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Intimate partner violence (IPV) has harmful effects on women's physical, mental, and reproductive health. This study investigates the relationship between experiencing IPV and unmet need for family planning in two provinces of the Democratic Republic of the Congo (DRC), emphasizing the potential mediating effect of reproductive coercion. To our knowledge, this is the first examination of the connection between IPV and unmet need for family planning in the DRC, particularly regarding the underlying mechanisms of this association. This research utilized secondary data from the third wave of the Performance Monitoring for Action (PMA) surveys carried out in two provinces of the DRC during the period from 2021 to 2022. The analysis focused on a sample comprising 1,387 women in unions aged between 15 and 49 years. To investigate the relationship between IPV and unmet need for family planning, linear probability models were employed and various factors were controlled. Additionally, we explored the moderating influence of reproductive coercion in this context. The linear probability model indicated that experiencing sexual IPV within the past 12 months was linked to an unmet need for family planning [aCoef = 0.12, CI95% = 0.04-0.21]. When sexual IPV occurred alongside reproductive coercion, a stronger correlation with unmet need was detected [aCoef = 0.24, CI95% = 0.03-0.44]. We showed that sexual IPV is associated with an unmet need for family planning in the DRC. While IPV should be considered a policy target, these results emphasize the importance of responding appropriately to IPV when sexual and reproductive health services are provided to women. This was the first study on the DRC and, more generally, on sub-Saharan Africa (SSA) to illuminate the underlying mechanisms of the association, revealing the moderating role of reproductive coercion.
In the last 2 decades, transcatheter aortic valve replacement (TAVR) has become widely adopted for the treatment of aortic valve stenosis, and prosthetic valve embolization (PVE) is one of the rarely reported, but often catastrophic, complications of this procedure. The authors performed an updated systematic review of contemporary studies to determine the prevalence of post-TAVR PVE and its associated risk factors. A systematic search was conducted in multiple databases for all relevant published studies from 2014 to August 2024. Studies reporting on embolization were included. Data extracted encompassed participants' characteristics, study characteristics, and clinical outcomes. Pooled event rates were calculated using the random effects method. In the final analysis, 34 studies reported 501 cases of device embolization, of which 50% were male with a mean age of 80.7 ± 3.16 years while the other 50% were female. The rate of PVE was 1.4%. About 80% of the embolization occurred in the intraprocedural period, with 61% of the embolized valves requiring surgical treatment. The prevalence of embolization across included studies was 1.4%, with most embolization occurring during the procedure. The chance of mortality is significantly heightened at about 18% to 20% at 30 days and ~30% at 1 year in some series, compared with much lower baseline rates for uncomplicated TAVR. Prosthetic valve embolization complicates TAVR procedures, increasing procedural complexity, with over 50% of instances resulting in conversion to surgical intervention. Given that this complication is rare (~1%), the overall risk is low in the general TAVR population, but for the individual, it is serious and warrants aggressive management.
Multiple publications have shown that there is gender-based discrimination in surgery, aimed against surgeons who are women. The authors theorize that it was not due to a difference in clinical competence, but due to implicit bias: a subconscious prejudice that traditionally assigned women to homemaker roles. The authors designed this study to determine whether gender discrimination was due to implicit bias or a quantifiable difference in clinical competence. This questionnaire study investigated prevailing attitudes among a professional association of surgeons in the Anglophone Caribbean. The authors collected data on gender discrimination and 4 parameters as proxies for clinical competence: judgment, thoroughness, surgical skill, and task completion. The SPSS version 20 was used to perform statistical analyses. A total of 140 questionnaires were distributed and 95 (68%) respondents observed gender discrimination in the workplace, with surgeons who are women significantly more likely to be victims of discrimination (64.2% vs 4.2%; z -8.7165; P < .0001). There was no difference between genders in clinical judgment nor surgical skill. There was a significant difference in thoroughness (47.4% vs 2.1%; P < .0001) and task completion (60% vs 24.2%; P < .0001), favoring surgeons who are women. Gender discrimination is still prevalent in surgical disciplines as the second quarter of the 21st century begins. The authors have demonstrated that surgeons who are women are substantially more likely to be the victims, likely due to implicit gender bias. The surgical community must address this urgently, because impeding full participation by women creates the chance for undermining the expansion of the workforce needed for the next generations' surgical care.
Chronic kidney disease (CKD) affected > 35 million US adults in 2023. Effective therapies exist to reduce CKD progression and risk of cardiovascular events. However, whether population-level management strategies are effective is not known. The authors evaluated a program that proactively identified and referred high-risk patients to a structured CKD management approach aimed at improving guideline-direct care. Within a large, integrated health care delivery system, the authors enrolled adults with high-risk CKD identified from electronic health records between June 2021 and March 2022 who were not receiving nephrology care into a structured CKD management program based on a multidisciplinary, nephrologist-led model of care. These patients were compared to a matched cohort of high-risk patients with CKD receiving usual care. The authors evaluated feasibility and differences in targeted process measures over a 3-month follow-up period. Among 120 eligible patients with CKD enrolled in the program and 120 matched patients with CKD receiving usual care, mean (standard deviation) age was 73.9 (8.4) years, 57.8% were women, and demographic characteristics and comorbidity burden were well matched. Despite the COVID-19 pandemic, implementing the structured CKD management program was feasible. During the 3-month follow-up period, those enrolled in the CKD management program experienced a higher rate of estimated glomerular filtration (58% vs 43%, P = .02) and urinary protein (38% vs 11%, P < .0001) testing. Proactive referral to structured CKD management was feasible and led to increased short-term surveillance of kidney function. Future studies should assess whether engagement at earlier stages of CKD and longer systematic care and follow-up can improve outcomes and inform broader implementation of population-level CKD management strategies.
This national survey of clinically inactive physicians was conducted to identify the factors driving early exit from the clinical physician workforce in the United States, aiming to evaluate characteristics and motivations for leaving early. A sample of clinically inactive physicians drawn from American Medical Association Physician Professional Data™ completed a survey between May and June 2024, with questions assessing demographics, education, clinical training, and reasons for leaving clinical practice. In addition to standard descriptive statistics, gender differences were also explored. Among the 971 respondents included in the analysis, the majority (63.9%) identified as women, the mean age was 45.8 years, and 11.0% had never practiced after graduate medical education. The physicians who left practice reported "hassle factor" (44.7%) and "too stressful" (44.5%) as prime motivators for their departure. Physicians who were women were more likely than men to have exited due to needing to care for family members (7.9% vs 0.6%, P < .001) or children (21.3% vs 4.2%, P < .001). The mean age of physicians who left clinical practice was 48.1 years, 9 years younger than observed in a similar cohort in 2008. This study suggests that physicians who have left practice early have had shorter clinical careers than in the past. Interventions to reduce "hassle factor" and workplace stress may address the motivations for leaving practice. Understanding early attrition from clinical practice may improve interventions in sustaining the physician workforce. Specifically, further study is needed for women physicians who were fully trained but never entered clinical practice, as these groups will likely contribute an outsized effect on the magnitude of the workforce shortage.
Trauma-informed care (TIC) provides a framework for understanding and mitigating trauma's impact on health. Integrating TIC principles into medical school education equips physicians with the skills necessary for delivering compassionate, patient-centered care. A survey regarding experiences with TIC education was emailed to medical students and faculty at the University of Oklahoma College of Medicine. Qualitative and standard quantitative analysis of the results was performed. A significant majority of faculty (83.7%) and students (92.5%) recognized the relevance of TIC to clinical practice. However, only 37.0% of faculty reported incorporating TIC into their teaching. Despite its acknowledged importance, only 20.4% of students felt satisfied with how TIC was taught. On a Likert scale of 1-5, students reported a comfort level of 1-2 for trauma-informed screenings (31.5%) and physical examinations (62.9%). Proposed solutions to increase TIC education included the implementation of longitudinal curricula, workshops, and conversations about trauma when interacting with patients. TIC is perceived as relevant to medical education and practice among students and faculty. However, its integration into the undergraduate medical education curriculum is sporadic. Although certain courses incorporate TIC, a cohesive teaching approach throughout the curriculum is lacking. There is uncertainty among faculty regarding the definition of TIC and what aspects may be lacking in the curriculum, highlighting a gap in knowledge and application. The intermittent teaching of TIC affects students' ability to fully understand the impact of trauma in the clinical setting. The authors' results supported the integration of a more comprehensive TIC education in undergraduate medical curricula.
Disasters, including the recent COVID-19 pandemic, have disproportionately impacted nursing homes (NHs). NH residents experienced higher mortality during the pandemic, but not all NH were affected equally. Appalachia has a history of reduced health compared to the general United States. Therefore, this study is focused on NHs in Appalachia during the COVID-19 pandemic. This study aimed to investigate how the neighborhood and NH characteristics are associated with mortality in Appalachian NHs during the COVID-19 pandemic. Using publicly available datasets, including NH, patient, and county-level characteristics, the authors' investigated how the these factors impacted COVID-19 death, COVID-19 death rate, and total NH deaths by adopting negative binomial regression outcomes and multiple linear regression models. A total of 1259 NHs in Appalachia were included in the analysis. Deaths from COVID-19 were positively associated with the number of NH beds, share of White residents, and resident age. Centers for Medicare & Medicaid Services 5-star quality rating was negatively associated with COVID-19 deaths. On the other hand, although number of beds, acuity index, share of White residents, average age, and share of White residents in the community were positively associated with total deaths, lower county education levels and county income were negatively associated with total deaths. NH and county characteristics associated with NH deaths varied from prior literature that included the general United States. Policymakers and NH leaders responsible for NHs in Appalachia should be sensitive to regional differences when making decisions and resource allocations.
Falls are common among older people, and medications, in particular central nervous system-active medications, increase fall risk. The Centers for Disease Control and Prevention funded a pragmatic trial to test a deprescribing intervention (STOP-FALLS) for its effect on falls, while simultaneously collecting implementation process data. This article describes prospective modifications to the STOP-FALLS intervention and offers a summary of the strategies deployed per reporting recommendations from implementation science. In a preimplementation phase for this pragmatic trial, the multidisciplinary research team collaborated with delivery system leaders to modify the intervention for this new context, held focus groups with end users representative of the new population to optimize patient educational brochures, and pilot-tested the intervention in a single clinic. This study took place in the Kaiser Permanente Washington integrated health care delivery system, primary care settings. Preimplementation activities were systematically tracked using 2 established implementation frameworks for: 1) intervention adaptation and 2) strategy deployment. Twenty-seven adaptations were made to STOP-FALLS, and 13 discrete implementation strategies were deployed across the 3 preimplementation phases of the study. Adaptation tracking revealed several changes to the intervention context and content that reflected different guidelines for this trial (eg, include opioid medications) and idiosyncrasies of Kaiser Permanente Washington delivery system operations, in addition to refinements to optimize the intervention according to patient and primary care practitioner preferences. Implementation strategies were not specific to the focus of the trial and may reflect best practices for health system-embedded pragmatic effectiveness trials moving forward.
Colorectal cancer (CRC) disproportionately affects American Indian and Alaska Native communities. One approach to increasing CRC screening is to develop tailored messages and materials. In collaboration with the Great Plains Tribal Leaders Health Board (GPTLHB) and the South Puget Intertribal Planning Agency (SPIPA), the authors employed an adapted approach of boot camp translation (BCT), a validated community-based participatory method, to co-create tailored CRC materials. To enhance cultural relevance, the authors reframed the BCT process and renamed the sessions as "listening sessions." Listening sessions were conducted with GPTLHB in Rapid City, South Dakota, and with SPIPA in Shelton, Washington. Each included a 1-day in-person meeting and 2 virtual conferences. The objectives were to co-create materials and messages that motivate members to complete CRC screening and identify preferred communication channels for CRC-related information within the tribal community. The authors met with 53 tribal members across organizations. Both GPTLHB and SPIPA sessions emphasized the need for a multigenerational approach and culturally and locally relevant imagery, language, and traditions. GPTLHB members wished to include Lakota words, simple illustrations for colon health education, and recognition of traditional healing practices. SPIPA members underscored the importance of water as a symbol of healing and local intertribal milestones, such as the canoe journey. Preferred dissemination channels included physical fact sheets, posters, visual stories, animated videos, and live-action videos. Using modified BCT, the authors partnered with American Indian and Alaska Native communities to co-create screening messages for CRC and identified favored dissemination networks tailored to each community's context.
Annual variations in the population-based incidence of acute urticaria (AU) and chronic urticaria (CU) are poorly understood, specifically in relationship to non-COVID-19 viral respiratory infections (NCVRIs). To determine the annual incidence of AU and CU, health care utilization for NCVRIs and demographic associations across 3 periods: pre-COVID-19, COVID-19 without vaccinations, and COVID-19 with vaccinations. The researchers reviewed the medical records from 2017 to 2022 of all Kaiser Permanente Southern California Health Plan members with and without urticaria leading to health care utilization. There was a total of 7,404,343 unique individuals with any Kaiser Permanente Southern California Health Plan coverage between 2017 and 2022, contributing to 26,852,884 patient-years of follow-up. The annual incidence of AU per 100,000 patient-years was 1543 in 2017, 1533 in 2018, 1586 in 2019, 1194 in 2020, 1345 in 2021, and 1434 in 2022. The annual incidence of CU per 100,000 patient-years was 101 in 2017, 113 in 2018, 123 in 2019, 95 in 2020, 113 in 2021, and 129 in 2022. The number of annual health care visits for NCVRIs per 100,000 patient-years was 14,588 in 2017, 13,409 in 2018, 14,843 in 2019, 8671 in 2020, 6507 in 2021, and 11,191 in 2022. There was a significant correlation between NCVRIs and AU (r = 0.82, P = .05) but not between NCVRIs and CU (r = 0.10, P = .86). There was a decrease in AU incidence during the COVID-19 era before and after vaccines. AU may be associated with NCVRIs.
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have traditionally been the treatment for colorectal peritoneal metastasis (CPM). PRODIGE 7, a French multicenter trial, showed no survival difference with the addition of HIPEC to CRS but showed increased morbidity. With substantial differences between US and French HIPEC regimens, validity of PRODIGE 7 in US practice has been questioned with concern that omission of HIPEC will result in undertreatment. Given these controversies, the authors evaluated their experience of CRS with and without HIPEC in patients with CPM to compare morbidity, recurrence patterns, and overall survival (OS). Retrospective cohort study was performed to evaluate patients with CPM undergoing CRS with or without HIPEC within a single health care system. HIPEC regimen was mitomycin-C/90 min. Thirty patients with CPM were identified; 23 underwent CRS-HIPEC, while 7 underwent CRS only. Between groups, there were no differences in age, sex, surgical or systemic treatment history, preoperative carcinoembryonic antigen levels, and time from diagnosis of CPM to surgery. There was no difference in peritoneal cancer index scores, regions affected by CPM, resected organs, and operative time. There was no difference in length of stay, surgical reinterventions, and all 30-day morbidity. There was no difference in 1-year OS. With addition of HIPEC-mitomycin to CRS, patients had longer time to return to regular diet and intensive care unit length of stay, without difference in 1-year OS. CRS with mitomycin-HIPEC can be considered for treatment of CPM without significant morbidity and equivalent short-term oncologic benefits. However, the long-term benefit of HIPEC remains unclear.
Missed medical appointments lead to adverse health outcomes and financial costs. Adverse childhood experiences (ACEs) are associated with poor health outcomes and may influence health care-seeking behavior in adulthood. This study explored the relationship between ACE scores and missed primary care appointments in a predominantly Black safety-net population. The authors conducted a retrospective cohort study of 307 adult patients in a primary care clinic between January and August of 2022. Patients were recruited using a systematic sampling protocol and completed the 10-item Adverse Childhood Experiences Questionnaire. The primary outcome was no-show behavior, defined as having at least 1 scheduled appointment not attended and not canceled in advance. Logistic regression analyses assessed associations between ACE scores and missed appointments. The sample was 91.9% Black, 44.0% male, with mean age 59.6 years. Average ACE score was 2.3, with 22.5% having ACE scores ≥ 4. Overall, 43.7% of patients had at least 1 no-show visit. ACE scores were not significantly associated with missed appointments (odds ratio, 1.01; 95% confidence interval, 0.89-1.14; P = .94). Medicaid insurance status was the only significant predictor in multivariable analysis (odds ratio, 2.15; 95% confidence interval, 1.07-4.30; P = .03). Contrary to the authors' hypothesis, ACE scores were not associated with appointment adherence. Medicaid insurance status was the strongest predictor of no-show behavior, highlighting the impact of socioeconomic disadvantage on health care engagement. Social determinants such as insurance status may have a stronger influence on appointment adherence than childhood trauma history. Findings underscore the need to address structural barriers in vulnerable populations.
Inquiring about a patient's adverse childhood experiences (ACEs) and assessment for mental health conditions such as depression and anxiety using trauma-informed care (TIC) approaches may enhance maternity care quality. This study aimed to evaluate the feasibility of a TIC program that integrated mental health and ACE assessment by examining patient and physician perspectives following clinical implementation in a primary care setting. In this exploratory quality improvement project, a maternity care clinic in Calgary, Alberta, implemented a TIC program to assess and address patients' mental health and ACEs between July 2017 and January 2018. Patients' and physicians' perspectives of the program were also attained to understand the feasibility of implementation and use. Patients responded positively to their clinic's use of the TIC program and discussions about their mental health and ACEs with their physicians. They reported feelings of safety, respect, understanding, and receiving informed care. Patients also reported that discussing their ACEs encouraged them to engage in related conversations in their personal lives, seek parenting resources, and expand their knowledge about their ACEs. Physicians reported improved confidence in discussing their patients' ACEs and routine integration of the assessment tools into clinical practice. Integrating ACE and mental health assessment into routine maternity care through the TIC program was associated with positive perceptions from both patients and physicians. Enhanced communication, improved patient-physician relationships, and more optimal patient-centered care resulted. By incorporating these tools into maternity care, health care practitioners can more effectively identify psychosocial risks early, thus supporting improved maternal and fetal health outcomes.
High-quality care for people with serious illness requires understanding what matters most. Although goals-of-care conversations may emphasize values and treatment preferences, patients hold goals related to identity, relationships, and legacy; how they wish to be remembered and what they hope to leave behind. These legacy goals can shape treatment choices, yet they are rarely elicited in clinical care. The authors explored how people living with serious illness consider legacy, how legacy goals inform care decisions, and how health care supports or constrains them. The authors conducted 1-hour telephone interviews with Kaiser Permanente Washington members who received at least 1 palliative care consultation in the prior year. Interviews were recorded, transcribed, and analyzed using inductive thematic analysis with iterative coding and consensus. Five themes emerged: 1) participants actively planned for legacy, with legacy goals often clarified by serious illness; 2) illness and its care introduced threats to legacy goals; 3) financial strain and insurance coverage were major threats; 4) participants believed their care would differ if teams understood their legacy goals; and 5) participants wanted to communicate their legacy goals to their care teams. Legacy goals often become more salient after a serious illness diagnosis, helping people clarify priorities and values as they approach end of life. Integrating legacy-related conversations into palliative care may enhance person-centered care by addressing identity, relationships, and meaning alongside medical preferences. Serious illness and its treatment can jeopardize patients' ability to achieve legacy goals. Interventions to elicit and support legacy goals may improve high-quality palliative care.
Congenital stapes footplate fixation (CSFF) is a rare cause of nonprogressive conductive hearing loss in pediatric patients. The concurrent absence of the stapedial tendon is exceptionally uncommon, and bilateral involvement has not been previously reported. This article describes a case of a 15-year-old male with a history of left hemifacial microsomia, bilateral microtia, and complex congenital heart disease who presented with longstanding bilateral conductive hearing loss with air-bone gap of 64 dB and 58 dB on the right and left, respectively. Surgical exploration revealed bilateral CSFF with absent stapedial tendons, with associated malformed ossicles including shortened and thinned incudal long processes with fibrous nonunion to malformed stapes suprastructures. After undergoing staged bilateral stapedotomy, postoperative audiometry demonstrated substantial improvement with air-bone gap reduced to 19 dB on the right and 15 dB on the left. Speech reception thresholds improved to 25 dB on the right and 15 dB on the left, representing functional hearing restoration. This case represented the first reported instance of bilateral CSFF with absent stapedial tendons. Surgical exploration remains essential in select patients, and stapedotomy can result in meaningful hearing restoration even in the setting of complex congenital ossicular anomalies.
Head and neck cancer (HNC) is associated with poor health outcomes. The receipt of regular dental care may increase the likelihood of diagnosing HNC earlier but has not been studied extensively. The authors' objective was to examine the association of receipt of dental care with late-stage HNC, adjusting for key covariate measures. This was a retrospective study of 468 Kaiser Permanente Northwest patients with HNC diagnosed between January 1, 2010 and December 31, 2023. All data elements needed for the analysis were constructed from Kaiser Permanente Northwest's electronic health record. The main outcome measure was incident late-stage HNC, defined as American Joint Committee on Cancer stage 3-4 (vs stage 0-2). The independent variable was receipt of dental care (yes, no) in the 12 months prior to cancer diagnosis. Multivariable logistic regression assessed the association between receipt of dental care and late-stage HNC diagnosis, adjusted for key covariate measures. Those who had any dental visits in the year before diagnosis (odds ratio, 0.64; 95% confidence interval, 0.43-0.95) had lower odds of being diagnosed with late-stage HNC compared to those with no dental visits, after adjusting for study covariates. Future research should determine whether providing ongoing dental care for populations at risk of developing HNC lowers the incidence of late-stage cancer diagnosis. Patients who had any dental visits in the year prior to cancer diagnosis had lower odds of being diagnosed with late-stage HNC.
This review aims to compare the FICA (faith, importance/influence, community, address in care) and HOPE (sources of hope, organized religion, personal spirituality/practices, effects on care) spiritual screening tools across multiple domains, including clinical utility, implementation feasibility, and psychometric properties, in order to synthesize evidence and provide guidance to health care practitioners and educators regarding the relative strengths and limitations of the 2 tools. This review of published literature involved a structured search in PubMed, CINAHL, Embase, and PsycINFO, from which 2 reviewers independently screened, extracted, and synthesized data using predefined criteria. The studies included in the review assessed the use of the FICA and/or HOPE tools with adult patient populations and health care professionals in multiple countries, primarily within academic and hospital-based settings. FICA was more frequently used in clinical and educational settings and was noted for its structured format and integration into serious illness care. Meanwhile, HOPE was noted for its open-ended format and greater flexibility in exploring personal spirituality, particularly among patients identifying as spiritual but not religious. Although there does not seem to be research validating or using psychometric resources to analyze these tools, qualitative studies indicated their perceived value in enhancing holistic care. Both FICA and HOPE are valuable frameworks for initiating spiritual screenings in clinical practice. FICA may be more suitable in fast-paced environments because of its concise structure, whereas HOPE offers greater depth and personalization. Further research should focus on developing validated outcome measures and examining the impact of spiritual screenings on patient care.