Recent Publications by CFE Educators

OBJECTIVE

To determine whether integrating family planning services into HIV care is associated with increased use of more effective contraceptive methods (sterilization, intrauterine device, implant, injectable or oral contraceptives).

DESIGN

Cluster-randomized trial.

SETTING

Eighteen public HIV clinics in Nyanza Province, Kenya.

PARTICIPANTS

Women aged 18-45 years receiving care at participating HIV clinics; 5682 clinical encounters from baseline period (December 2009-February 2010) and 12,531 encounters from end-line period (July 2011-September 2011, 1 year after site training).

INTERVENTION

Twelve sites were randomized to integrate family planning services into the HIV clinic, whereas six clinics were controls where clients desiring contraception were referred to family planning clinics at the same facility.

MAIN OUTCOME MEASURES

Increase in use of more effective contraceptive methods between baseline and end-line periods. Pregnancy rates during the follow-up year (October 2010-September 2011) were also compared.

RESULTS

Women seen at integrated sites were significantly more likely to use more effective contraceptive methods at the end of the study [increased from 16.7 to 36.6% at integrated sites, compared to increase from 21.1 to 29.8% at controls; odds ratio (OR) 1.81, 95% confidence interval (CI) 1.24-2.63]. Condom use decreased non-significantly at intervention sites compared to controls (OR 0.64, 95% CI 0.35-1.19). No difference was observed in incident pregnancy in the first year after integration comparing intervention to control sites (incidence rate ratio 0.90; 95% CI 0.68-1.20).

CONCLUSIONS

Integration of family planning services into HIV care clinics increased use of more effective contraceptive methods with a non-significant reduction in condom use. Although no significant reduction in pregnancy incidence was observed during the study, 1 year may be too short a period of observation for this outcome.

OBJECTIVE

To evaluate costs, cost-efficiency and cost-effectiveness of integration of family planning into HIV services.

INTERVENTION

Integration of family planning services into HIV care and treatment clinics.

DESIGN

A cluster-randomized trial.

SETTING

Twelve health facilities in Nyanza, Kenya were randomized to integrate family planning into HIV care and treatment; six health facilities were randomized to (nonintegrated) standard-of-care with separately delivered family planning and HIV services.

MAIN OUTCOME MEASURES

We assessed costs, cost-efficiency (cost per additional use of more effective family planning), and cost-effectiveness (cost per pregnancy averted) associated with the first year of integration of family planning into HIV care. More effective family planning methods included oral and injectable contraceptives, subdermal implants, intrauterine device, and female and male sterilization.

PATIENTS AND PARTICIPANTS

We collected cost data through interviews with study staff and review of financial records to determine costs of service integration.

RESULTS

Integration of services was associated with an average marginal cost of $841 per site and $48 per female patient. Average overall and marginal costs of integration were associated with personnel costs [initial ($1003 vs. $872) and refresher ($498 vs. $330) training, mentoring ($1175 vs. $902) and supervision ($1694 vs. $1636)], with fewer resources required for other fixed ($18 vs. $0) and recurring expenses ($471 vs. $287). Integration was associated with a marginal cost of $65 for each additional use of more effective family planning and $1368 for each pregnancy averted.

CONCLUSION

Integration of family planning and HIV services is feasible, inexpensive to implement, and cost-efficient in the Kenyan setting, and thus supports current Kenyan integration policy.

PURPOSE

As third-year medical students rotate between clerkships, they experience multiple transitions across workplace cultures and shifting learning expectations. The authors explored clerkship transitions from the students' perspective by examining the advice they passed on to their peers in preparation for new clerkships.

METHOD

Seventy-one students from three Veterans Affairs-based clerkship rotations at the University of California, San Francisco, School of Medicine participated in a peer-to-peer handoff session from 2008 to 2011. In the handoff session, they gave tips for optimizing performance to students starting the clerkship they had just completed. The authors transcribed student comments from four handoff sessions and used qualitative content analysis to identify and compare advice across clerkships.

RESULTS

Students shared advice about workplace culture, content learning, logistics, and work-life balance. Common themes included expectations of the rotation, workplace norms, specific tasks, learning opportunities, and learning strategies. Comments about patient care and work-life balance were rare. Students emphasized different themes for each clerkship; for example, for some clerkships, students commented heavily on tasks and content learning, while in another students focused on workplace culture and exam preparation.

CONCLUSIONS

These findings characterize the transitions that third-year students undergo as they rotate into new clinical training environments. Students emphasized different aspects of each clerkship in the advice they passed to their peers, and their comments often describe informal norms or opportunities that official clerkship orientations may not address. Peer-to-peer handoffs may help ease transitions between clerkships with dissimilar cultures and expectations.

PURPOSE

A variety of clinical and imaging findings are used by clinicians to determine utility of renal angioembolization (AE) in managing renal trauma. Our purpose was to investigate specific criteria that clinicians who manage high-grade renal trauma (HGRT) utilize in decision-making for primary or delayed AE.

METHODS

A total of 413 urologists and interventional radiologists (IRs) who practice at level 1 or 2 trauma centers within the United States were provided an original survey via email on experience and opinions regarding the utility of AE for HGRT. We described overall practice patterns and assessed differences by clinician type, using the Fisher's exact test.

RESULTS

A total of 79 (20 %) clinicians completed the survey. All clinicians had AE capability for HGRT management. A higher proportion of IRs reported using AE for grade I-II (33 vs. 3 %, p = 0.002), grade III (65 vs. 26 %, p = 0.001), and penetrating injuries (83 vs. 58 %, p = 0.02). A greater proportion of urologists reported using AE for grade V injuries (81 vs. 56 %, p = 0.03). Clinicians most commonly cited computed tomography evidence of active arterial bleeding (97 %), or arteriovenous fistula/pseudoaneurysm (94 %) as indications for primary AE, and 62 % identified concurrent visceral injury as factor that would necessitate surgical intervention.

CONCLUSION

In a survey of clinicians, we report that IRs and urologists utilize AE differently when managing HGRT, as a higher proportion of IRs use AE to manage lower grade as well as penetrating injuries. Validation studies are needed to establish algorithms to identify patients with HGRT who would benefit from selective renal AE.

Recent genome-wide association studies (GWAS) have identified multiple genetic risk factors for psoriasis, but data on their association with age of onset have been marginally explored. The goal of this study was to evaluate known risk alleles of psoriasis for association with age of psoriasis onset in three well-defined case-only cohorts totaling 1,498 psoriasis patients. We selected 39 genetic variants from psoriasis GWAS and tested these variants for association with age of psoriasis onset in a meta-analysis. We found that rs10484554 and rs12191877 near HLA-C and rs17716942 near IFIH1 were associated with age of psoriasis onset with false discovery rate 0.05. The association between rs17716942 and age of onset was not replicated in a fourth independent cohort of 489 patients (P = 0.94). The imputed HLA-C∗06:02 allele demonstrated a much stronger association with age of psoriasis onset than rs10484554 and rs12191877. We conclude that despite the discovery of numerous psoriasis risk alleles, HLA-C∗06:02 still plays the most important role in determining the age of onset of psoriasis. Larger studies are needed to evaluate the contribution of other risk alleles, including IFIH1, to age of psoriasis onset.

OBJECTIVES

(1) Determine procedure-specific rates of postdischarge complications (PDCs) and their risk factors in the first 30 days following inpatient otolaryngologic surgery. (2) Evaluate association between PDCs and risk of reoperation and mortality.

STUDY DESIGN

Retrospective cohort study.

SETTING

American College of Surgeons National Surgical Quality Improvement Program (2005-2011).

SUBJECTS AND METHODS

We identified 48,028 adult patients who underwent inpatient otolaryngologic surgery. Outcomes of interest included complications, reoperation, and mortality in the first 30 days following surgery. Statistical analysis included chi-square, t tests, and multivariate regression.

RESULTS

Laryngectomy, lip, and tongue/floor of mouth surgery had the highest PDC rates (8.0%, 7.4%, and 4.1%, respectively). Within the first 48 hours, week, and 2 weeks post discharge, 10%, 44%, and 73% of PDCs occurred, respectively. Common PDCs included surgical site infections (53.6%), other infections (37.4%), and venous thromboembolic events (7.4%). Multivariate analysis demonstrated that increasing age (odds ratio [OR] = 1.01; 95% confidence interval [CI], 1.01-1.02), prolonged operative time (OR = 1.68; 95% CI, 1.39-2.03), hospital stay >1 day (OR = 1.49; 95% CI, 1.18-1.86), and American Society of Anesthesiologists (ASA) class ≥ 3 (OR = 1.45; 95% CI, 1.18-1.78) were independently associated with PDCs. Patients with PDCs were more likely to die (0.9% vs 0.1%, P .001) or have a reoperation (10.4% vs 1.2%, P .001).

CONCLUSION

This is the first study of overall postdischarge events after otolaryngologic surgery. PDC rates in otolaryngology occur soon after discharge, are procedure specific, and are associated with reoperation and mortality. Targeted procedure-specific triage and follow-up plans for high-risk patients may improve outcomes.

BACKGROUND

Many of India's estimated 40 million migrant workers in the construction industry migrate with their children. Though India is undergoing rapid economic growth, numerous child protection issues remain. Migrant workers and their children face serious threats to their health, safety, and well-being. We examined risk and protective factors influencing the basic rights and protections of children and families living and working at a construction site outside Delhi.

METHODS

Using case study methods and a rights-based model of child protection, the SAFE model, we triangulated data from in-depth interviews with stakeholders on and near the site (including employees, middlemen, and managers); 14 participants, interviews with child protection and corporate policy experts in greater Delhi (8 participants), and focus group discussions (FGD) with workers (4 FGDs, 25 members) and their children (2 FGDs, 9 members).

RESULTS

Analyses illuminated complex and interrelated stressors characterizing the health and well-being of migrant workers and their children in urban settings. These included limited access to healthcare, few educational opportunities, piecemeal wages, and unsafe or unsanitary living and working conditions. Analyses also identified both protective and potentially dangerous survival strategies, such as child labor, undertaken by migrant families in the face of these challenges.

CONCLUSIONS

By exploring the risks faced by migrant workers and their children in the urban construction industry in India, we illustrate the alarming implications for their health, safety, livelihoods, and development. Our findings, illuminated through the SAFE model, call attention to the need for enhanced systems of corporate and government accountability as well as the implementation of holistic child-focused and child-friendly policies and programs in order to ensure the rights and protection of this hyper-mobile, and often invisible, population.

Using data from a socioeconomically diverse sample of Chinese American children (n = 258, aged 6-9 years) in immigrant families, we examined the concurrent relations among neighborhood economic disadvantage and concentration of Asian residents, parenting styles, and Chinese American children's externalizing and internalizing problems. Neighborhood characteristics were measured with 2000 U.S. Census tract-level data, parents (mostly mothers) rated their own parenting styles, and parents and teachers rated children's behavioral problems. Path analysis was conducted to test two hypotheses: (a) parenting styles mediate the relations between neighborhood characteristics and children's behavioral problems, and (b) children's behavioral problems mediate the relations between neighborhood and parenting styles. We found that neighborhood Asian concentration was positively associated with authoritarian parenting, which in turn was associated with Chinese American children's higher externalizing and internalizing problems (by parents' reports). In addition, neighborhood economic disadvantage was positively related to children's externalizing problems (by parents' reports), which in turn predicted lower authoritative parenting. The current results suggest the need to consider multiple pathways in the relations among neighborhood, family, and child adjustment, and they have implications for the prevention and intervention of behavioral problems in Chinese American children.

BACKGROUND

Tall cell variant (TCV) and diffuse sclerosing variant (DSV) of papillary thyroid cancer are aggressive subtypes, for which tumors ≤1 cm have not been exclusively studied.

METHODS

The SEER database (1988-2009) was used to compare characteristics of TCV ≤1 cm (mTCV) and DSV ≤1 cm (mDSV) with classic papillary thyroid microcarcinoma (mPTC). Survival was analyzed with the Kaplan-Meier method and log-rank test, and risk factors for nodal metastases with chi-square analysis and binary logistic regression.

RESULTS

There were 97 mTCV, 90 mDSV, and 18,260 mPTC patients. mTCV incidence increased by 79.9% (p=0.153) over the study period, while mDSV incidence decreased by 10.3% (p=0.315). Compared to classic mPTC, mTCV tended to be larger on average (7.1 mm vs. 5.3 mm, p0.001), with higher rates of multifocality (47.2% vs. 34.0% respectively, p=0.018) and lymph-node examination (63.9% vs. 39.2% respectively, p0.001), while in mDSV, nodal metastases were more frequent (57.1% vs. 33.1% respectively, p=0.007). Both aggressive variants had higher rates of extrathyroidal extension (27.8% mTCV vs. 13.3% mDSV vs. 6.1% mPTC, p0.001). Aggressive variants also received radioactive iodine more frequently (39.2% mTCV vs. 40.0% mDSV vs. 29.1% mPTC, p0.001). However, they were not statistically more likely to receive thyroidectomy over lobectomy compared to classic mPTC. There were no significant differences in overall and disease-specific survival between the histologies. In mTCV, after adjustment, extrathyroidal extension was independently associated with size >7 mm (odds ratio (OR) 4.4 [CI 1.5-13.6]) and nodal metastasis with multifocality (OR 5.4 [CI 1.3-23.4]) and extrathyroidal extension (OR 5.8 [CI 1.3-25.4]). No statistically significant predictors of extrathyroidal extension or nodal metastasis in mDSV were observed.

CONCLUSIONS

Aggressive variants of mPTC tend to exhibit more aggressive pathologic characteristics than classic mPTC, but survival appears to be similar. Treatment with total thyroidectomy and central lymphadenectomy may be warranted if the diagnosis can be made pre- or intraoperatively.