Evaluating the WISE (Women in the South-East) Telehealth Network: A Model of Healthcare and Health Promotion at Rural Libraries

PURPOSE

The purpose of this study was to evaluate the effectiveness of the WISE (Women in the South-East) Telehealth Network.

DESIGN

A follow-up survey design was used to determine the impact of the program on access to healthcare.

SETTING

WISE provided preventive care to women and gender expansive people at local libraries and the Mobile Library in the rural South Carolina Lowcountry.

SUBJECTS

In 1 year (February 2021-2022), WISE reached 523 individuals with 151 agreeing to participate in the study. Most participants identified as white (66%) or Black (22%).

INTERVENTION

A Community Health Worker provided health education, connection to telehealth services, referrals, and connected individuals with community and social services.

MEASURES

The Telehealth Usability Questionnaire (TUQ), changes in knowledge, satisfaction with WISE, Acceptability of Intervention measure (AIM), and sociodemographic characteristics.

RESULTS

Participants with a high telehealth usability score were significantly more likely to be under the age of 35 (OR 4.60 [95% CI 1.21-17.52]), married (OR 10.00 [95% CI 2.19-45.64]), or white (OR 4.00 [95% CI 1.06-15.08]). The intervention earned a high acceptability score 4.46 (± .61)/5.0 by helping participants obtain necessary medical care and resources, as well as meeting their educational needs.

CONCLUSION

This study offers practical suggestions to expand the use of telehealth initiatives to improve health outcomes by engaging libraries in rural communities.

"Do you want a period?" Launching and evaluating a brief contraceptive decision-making educational intervention

OBJECTIVE

Do you want a period? empowers people who menstruate to better understand their reproductive health and contraceptive choices through informed patient-centered contraceptive decision-making.

METHODS

Researchers partnered with the WISE (Women in the South-East) Telehealth Network to design, implement and evaluate the Do you want a period? brief educational intervention. Participants completed a longitudinal research study, including a web-based survey at baseline and a mobile-optimized text-based survey up to 6 weeks following baseline.

RESULTS

Do you want a period? was believable (93%, n = 79), informative (89%, n = 76), and helpful (85%, n = 72). Participants who reported that the intervention was helpful were significantly more likely to be satisfied with the usefulness of information provided (OR 5.61 [95% CI 1.65-19.12]), the overall quality of services (OR 3.39 [95% CI 1.04-11.08)], and obtaining necessary medical care (OR 2.40 [95% CI 1.08-5.33)]. At longitudinal follow-up, participants who received contraceptive services reported high acceptability of intervention (4.51 (±0.53) out of 5).

CONCLUSIONS

Do you want a period? envisions a new dialogue between women and clinicians, family, and friends. This brief educational intervention supports people who menstruate to determine if a safe and effective tailored contraceptive regimen is right for them.

The remarkable journey of one female individual with ornithine transcarbamylase deficiency diagnosed post-mortem

Urea cycle disorders (UCDs) comprise a group of inborn errors of metabolism with impaired ammonia clearance and an incidence of ~1:35 000 individuals. First described in the 1970s, the diagnosis and management of these disorders has evolved dramatically. We report on a 59-year-old woman with a UCD who contributed to advances in the understanding and treatment of this group of disorders. This individual was diagnosed with carbamoyl phosphate synthetase 1 deficiency based on a biochemical assay under a research context predating genetic sequencing, treated longitudinally as having this metabolic disorder, and was among the first participants to trial UCD pharmaceutical therapies. She ultimately succumbed to a SARS-CoV-2 infection while maintaining unexpectedly normal ammonium levels. Postmortem genetic testing revealed ornithine transcarbamylase deficiency. This individual's contributions to the field of UCDs is discussed herein.

Improving feedback students receive on documentation during the obstetrics and gynecology clerkship

BACKGROUND

Students need feedback on written documentation to optimize their long-term development of this important clinical skill. The culture in surgical specialties does not always prioritize feedback regarding this skill.

OBJECTIVE

This study aimed to examine the effectiveness of 2 specific forms to improve the quantity and quality of feedback to students about their medical documentation.

STUDY DESIGN

In a multiphase quality improvement project, medical students were surveyed after the obstetrics and gynecology clerkship regarding their experience of receiving feedback on written notes. The proportions of students who received feedback on notes and those rating the feedback as meaningful were measured before and after the implementation of a required, formative feedback card. In phase 2, students were randomized to use a simplified feedback card or the original detailed card, and outcomes were compared. This study was conducted at the Medical University of South Carolina, a tertiary care academic medical center. The participants included third-year medical students that completed their 6-week obstetrics and gynecology clerkship.

RESULTS

Before the intervention, of 82 students, 70 (85%) and 55 (67%) received feedback on written notes in the inpatient and outpatient settings, respectively, which increased to 99.6% (254/255) and 98.5% (251/255) (P<.001) after the implementation of any feedback card. Moreover, the proportion of students who felt the feedback helped them improve their clinical documentation skills increased from 72% to 90% (P<.001) with the use of a feedback card. These improvements were noted in all clinical units within the clerkship. There was no difference (P=.3) in outcomes between the simplified and detailed cards.

CONCLUSION

A formative card is a simple, cost-effective, low-resource intervention that can increase both the quantity and quality of written note feedback that students receive during their obstetrics and gynecology clerkship. A less detailed card achieved comparable outcomes and increased faculty satisfaction.

Accelerated 3-Year MD Pathway Programs: Graduates' Perspectives on Education Quality, the Learning Environment, Residency Readiness, Debt, Burnout, and Career Plans

PURPOSE

To compare perception of accelerated and traditional medical students, with respect to satisfaction with education quality, and the learning environment, residency readiness, burnout, debt, and career plans.

METHOD

Customized 2017 and 2018 Medical School Graduation Questionnaires (GQs) were analyzed using independent samples t tests for means and chi-square tests for percentages, comparing responses of accelerated MD program graduates (accelerated pathway [AP] students) from 9 schools with those of non-AP graduates from the same 9 schools and non-AP graduates from all surveyed schools.

RESULTS

GQ completion rates for the 90 AP students, 2,573 non-AP students from AP schools, and 38,116 non-AP students from all schools in 2017 and 2018 were 74.4%, 82.3%, and 83.3%, respectively. AP students were as satisfied with the quality of their education and felt as prepared for residency as non-AP students. AP students reported a more positive learning climate than non-AP students from AP schools and from all schools as measured by the student-faculty interaction (15.9 vs 14.4 and 14.3, respectively; P < .001 for both pairwise comparisons) and emotional climate (10.7 vs 9.6 and 9.6, respectively; P = .004 and .003, respectively) scales. AP students had less debt than non-AP students (P < .001), and more planned to care for underserved populations and practice family medicine than non-AP students from AP schools (55.7% vs 33.9% and 37.7% vs 9.4%; P = .002 and < .001, respectively). Family expectations were a more common influence on career plans for AP students than for non-AP students from AP schools and from all schools (26.2% vs 11.3% and 11.7%, respectively; P < .001 for both pairwise comparisons).

CONCLUSIONS

These findings support accelerated programs as a potentially important intervention to address workforce shortages and rising student debt without negative impacts on student perception of burnout, education quality, or residency preparedness.

Association of Trust and Locus of Control with Postpartum Contraception Choice

Objective: In this study, we explored associations of trust in the healthcare system, health locus of control, and patient factors with choice of effective postpartum contraception. Methods: For this observational study, we measured trust in the healthcare system and health locus of control using validated scales. The primary outcome was postpartum contraceptive choice. We defined effective contraception as methods with failure rate ≤ 10%. We used bivariate and multivariate analyses to determine associated variables. Results: Neither trust in the healthcare system nor health locus of control were associated with effective contraceptive choice. Black women were more likely to report choice of effective contraception compared to white women (OR = 4.26, 95% CI 1.43, 12.68). Choice of effective contraception did not differ between women who intended to become pregnant again in less than 2 years versus greater than 2 years although women with no desire for future pregnancy were more likely to choose effective methods (OR = 4.78, 95% CI 1.56, 14.64). Conclusions: Neither trust nor health locus of control were associated with choice of effective postpartum contraception. The increased likelihood of effective post-partum contraception in black women suggests coercion and bias in counseling and provision.

Prevalence of early discontinuation and associated factors among a retrospective cohort of etonogestrel contraceptive implant users

Purpose: To characterise the frequency of and predictors of contraceptive implant discontinuation within 12 months of insertion in our clinical setting.Materials and methods: This retrospective cohort study included women receiving the etonogestrel contraceptive implant at our hospital between May 2007 and May 2012. We abstracted data from charts including implant removal date, bleeding complaints, reproductive and demographic characteristics, prior contraceptive use, tobacco use and implant insertion timing. Our primary outcome was implant discontinuation within 12 months following insertion. SAS 9.4 (SAS Institute Inc., Cary, NC, USA) was used to generate frequencies, bivariate analyses and multivariate logistic regression models.Results: Implant discontinuation was documented in 16% of implant users prior to 12 months (89/544). Women with documented bleeding complaints in the medical record were more likely to discontinue within 12 months (OR: 4.36, CI: 2.71, 7.00). No other demographic or clinical characteristics were associated with premature discontinuation. Having less than two prior pregnancies and tobacco use were associated with documented bleeding complaints.Conclusions: Discontinuation of the implant is associated with bleeding complaints. Women with lower parity and tobacco users may be more likely to experience bleeding or to find it intolerable.

Wikipedia Editing Courses at Three US Medical Schools in the 2017-2018 Academic Year

This article was migrated. The article was marked as recommended. Introduction: Most medical students use Wikipedia, yet most medical schools do not train students to improve Wikipedia or use it critically. Methods: During academic year 2017 - 2018, the University of California San Francisco School of Medicine, Medical University of South Carolina & University of Central Florida College of Medicine offered credit-bearing Wikipedia-editing courses to 4th year medical students. We sought to assess student experiences across these schools and courses. Results: 78 students participated in the courses, making 3,368 edits, adding 155,100 words to 71 health-related Wikipedia pages. Collectively student contributions were viewed 2,688,500 times (37,866/page) during active dates of each course. Feedback from the 18 students who completed our study survey (23% response rate) reflected that students 1) increased their perception on Wikipedia reliability, 2) increased their ability to practice evidence based medicine, 3) were positively inclined to encourage peers to also edit Wikipedia, and 4) desired to contribute to public good. All students felt they improved their respective articles, and all but one felt that editing Wikipedia was a good investment in the future of healthcare. Despite our low response rate, qualitative comments suggest several students felt their courses impacted their professional identity as future physicians. Conclusions: We encourage the implementation of similar Wikipedia-editing courses across all health professional schools. Study replication will help clarify generalizability of these findings. Standardizing outcome metrics (e.g. impact on students, impact on Wikipedia quality, and impact on readers of Wikipedia) will allow more robust assessment of the impact of Wikipedia-editing courses and assignments across health professional schools globally.

Postpartum LARC discontinuation and short interval pregnancies among women with HIV: a retrospective 9-year cohort study in South Carolina

OBJECTIVES

To evaluate rates of discontinuation and short interval pregnancy among women with HIV who received a postpartum IUD or implant.

METHODS

We conducted a retrospective cohort study of women who had an IUD or implant placed within 3 months postpartum during a 9-year period (1/1/09 to 2/14/18). We assessed the prevalence of discontinuation within 12 months and rates of subsequent delivery within 18 months. We examined differences in these outcomes between women with and without HIV.

RESULTS

Of the 794 women who received a long-acting reversible contraception (LARC) within 3 months postpartum, most chose an IUD (85%). Twenty-one percent (165) elected for immediate postpartum placement: 119 IUDs and 46 implants. Women with HIV were more likely to receive an implant (48% vs 13%, p<.0001) and were more likely to have immediate postpartum placement (76% vs 17%, p<.0001). Women with HIV (n=50) were not more likely to remove LARC devices within 12 months of placement (38% vs 36%, p=.9), and they did not experience any short interval pregnancies.

CONCLUSIONS

Women with HIV in South Carolina were more likely than HIV-negative women to receive immediate postpartum LARC and to receive an implant. They were not more likely to discontinue LARC within 12 months nor experience short interval pregnancies.

IMPLICATIONS

Further study is needed to evaluate preferences for implants and immediate postpartum insertion among women with HIV.

"My Body. My Choice": A Qualitative Study of the Influence of Trust and Locus of Control on Postpartum Contraceptive Choice

Postpartum contraception helps reduce unintended pregnancy and space births to improve maternal and child health. This study explored women's perceptions of contraceptive choice during the postpartum period in the context of locus of control and trust in healthcare providers. Researchers conducted six focus groups with 47 women, ages 18-39, receiving postpartum care at an outpatient clinic. Techniques from grounded theory methodology provided an inductive approach to analysis. HyperRESEARCH 3.5.2 qualitative data analysis software facilitated a constant-comparative coding process to identify emergent themes. Participants expressed a preference for relationship-centered care, in which healthcare providers listened, individualized their approach to care through rapport-building, and engaged women in shared decision-making about contraceptive use through open communication, reciprocity, and mutual influence. Conflicting health messages served as barriers to uptake of effective contraception. While participants trusted their healthcare provider's advice, many women prioritized personal experience and autonomy in decisions about contraception. Providers can promote trust and relationship-centered care to optimize contraceptive uptake by listening, exploring patient beliefs and preferences about contraception and birth spacing, and tailoring their advice to individuals. Results suggest that antenatal contraceptive counseling should incorporate information about effectiveness, dispel misconceptions, and engage patients in shared decision-making.

The governing body nurse as a clinical commissioning group nurse leader

Aim The aim of this study was to understand governing body nurses' perspective of their effect on, and leadership of, clinical commissioning groups (CCGs). Method Semi-structured face-to-face and telephone interviews were conducted with a sample of governing body nurses, CCG chairs and regional chief nurses. A total of 23 individuals were interviewed. Findings Governing body nurses were overwhelmingly positive about their role and believed they had a positive effect on the CCG governing body. Specifically, they provided leadership for the quality agenda and compassionate practice. Challenges experienced by some governing body nurses related to their capacity to undertake the role where this was on a part-time basis, time restraints and difficulties working with colleagues. Conclusion The role of the governing body nurse was not well defined when it was introduced, and as a result its development across CCGs has varied. Governing body nurses have used their leadership skills to advance important agendas for their profession, such as workforce redesign, new integrated care pathways and co-commissioned services.

Vaginal estrogen supplementation during Depo-Provera initiation: a randomized controlled trial

BACKGROUND

Irregular bleeding is often cited as the reason for discontinuation of depot-medroxyprogesterone acetate (DMPA) after the first injection. Estrogen supplementation during DMPA initiation may decrease bleeding and improve continuation.

STUDY DESIGN

This prospective, randomized, controlled trial evaluated estrogen supplementation during DMPA initiation. Women initiating DMPA were randomized to receive an estradiol vaginal ring for 3 months versus DMPA alone. Bleeding diaries and questionnaires at three and 6 months assessed bleeding, continuation and ring acceptability.

RESULTS

Seventy-one participants enrolled; 49 completed the first follow-up period. The median number of bleeding or spotting days was 16 in the estrogen ring group (n=26) versus 28 in the DMPA alone group (n=23) (p=.19). Seventy-seven percent of the intervention group received a second injection compared with 70% in the DMPA alone group (p=.56). For each additional day of bleeding and/or spotting reported, women were 3% less likely to receive a second injection (OR 0.97, 95% CI 0.94-0.99). Acceptability of the vaginal ring was high among those in the intervention group.

CONCLUSIONS

Vaginal estrogen supplementation during DMPA initiation is acceptable to women and may decrease total bleeding.

Medical management of early pregnancy failure: how to treat and what to expect

Medical management is gaining acceptance as a treatment option for women with early pregnancy failure (EPF). We reviewed randomized trials comparing misoprostol for EPF with surgical (dilation and curettage) or expectant management. Overall, approximately 85% of women with EPF can expect complete uterine evacuation after one or two doses of 600 or 800 microg misoprostol without surgery. Medical management is safe. As with surgical therapy, serious complications are rare. Women undergoing medical management of EPF may expect moderate pain and bleeding for several days, which may persist for 2 weeks or longer. Side effects associated with misoprostol are common; however, acceptability of medical management remains high.

Blood-based biomarkers for detecting mild osteoarthritis in the human knee

OBJECTIVE

This study was designed to test the utility of a blood-based approach to identify mild osteoarthritis (OA) of the knee.

METHODS

Blood samples were drawn from 161 subjects, including 85 subjects with arthroscopically diagnosed mild OA of the knee and 76 controls. Following RNA isolation, an in-house custom cDNA microarray was used to screen for differentially expressed genes. A subset of selected genes was then tested using real-time RT-PCR. Logistic regression analysis was used to evaluate linear combinations of the biomarkers and receiver operating characteristic curve analysis was used to assess the discriminatory power of the combinations.

RESULTS

Genes differentially expressed (3543 genes) between mild knee OA and control samples were identified through microarray analysis. Subsequent real-time RT-PCR verification identified six genes significantly down-regulated in mild OA: heat shock 90kDa protein 1, alpha; inhibitor of kappa light polypeptide gene enhancer in B-cells, kinase complex-associated protein; interleukin 13 receptor, alpha 1; laminin, gamma 1; platelet factor 4 (also known as chemokine (C-X-C motif) ligand 4) and tumor necrosis factor, alpha-induced protein 6. Logistic regression analysis identified linear combinations of nine genes--the above six genes, early growth response 1; alpha glucosidase II alpha subunit; and v-maf musculoaponeurotic fibrosarcoma oncogene homolog B (avian)--as discriminatory between subjects with mild OA and controls, with a sensitivity of 86% and specificity of 83% in a training set of 78 samples. The optimal biomarker combinations were then evaluated using a blind test set (67 subjects) which showed 72% sensitivity and 66% specificity.

CONCLUSIONS

Linear combinations of blood RNA biomarkers offer a substantial improvement over currently available diagnostic tools for mild OA. Blood-derived RNA biomarkers may be of significant clinical value for the diagnosis of early, asymptomatic OA of the knee.

Cardiac genes and gene databases for cardiovascular disease genetics

Genes play a very important role in the etiology of hypertension. This paper reviews the current pool of candidate genes for human hypertension. Some of the genes studied in rat models of hypertension are also discussed. The methods for studying the genetics of hypertension are reviewed. A discussion of the role of cardiac gene libraries and gene databases in the characterization of cardiovascular disease is also included. This review is concluded by a discussion on the future role of genomics and cardiovascular gene databases in medical research.

Split-thickness skin graft donor sites

An update on management from pre-operative preparation of donor site skin for grafting to post-operative care of the wound

Construction of a human heart cDNA library and identification of cardiovascular based genes (CVBest)

The availability of high quality cDNA libraries is often crucial to the successful identification and characterization of genes. The concepts and potential pitfalls of constructing cDNA libraries are presented. Various applications requiring high quality cDNA libraries are outlined, including large-scale single pass sequencing of cDNA clones to generate expressed sequence tags (ESTs) and differential screening of cDNA libraries. The usefulness of combining such approaches for the discovery of novel disease-related and cardiovascular-based ESTs (CVBest) is discussed.

A modular domain of NifU, a nitrogen fixation cluster protein, is highly conserved in evolution

hnifU, a gene exhibiting similarity to nifU genes of nitrogen fixation gene clusters, was identified in the course of expressed sequence tag (EST) generation from a human fetal heart cDNA library. Northern blot of human tissues and polymerase chain reaction (PCR) using human genomic DNA verified that the hnifU gene represented a human gene rather than a microbial contaminant of the cDNA library. Conceptual translation of the hnifU cDNA yielded a protein product bearing 77% and 70% amino acid identity to NifU-like hypothetical proteins from Haemophilus influenzae and Saccharomyces cerevisiae, respectively, and 40-44% identity to the N-terminal regions of NifU proteins from several diazatrophs (i.e., nitrogen-fixing organisms). Pairwise determination of amino acid identities between the NifU-like proteins of nondiazatrophs showed that these NifU-like proteins exhibited higher sequence identity to each other (63-77%) than to the diazatrophic NifU proteins (40-48%). Further, the NifU-like proteins of non-nitrogen-fixing organisms were similar only to the N-terminal region of diazatrophic NifU proteins and therefore identified a novel modular domain in these NifU proteins. These findings support the hypothesis that NifU is indeed a modular protein. The high degree of sequence similarity between NifU-like proteins from species as divergent as humans and H. influenzae suggests that these proteins perform some basic cellular function and may be among the most highly conserved proteins.

Labour: when to worry

To ensure an optimum result in pregnancy it is essential that the physician be alert in the antenatal period to recognize those women and their babies who are at risk during labour. Premature labour, with its attendant risk of respiratory distress syndrome in the newborn, continues to be an important factor in perinatal morbidity and mortality. Early recognition of predisposing factors and the judicious use of myometrial inhibiting agents have helped to reduce the incidence of fetal prematurity in these cases. A long interval between rupture of the membranes and delivery continues to be a danger to both mother and fetus. Delivery is recommended when gestation is beyond 36 weeks or when there are signs of incipient infection, and once labour has begun antibiotics should be used prophylactically. Failure of labour to progress should be recognized and managed aggressively in its early stages. Amniotomy and oxytocin infusion have reduced considerably the incidence of prolonged labour and its risks to both mother and fetus. The role of intrapartum monitoring of the fetal heart rate, measurement of the pH in the fetus's scalp blood and assessment of amniotic fluid is discussed, as is the monitoring of maternal well-being.

Graphic monitoring of labour

The parturograph is a composite record designed for the monitoring of fetal and maternal well-being and the progress of labour. It permits the early recognition of abnormalities and pinpoints the patients who would benefit most from intervention. Observations are made from the time of admission of the mother to the caseroom and recorded graphically. Factors assessed include fetal heart rate, maternal vital signs and urine, cervical dilatation, descent of the presenting fetal part, and frequency, duration and intensity of uterine contractions.