated learning”. All 39 residents enrolled in a USA family medicine residency program during the first year of curricular implementation completed this new 4-week rotation. This study examines the effects of this rotation after 1 year. Methods: A total of 39 intervention and 13 comparison residents were eligible participants. This multimethod study included: 1) individual interviews of postgraduate year (PGY) 3 intervention vs PGY3 comparison residents, assessing residents’ PCMH attitudes, knowledge, and clinical experience, and 2) routine rotation evaluations. Interviews were audiorecorded, transcribed, and analyzed using immersion/crystallization. Rotation evaluations were analyzed using descriptive statistics and qualitative analysis of free text responses. Results: Authors analyzed 23 interviews (88%) and 26 rotation evaluations (67%). Intervention PGY3s’ interviews revealed more nuanced understanding of PCMH concepts and more experience with system-level PCMH tasks than those of comparison PGY3s. More intervention PGY3s rated themselves “extremely prepared” to implement PCMH than comparison PGY3s; however, most self-rated “somewhat prepared”. Their reflections demonstrated deeper understanding of PCMH implementation and challenges than comparison PGY3s but inadequate experience to directly see the results of successful solutions. Rotation evaluations from PGY1, PGY2, and PGY3s revealed strengths and several areas for improvement. Conclusion: Adding one 4-week block rotation to existing longitudinal training appears to improve residents’ PCMH knowledge, skills, and experience from “basic” to “intermediate”. However, this training level appears inadequate for PCMH leadership or for teaching junior learners. Further study is needed to determine the optimum training for different settings