Residents and Fellows’ Confidence in Prescribing Pre-exposure Prophylaxis (PrEP)

OBJECTIVE

Residents and fellows are often the first health.ßcare providers to discuss sexual health and prevention with adolescents and young adults at academic institutions. This study characterized when learners in Pediatrics, Obstetrics and Gynecology, and Family Medicine believed that one should receive training in pre-exposure prophylaxis (PrEP) and it described confidence in prescribing PrEP.

METHODS

Learners at a large, urban, southern academic center completed an online survey about adolescent sexual health services. Measures included whether participants were taught how to prescribe PrEP and how to do so in a confidential manner. Confidence in these two behaviors was measured with a Likert scale and dichotomized for bivariate analysis.

RESULTS

Among the 228 respondents (63% response rate), most learners preferred sexual health communication to be emphasized early in medical school and throughout training. Overall, 44% reported being ..únot confident at all..Ñ in prescribing PrEP, and 22% were ..únot confident at all..Ñ in prescribing in a confidential manner. Those who reported ..únot confident at all" in prescribing PrEP were more likely in pediatrics (51%) than family medicine (23%) or obstetrics-gynecology (35%) (P.ß<.ß.01). Those who had been taught how to prescribe were more confident in prescribing PrEP (P.ß..±.ß.01) and prescribing in a confidential manner (P.ß<.ß.01).

CONCLUSIONS

Given the continued high rates of new human immunodeficiency virus infections among adolescents, effective communication with patients eligible for PrEP is critical. Future studies should evaluate and inform tailored curricula about the importance of PrEP and build communication skills around confidential prescribing.

Medicaid expansion and provision of prescription contraception to Medicaid beneficiaries

INTRODUCTION

Medicaid expansion increased access to care, but longitudinal patterns of contraception use after the Medicaid expansion have not been described.

METHODS

We evaluated the effects of Medicaid expansion on the amount and type of contraceptive prescriptions using the Medicaid State Utilization Dataset.

RESULTS

Overall long-acting reversible contraception (LARC) use increased in both expansion and non-expansion states. In a difference-in-differences analysis, states that expanded Medicaid had no appreciable increase in per-capita prescription rates of LARC (p = 0.26) or short-acting hormonal contraception (p = 0.09) when compared to nonexpansion states.

DISCUSSION

The Medicaid expansion was not associated with a change in per-capita LARC or short-acting hormonal contraception use.

Reduction in mortality from upper gastrointestinal haemorrhage

A study of 2377 cases of haemorrhage from the upper gastrointestinal tract shows a significant fall in mortality rate--from 15.5% in the period of retrospective study from 1961 to 1970 to 7% in the prospective study from 1972 to 1982. The fall in mortality rate from non-variceal bleeding was from 12.8% to 5%. In the second five years of the prospective study, the total mortality rate was 5.8%, with 4.5% for non-variceal haemorrhage. This improvement occurred despite a significant rise in the proportion of patients of 60 years of age and over, and was particularly evident in patients with bleeding chronic gastric ulcers. There was also a significant reduction in mortality in the 60 years and over age group in the latter five years of the prospective study. The data suggest that there were three aspects of management which were important in the reduction of mortality. These were early fibreoptic endoscopic diagnosis, improved resuscitation and postoperative care, and early control of bleeding from oesophageal varices by balloon tamponade and surgery in selected cases. These complicated procedural aspects of management are best applied in a special unit for the treatment of patients with haemorrhage from the upper gastrointestinal tract. It is concluded that there has been significant progress in the treatment of this problem during the last decade.

The management of bleeding gastric ulcer: a prospective study

In a prospective study of six years' experience with a haematemesis and melaena unit from 1972 to 1978, there were 98 admissions of patients with bleeding gastric ulcer. There were ten deaths, giving a mortality of 11%. Forty-one patients were treated by emergency surgery with seven deaths, an operative mortality of 17%. All ten deaths occurred in the first four years; there were no deaths during the final two-year period (38 admissions). In retrospective studies at Prince Henry's Hospital, Melbourne, it was found that the mortality for bleeding gastric ulcer was 17% to 18% for the period 1951 to 1970. It is concluded that a prospective system of management with an active policy of early endoscopy and surgery and regular audit of results reduces the mortality from bleeding gastric ulcer.

Tinidazole in the prevention of wound infection after elective colorectal surgery

During the first six months of 1978, 71 patients were the subject of a controlled trial of the use of tinidazole for the prevention of wound infection after elective colonic surgery. The trial design was prospective, randomized and double-blind with tinidazole or placebo given at the last oral intake before operation. The objective endpoint of the trial was the presence or absence of wound infection manifested by pus. All patients underwent a standard preoperative preparation of bowel washouts, and a standardized surgical technique included, in all cases, the use of wound drainage. At the end of the trial there were three wound infections in 40 patients who were given tinidazole, and eleven wound infections in 31 patients who were given placebo. The difference in wound infection rate between these two groups is significant (x2 with Yates correction = 7.3; P less than 0.01).

Spironolactone and acute mountain sickness

Thirteen adults trekking in Nepal in 1974 to altitudes between 4,300 m and 5,500 m remained free from acute mountain sickness while taking spironolactone as a prophylactic measure. Two years previously five of these adults trekking at similar altitudes, but without treatment, had suffered from acute mountain sickness. The regime used was spironolactone in a dosage of 25 mg three times a day for two days preceding and during the periods spent at altitudes above 3,000 m.