An electronic registry to improve adherence to active surveillance monitoring among men with prostate cancer at a safety-net hospital: protocol for a pilot study.

BackgroundThe evidence-based practice of active surveillance to monitor men with favorable-risk prostate cancer in lieu of initial definitive treatment is becoming more common. However, there are barriers to effective implementation, particularly in low-resource settings. Our goal is to assess the efficacy and feasibility of a health information technology registry for men on active surveillance at a safety-net hospital to ensure patients receive guideline-recommended care.MethodsWe developed an electronic registry for urology clinic staff to monitor men on active surveillance. The health information technology tool was developed using the Systems Engineering Initiative for Patient Safety model and iteratively tailored to the needs of the clinic by engaging providers in a co-design process. We will enroll all men at Zuckerberg San Francisco General Hospital and Trauma Center who choose active surveillance as a treatment strategy. The primary outcomes to be assessed during this non-randomized, pragmatic evaluation are number of days delayed beyond recommended date of follow-up testing, the proportion of men who are lost to follow-up, the cancer stage at active treatment, and the feasibility and acceptability of the clinic-wide intervention with clinic staff. Secondary outcomes include appointment adherence within 30 days of the scheduled date.DiscussionUse of a customized electronic approach for monitoring men on active surveillance could improve patient outcomes. It may help reduce the number of men lost to follow-up and improve adherence to timely follow-up testing. Evaluating the adoption and efficacy of a customized registry in a safety-net setting may also demonstrate feasibility for implementation in diverse clinical contexts.Trial registrationClinicalTrials.gov identifier NCT03553732, An Electronic Registry to Improve Adherence to Active Surveillance Monitoring at a Safety-net Hospital. Registered 11 June 2018

Gaps in Treatment and Surveillance: Head and Neck Cancer Care in a Safety-Net Hospital.

Objective:Treatment delays and suboptimal adherence to posttreatment surveillance may adversely affect head and neck cancer (HNC) outcomes. Such challenges can be exacerbated in safety-net settings that struggle with limited resources and serve a disproportionate number of patients vulnerable to gaps in care. This study aims to characterize treatment delays and adherence with posttreatment surveillance in HNC care at an urban tertiary care public hospital in San Francisco. Study Design:Retrospective chart review. Setting:Urban tertiary care public hospital in San Francisco. Subjects and Methods:We identified all cases of HNC diagnosed from 2008 to 2010 through the electronic medical record. We abstracted data, including patient characteristics, disease characteristics, pathology and radiology findings, treatment details, posttreatment follow-up, and clinical outcomes. Results:We included 64 patients. Median time from diagnosis to treatment initiation (DTI) was 57 days for all patients, 54 days for patients undergoing surgery only, 49 days for patients undergoing surgery followed by adjuvant radiation ± chemotherapy, 65 days for patients undergoing definitive radiation ± chemotherapy, and 29 days for patients undergoing neoadjuvant chemotherapy followed by radiation or chemoradiation. Overall, 69% of patients completed recommended treatment. Forty-two of 61 (69%) patients demonstrated adherence to posttreatment visits in year 1; this fell to 14 out of 30 patients (47%) by year 5. Conclusion:DTI was persistently prolonged in this study compared with prior studies in other public hospital settings. Adherence to posttreatment surveillance was suboptimal and continued to decline as the surveillance period progressed

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Maternal knowledge of the risk of vertical transmission and offspring acquisition of hepatitis B.

INTRODUCTION AND OBJECTIVES: Universal vaccination at birth and in infancy is key to the elimination of chronic hepatitis B infection. We aimed to assess hepatitis B immune-prophylaxis and perinatal transmission knowledge, in a large and ethnically diverse cohort of previously pregnant North American women, chronically infected with hepatitis B. MATERIALS AND METHODS: The Hepatitis B Research Network (HBRN) is comprised of 28 Clinical Centers in the United States and Canada. Female cohort participants were administered a questionnaire to assess: (1) their assertion of knowledge regarding HBV prophylaxis at birth, testing, and diagnosis of hepatitis B in their children, and (2) the percentage of affirmative to negative responses for each of the HBV-related interventions her child may have received. The relationship between asserted knowledge, actions taken and maternal demographics were assessed. RESULTS: A total of 351 mothers with 627 children born in or after 1992 were included. Median age at enrollment was 39.8 years. Mothers were mostly foreign-born with the largest percentage from Asia (73.4%) and Africa (11.7%). Of the 627 children, 94.5% had mothers who asserted that they knew whether their child had received HBIG or HBV vaccine at birth, for 88.8% of the children, their mothers indicated that they knew if their child was tested for HBV and for 84.5% of children, their mothers knew if the child was diagnosed with HBV infection. Among children whose mothers asserted knowledge of their HBV management, 95.3% were reported to have received HBIG or HBV vaccine, 83.4% of children were said to have been tested for HBV, and 4.8% of children were said to have been diagnosed with HBV. Younger maternal age was the only factor significantly associated with higher percentage of children for whom mothers reported knowledge of testing (p=0.02) or diagnosis of HBV (p=0.02). CONCLUSIONS: While high percentages of North American children had mothers asserting knowledge of HBV prophylaxis and testing, knowledge gaps remain, with mothers of 5.5-15.5% of children lacking knowledge of key components of the HBV prevention and diagnosis in the perinatal setting. Targeted education of HBsAg-positive mothers may aid in closing this gap and reducing vertical transmission

Influence of syllable-coda voicing on the acoustic properties of syllable-onset /l/ in English

International audienceProperties of syllable onset /l/ that depend on the voicing of the syllable coda were measured for four speakers, representing different nonrhotic British English accents that differ in their phonetic realization of onset /l/ and in their system of phonological contrast involving onset /l/ and /r/. Onset /l/ was longer before voiced than voiceless codas for all four speakers, and darker for two of them as measured by lower F2 frequency, and for these two and one other as measured by spectral center of gravity (COG). There were no coda-dependent differences in f0 in the /l/, and F1 frequency differed only for the fourth speaker. The vowel was also longer for all four speakers when the coda was voiced (as expected), while F1 was lower and F2 normally higher. One speaker provided data with fricative or affricate onsets: fricated segments were longer before voiced codas, but no coda-dependent COG differences were found. At least when the onset includes /l/, phonological voicing of the coda seems to be reflected in complex acousticphonetic properties distributed across the whole syllable, some properties being localized, others not. We describe these properties as variations in a brightsomber dimension. In most accents, when the coda is voiceless, the syllable is relatively bright: small proportions of periodic energy which is relatively high frequency at the syllable edges, and a high proportion of silence or aperiodic energy. When the coda is voiced, the syllable is relatively somber: a high proportion of periodic energy which is relatively low frequency at the syllable edges, and relatively small amounts of silence and aperiodic energy. Other accents use other combinations, dependent on the phonetic and phonological properties of liquids in the particular accent. The association of onset darkness and coda voicing does not seem to be ascribable to anticipatory coarticulation of features essential to voicing itself; this observation provides support for nonsegmental models of speech perception in which fine phonetic detail is mapped directly to linguistic structure without reference to phoneme-sized segments

The Eighth Data Release of the Sloan Digital Sky Survey: First Data from SDSS-III

The Sloan Digital Sky Survey (SDSS) started a new phase in August 2008, with new instrumentation and new surveys focused on Galactic structure and chemical evolution, measurements of the baryon oscillation feature in the clustering of galaxies and the quasar Ly alpha forest, and a radial velocity search for planets around ~8000 stars. This paper describes the first data release of SDSS-III (and the eighth counting from the beginning of the SDSS). The release includes five-band imaging of roughly 5200 deg^2 in the Southern Galactic Cap, bringing the total footprint of the SDSS imaging to 14,555 deg^2, or over a third of the Celestial Sphere. All the imaging data have been reprocessed with an improved sky-subtraction algorithm and a final, self-consistent photometric recalibration and flat-field determination. This release also includes all data from the second phase of the Sloan Extension for Galactic Understanding and Evolution (SEGUE-2), consisting of spectroscopy of approximately 118,000 stars at both high and low Galactic latitudes. All the more than half a million stellar spectra obtained with the SDSS spectrograph have been reprocessed through an improved stellar parameters pipeline, which has better determination of metallicity for high metallicity stars.Comment: Astrophysical Journal Supplements, in press (minor updates from submitted version

An HST/WFC3-IR Morphological Survey of Galaxies at z = 1.5-3.6: I. Survey Description and Morphological Properties of Star Forming Galaxies

We present the results of a 42-orbit HST/WFC3 survey of the rest-frame optical morphologies of star forming galaxies with spectroscopic redshifts in the range z=1.5-3.6. The survey consists of 42 orbits of F160W imaging covering ~65 arcmin^2 distributed widely across the sky and reaching a depth of 27.9 AB for a 5 sigma detection within a 0.2 arcsec radius aperture. Focusing on an optically selected sample of 306 star forming galaxies with stellar masses in the range M* = 10^9 - 10^11 Msun, we find that typical circularized effective half-light radii range from ~ 0.7 - 3.0 kpc and describe a stellar mass - radius relation as early as z ~ 3. While these galaxies are best described by an exponential surface brightness profile, their distribution of axis ratios is strongly inconsistent with a population of inclined exponential disks and is better reproduced by triaxial stellar systems with minor/major and intermediate/major axis ratios ~ 0.3 and 0.7 respectively. While rest-UV and rest-optical morphologies are generally similar for a subset of galaxies with HST/ACS imaging data, differences are more pronounced at higher masses M* > 3 x 10^10 Msun. Finally, we discuss galaxy morphology in the context of efforts to constrain the merger fraction, finding that morphologically-identified mergers/non-mergers generally have insignificant differences in terms of physical observables such as stellar mass and star formation rate, although merger-like galaxies selected according to some criteria have statistically smaller effective radii and correspondingly larger SFR surface density.Comment: 42 pages, 2 appendices, 25 figures. Revised version accepted for publication in ApJ. Version with full-resolution figures is available at http://www.astro.ucla.edu/~drlaw/Papers/wfc3morph.pd

Implementation science for ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk patients

Abstract Background Missed evidence-based monitoring in high-risk conditions (e.g., cancer) leads to delayed diagnosis. Current technological solutions fail to close this safety gap. In response, we aim to demonstrate a novel method to identify common vulnerabilities across clinics and generate attributes for context-flexible population-level monitoring solutions for widespread implementation to improve quality. Methods Based on interviews with staff in otolaryngology, pulmonary, urology, breast, and gastroenterology clinics at a large urban publicly funded health system, we applied journey mapping to co-develop a visual representation of how patients are monitored for high-risk conditions. Using a National Academies framework and context-sensitivity theory, we identified common systems vulnerabilities and developed preliminary concepts for improving the robustness for monitoring patients with high-risk conditions (“design seeds” for potential solutions). Finally, we conducted a face validity and prioritization assessment of the design seeds with the original interviewees. Results We identified five high-risk situations for potentially consequential diagnostic delays arising from suboptimal patient monitoring. All situations related to detection of cancer (head and neck, lung, prostate, breast, and colorectal). With clinic participants we created 5 journey maps, each representing specialty clinic workflow directed at evidence-based monitoring. System vulnerabilities common to the different clinics included challenges with: data systems, communications handoffs, population-level tracking, and patient activities. Clinic staff ranked 13 design seeds (e.g., keep patient list up to date, use triggered notifications) addressing these vulnerabilities. Each design seed has unique evaluation criteria for the usefulness of potential solutions developed from the seed. Conclusions We identified and ranked 13 design seeds that characterize situations that clinicians described ‘wake them up at night’, and thus could reduce their anxiety, save time, and improve monitoring of high-risk patients. We anticipate that the design seed approach promotes robust and context-sensitive solutions to safety and quality problems because it provides a human-centered link between the experienced problem and various solutions that can be tested for viability. The study also demonstrates a novel integration of industrial and human factors methods (journey mapping, process tracing and design seeds) linked to implementation theory for use in designing interventions that anticipate and reduce implementation challenges

Multispecialty Physician Online Survey Reveals That Burnout Related to Adverse Event Involvement May Be Mitigated by Peer Support.

OBJECTIVES: Involvement in adverse events can negatively impact physician well-being. Because burnout is increasingly recognized as a threat to patient safety, we examined the relationship between physician adverse event involvement and burnout as well as facilitators and barriers to support among physicians experiencing burnout. METHODS: We surveyed physicians in the United States who are members of the networking platform, Doximity. We conducted quantitative and qualitative analyses investigating experiences with adverse events, the impact of adverse events, the type of support the physician sought and received after the event, and burnout. RESULTS: Across specialties, involvement in an adverse event and burnout was common. Most respondents involved in an adverse event experienced emotional impact, but only a minority received support. Those reporting that the error resulted in emotional impact were more likely to experience burnout (adjusted odds ratio, 1.90; 95% confidence interval, 1.18-3.07); this association was mitigated by the most common form of support sought, peer support (adjusted odds ratio for burnout among those who received peer support versus those who did not, 0.65; 95% confidence interval, 0.52-0.82). Barriers to support after an adverse event include punitive culture and systems factors such as administrative bureaucracy. Facilitators that emerged include peer, professional, and spiritual support, mentorship, helping others, the learning environment, and improved/flexible working hours. CONCLUSIONS: Physicians who experienced emotional repercussions from adverse events were more likely to report burnout compared with those who did not. Respondents proposed barriers and facilitators to support that have not been widely implemented. Peer support may help mitigate physician burnout related to adverse events

Usability, inclusivity, and content evaluation of COVID-19 contact tracing apps in the United States.

We evaluated the usability of mobile COVID-19 contact tracing apps, especially for individuals with barriers to communication and limited digital literacy skills. We searched the Apple App Store, Google Play, peer-reviewed literature, and lay press to find contact tracing apps in the United States. We evaluated apps with a framework focused on user characteristics and user interface. Of the final 26 apps, 77% were on both iPhone and Android. 69% exceeded 9th grade readability, and 65% were available only in English. Only 12% had inclusive illustrations (different genders, skin tones, physical abilities). 92% alerted users of an exposure, 42% linked to a testing site, and 62% linked to a public health website within 3 clicks. Most apps alert users of COVID-19 exposure but require high English reading levels and are not fully inclusive of the U.S. population, which may limit their reach as public health tools