Luciano Garofalo

Background: School based health centers (SBHCs) are essential for providing health care to students. Literature demonstrates student characteristics such as race and income are associated with SBHC utilization; however, little data exists on temporal trends in utilization. This gap in knowledge is crucial for informing policies and resource allocation.Methods: This study examined utilization across 27 SBHCs at elementary, middle, and high schools in King County, Seattle from 2017 to 2021. Negative binomial models with random intercepts were constructed to evaluate semester‐level variation in utilization, accounting for school‐level differences in race, income, and attendance. Interaction models were constructed to test for effect modification of utilization by race, income, and attendance.Results: Findings indicate that higher rates of utilization occurred in the fall. There was a decrease in utilization during the study, potentially due to the pandemic. Lower school‐level income was positively and significantly associated with higher utilization and none of the interaction models were significant.Implications: Our study holds important implications for planning and policy recommendations surrounding SBHC care delivery, such as the potential need for more staffing to meet the higher demand in the fall.Conclusion: SBHC utilization varies by semester and schools serving low‐income communities may experience higher rates of utilization, requiring increased staffing needs.

Objectives: Naturopathic physicians (ND) are uniquely situated to address areas of unmet health care need as primary care providers (PCPs). In several states, NDs have a broad scope of practice and are licensed as independent practitioners regardless of residency training. However, with a larger role in the health care system, the need for post-graduate medical training becomes more important for clinical success and patient safety. Our study aimed at assessing the feasibility of developing residencies for licensed NDs in rural federally qualified health centers (FQHCs) of Oregon and Washington. Methods: We conducted interviews with leadership from a convenience sample of eight FQHCs. Six centers were rural, two of which already employed NDs. Two urban centers that employed NDs as PCPs were included for their valuable insights related to study design. Two investigators independently reviewed and coded site visit notes for prominent themes through inductive reasoning analysis. Results: Consensus was met identifying the following themes: onboarding and mentorship; diversity of clinical training; financial structure; length of residency; and addressing health care needs in the community. We identified several opportunities for the development of primary care residencies for NDs, including the need for PCPs in rural communities, the ability of NDs to manage chronic pain with prescription drugs, and the prevention of morbidity from complex conditions such as diabetes and cardiovascular disease. Potential barriers to residency development include lack of Medicare reimbursement, mixed awareness of the ND scope of practice, and scarcity of dedicated mentors. Conclusion: These results may serve as guideposts for the future development of naturopathic residencies in rural community health centers.

Objective: Both the United Nations and the World Health Organization have identified antimicrobial resistance as a significant threat to global health. The Centers for Disease Control and Prevention identified five pediatric respiratory conditions as requiring particular scrutiny in terms of antibiotic stewardship. This study sought to identify strategies used by experienced naturopathic practitioners to treat acute respiratory infections in children. The authors theorize that naturopathic strategies safely fill the gap between watchful waiting and antibiotic prescription, thus reducing the use of antibiotics. Methods: Naturopathic practitioners in Canada, the United States, and Australia with a minimum of 5 years of experience in clinical naturopathic care of children were recruited for a modified Delphi study. A 14-person panel of practitioners was selected to complete a series of four iterative surveys assessing agreement to statements in five domains of knowledge/attitudes, assessment/diagnosis, management, monitoring, and education. Items were deemed to have reached consensus if they reached a predetermined threshold of 70% agreement, or failed to reach a threshold of 40% agreement. Items between these boundaries were modified and retested until either consensus was reached or the four surveys had been completed. Results: Results yielded a large degree of agreement on core naturopathic approaches to the management of acute pediatric respiratory infections, especially lifestyle strategies, including adequate rest and dietary recommendations. The use of vitamins C and D was strongly supported, as were herbs, particularly echinacea and elderberry. Some hydrotherapy and topical applications specific to the individual focus on infection also reached consensus. Results suggested that most respondents, even if they have the authority to prescribe antibiotics, rarely deem it necessary to do so. Conclusion: Findings of this study provide (1) clarity on the role of naturopathic doctors in the management of pediatric health concerns and the stewardship of antibiotics; and (2) initial guidance to less experienced naturopathic practitioners. The findings also identify key priorities for research into the safety and effectiveness of naturopathic interventions to reduce the unnecessary prescribing of antibiotics.

A healthy urinary tract contains a variety of microbes resulting in a diverse urobiome. Urobiome dysbiosis, defined as an imbalance in the microbial composition in the microenvironments along the urinary tract, is found in women with uncomplicated urinary tract infection (UTI). Historically, antibiotics have been used to address UTI. An alternative approach to uncomplicated UTI is warranted as the current paradigm fails to take urobiome dysbiosis into account and contributes to the communal problem of resistance. A whole-person, multi-modal approach that addresses vaginal and urinary tract dysbiosis may be more effective in reducing recurrent UTI. In this review, we discuss strategies that include reducing pathogenic bacteria while supporting commensal urogenital bacteria, encouraging diuresis, maintaining optimal pH levels, and reducing inflammation. Strategies for future research are suggested.

Introduction: Antibiotic overuse is a significant driver of bacterial resistance. Urinary tract infections (UTIs, cystitis) are the most common condition for which antibiotics are prescribed in the ambulatory setting. Many complementary and integrative approaches to cystitis have been proposed, including probiotics, D-mannose, and several herbal therapies. Trials comparing such therapies with placebo or antibiotics showed mixed, but promising, results. Naturopathy is a system of medicine that has potential to avoid antibiotic use for UTI because of its affinity for nonpharmacologic therapies and its theory that infection is a result of both the immune system's vulnerability and the pathogen's virulence. Methods: The authors conducted a retrospective chart review of cases treated at four naturopathic clinics in the Portland, OR, metro area, where naturopathic doctors (NDs) have a scope of practice consistent with their license as primary care providers. The primary aim was to characterize how NDs treat UTIs in a real-world setting. Secondary aims were to gather preliminary evidence on the types of patient cases receiving such treatments, outcomes of treatments, and associations between presentation and treatment prescriptions. Results: The authors found 82 distinct treatment regimens among 103 individual patients diagnosed with UTI. Most patients received a combination of herbal medicine and behavioral modification (e.g., increase fluid intake), whereas the most common monotherapeutic regimen was antibiotics. Of the 43 patients who were followed up, 15 had no success with nonpharmacologic therapies and required antibiotics. The sample was comparable with national data regarding composition of public versus private insurance, acute versus recurrent/chronic UTI, and percent of cases related to uropathogenic Escherichia coli. Conclusions: NDs practicing in a primary care context frequently prescribe antibiotic and nonantibiotic multimodal therapy for uncomplicated UTI. These results may guide future studies testing complementary and integrative therapies for uncomplicated UTI.

Luciano Garofalo, ND1,2; Joshua Corn, ND, MS1; Meghan Sperandeo, ND1...