Although guidelines recommend in-person counseling before BRCA1/BRCA2 gene testing, genetic counseling is increasingly offered by telephone. As genomic testing becomes more common, evaluating ...alternative delivery approaches becomes increasingly salient. We tested whether telephone delivery of BRCA1/2 genetic counseling was noninferior to in-person delivery.
Participants (women age 21 to 85 years who did not have newly diagnosed or metastatic cancer and lived within a study site catchment area) were randomly assigned to usual care (UC; n = 334) or telephone counseling (TC; n = 335). UC participants received in-person pre- and post-test counseling; TC participants completed all counseling by telephone. Primary outcomes were knowledge, satisfaction, decision conflict, distress, and quality of life; secondary outcomes were equivalence of BRCA1/2 test uptake and costs of delivering TC versus UC.
TC was noninferior to UC on all primary outcomes. At 2 weeks after pretest counseling, knowledge (d = 0.03; lower bound of 97.5% CI, -0.61), perceived stress (d = -0.12; upper bound of 97.5% CI, 0.21), and satisfaction (d = -0.16; lower bound of 97.5% CI, -0.70) had group differences and confidence intervals that did not cross their 1-point noninferiority limits. Decision conflict (d = 1.1; upper bound of 97.5% CI, 3.3) and cancer distress (d = -1.6; upper bound of 97.5% CI, 0.27) did not cross their 4-point noninferiority limit. Results were comparable at 3 months. TC was not equivalent to UC on BRCA1/2 test uptake (UC, 90.1%; TC, 84.2%). TC yielded cost savings of $114 per patient.
Genetic counseling can be effectively and efficiently delivered via telephone to increase access and decrease costs.
Background Laborist practice models are associated with lower rates of cesarean delivery than individual private practice models in several studies; however, this effect is not uniform. Further ...exploration of laborist models may help us better understand the observed decrease in rates of cesarean delivery in some hospitals that implement a laborist model. Objective Our objective was to evaluate the degree of variation in rates of primary cesarean delivery by individual laborists within a single institution that uses a laborist model. In addition, we sought to evaluate whether differences in rates of cesarean delivery resulted in different maternal or short-term neonatal outcomes. Study Design At this teaching institution, one laborist (either a generalist or maternal−fetal medicine attending physician) is directly responsible for labor and delivery management during each shift. No patients are followed in a private practice model nor are physicians incentivized to perform deliveries. We retrospectively identified all laborists who delivered nulliparous, term women with cephalic singletons at this institution from 2007 to 2014. Overall and individual primary cesarean delivery rates were reported as percentages with exact Pearson 95% confidence intervals. Laborists were grouped by tertile as having low, medium, or high rates of cesarean delivery. Characteristics of the women delivered, indications for cesarean delivery, and short-term neonatal outcomes were compared between these groups. A binomial regression model of cesarean delivery was estimated, where the relative rates of each laborist compared with the lowest-unadjusted laborist rate were calculated; a second model was estimated to adjust for patient-level maternal characteristics. Results Twenty laborists delivered 2224 nulliparous, term women with cephalic singletons. The overall cesarean delivery rate was 24.1% (95% confidence interval 21.4−26.8). In an unadjusted binomial model, the overall effect of individual laborist was significant ( P < .001), and a 2.9-fold (1.5−5.4, P = .001) variation between the cesarean delivery rates of the greatest (35.9%) and lowest (12.5%) physicians was observed. When adjusted for hypertensive disease, gestational age at delivery, race, and maternal age, the physician effect remained overall significant ( P = .0265) with the difference between physicians expanding to 3.58 (1.72−7.47, P <. 001). Between groups of laborists with low, medium, and high rates of cesarean delivery, patient demographics and clinical characteristics of the population managed were clinically similar and not different statistically. The primary indication for cesarean delivery did not differ between groups. Similarly there were no differences in short-term neonatal outcomes, including Apgar scores, arterial cord blood pH, or the incidence of neonatal encephalopathy. Conclusion The 3-fold variation in cesarean delivery rates between laborists at the same institution without observed differences in patient characteristics or short-term neonatal outcomes draws attention to the impact of individual physician decision-making on cesarean delivery rates even within a laborist care model. Further exploration of the role of individual physician decision-making on cesarean rates may help to better elucidate the effect of the laborist model.
A number of surgery practice models have been developed to address general and trauma surgeon workforce shortages and on-call issues and to improve surgeon satisfaction. These include the creation of ...acute or urgent care surgery services and “surgical hospitalist” programs. To date, no practice models corresponding to those developed for general and trauma surgeons have been proposed to address these same issues among vascular surgeons or other surgical subspecialists. In 2003, our practice established a Vascular Surgery Hospitalist program. Since its inception nearly a decade ago, it has undergone several modifications. We reviewed hospital administrative databases and surveys of faculty, residents, and patients to evaluate the program's impact. Benefits of the Vascular Surgery Hospitalist program include improved surgeon satisfaction, resource utilization, timeliness of patient care, communication among referring physicians and ancillary staff, and resident teaching/supervision. Elements of this program may be applicable to a variety of surgical subspecialty settings.
Numerous studies have documented the short-term impact of BRCA1/BRCA2 (BRCA1/2) testing; however, little research has examined the long-term impact of testing. We conducted the first long-term ...prospective study of psychosocial outcomes in a U.S. sample of women who had BRCA1/2 testing.
Participants were 464 women who underwent genetic testing for BRCA1/2 mutations. Prior to testing, we measured sociodemographics, clinical variables, and cancer specific and general distress. At long-term follow-up (Median = 5.0 years; Range = 3.4-9.1 years), we assessed cancer-specific and genetic testing distress, perceived stress, and perceived cancer risk. We evaluated the impact of BRCA1/2 test result and risk-reducing surgery on long-term psychosocial outcomes.
Among participants who had been affected with breast or ovarian cancer, BRCA1/2 carriers reported higher genetic testing distress (β = 0.41, P < 0.0001), uncertainty (β = 0.18, P < 0.0001), and perceived stress (β = 0.17, P = 0.005) compared with women who received negative (i.e., uninformative) results. Among women unaffected with breast/ovarian cancer, BRCA1/2 carriers reported higher genetic testing distress (β = 0.39, P < 0.0001) and lower positive testing experiences (β = 0.25, P = 0.008) than women with negative results. Receipt of risk-reducing surgery was associated with lower perceived cancer risk (P < 0.0001).
In this first prospective long-term study in a U.S. sample, we found modestly increased distress in BRCA1/2 carriers compared with women who received uninformative or negative test results. Despite this modest increase in distress, we found no evidence of clinically significant dysfunction.
Although a positive BRCA1/2 result remains salient among carriers years after testing, testing does not seem to impact long-term psychologic dysfunction.
La presente investigación se desarrolla en torno a los numerosos problemas de calidad que se presentan en las nuevas viviendas multifamiliares en Lima Metropolitana; enfocado específicamente en las ...instalaciones sanitarias, que es la especialidad que presenta más inconvenientes. Se pretende que, mediante la evaluación de la post venta y el enfoque a procesos, se detecten las causas de los principales reclamos, para diagnosticar las fallas incidentes en las instalaciones sanitarias, y así, realizar una propuesta que mejore los procedimientos actualmente utilizados.;
;
El trabajo consta de cinco partes. En la primera, se evidencia que la problemática está presente en muchas partes de Latinoamérica, específicamente en nuestra capital. En la segunda, se definen los reglamentos, normas y bases teóricas en las cuales se fundamenta la investigación; asimismo, se explican cómo son las instalaciones sanitarias y los procedimientos utilizados actualmente en nuestro país. En la tercera, se presenta la información recopilada, los reportes de post venta, y se realizan los respectivos análisis con distintas herramientas de calidad. En la cuarta, se hace una discusión de los resultados del capítulo anterior y se definen las causas de las fallas más recurrentes en las instalaciones sanitarias. Por último, en la quinta, se desarrolla la propuesta de mejora de la investigación.;
;
Finalmente, cuando se aplican las propuestas de mejora, se obtiene un porcentaje de problemas solucionados del 65% de los reclamos hechos a post venta en el rubro de instalaciones sanitarias.
This research is developed around the numerous quality problems that arise in new multi-family homes in Metropolitan Lima; specifically focused on sanitary facilities, which is the specialty that presents the most drawbacks. It is intended that, by evaluating the after-sales and focusing on processes, the causes of the main complaints are detected, to diagnose the incident failures in the sanitary facilities, and thus, make a proposal that improves the procedures currently used.;
;
The work consists of five parts. In the first, it is evident that the problem is present in many parts of Latin America, specifically in our capital. In the second, the regulations, standards and theoretical bases on which the research is based are defined; Likewise, it explains what the sanitary facilities and procedures currently used in our country are like. In the third, the information collected is presented, the post-sale reports, and the respective analyzes are carried out with different quality tools. In the fourth, a discussion of the results of the previous chapter is made and the causes of the most recurrent failures in sanitary facilities are defined. Finally, in the fifth, the research improvement proposal is developed.;
;
Finally, when the improvement proposals are applied, a percentage of problems solved is obtained of 65% of the claims made after sales in the area of sanitary facilities.
Tesis
Treatment of severe COVID-19 is currently limited by clinical heterogeneity and incomplete description of specific immune biomarkers. We present here a comprehensive multi-omic blood atlas for ...patients with varying COVID-19 severity in an integrated comparison with influenza and sepsis patients versus healthy volunteers. We identify immune signatures and correlates of host response. Hallmarks of disease severity involved cells, their inflammatory mediators and networks, including progenitor cells and specific myeloid and lymphocyte subsets, features of the immune repertoire, acute phase response, metabolism, and coagulation. Persisting immune activation involving AP-1/p38MAPK was a specific feature of COVID-19. The plasma proteome enabled sub-phenotyping into patient clusters, predictive of severity and outcome. Systems-based integrative analyses including tensor and matrix decomposition of all modalities revealed feature groupings linked with severity and specificity compared to influenza and sepsis. Our approach and blood atlas will support future drug development, clinical trial design, and personalized medicine approaches for COVID-19.
Display omitted
•Blood atlas delineating innate and adaptive immune dysregulation in COVID-19•Shared and specific immune signatures of COVID-19, influenza and all cause sepsis•Multi-omic immune profiling differentiates hospitalized patient severity in COVID-19•Immune activation and proliferation involving AP-1/p38MAPK associated with COVID-19
A multi-omic analysis of patient blood samples reveals both similarities and specific features of COVID-19 when compared with samples obtained from sepsis or influenza patients, which could yield better targeted therapies for severe COVID-19.
PDF
