Publications by authors named "Cynthia Chuang"

126 Publications

Impact of Scribe Intervention on Documentation in an Outpatient Pediatric Primary Care Practice.

Acad Pediatr 2021 May 18. Epub 2021 May 18.

Penn State Children's Hospital, Penn State College of Medicine, Department of Pediatrics, 500 University Drive, Hershey, PA 17033, United States of America; Penn State College of Medicine, Department of Humanities, 500 University Drive, MC-H134, Hershey, PA 17033, United States of America. Electronic address:

Purpose: The use of the Electronic Health Record (EHR) has led to physician dissatisfaction, physician burnout, and delays in documentation and billing. Medical scribes can mitigate these unintended consequences by reducing documentation workload and increasing efficiency.

Objective: To study the effects of medical scribes on time to completion of notes and clinician experience, with a focus on time spent charting during clinic and after-hours. We hypothesized that medical scribes in an outpatient pediatric setting would decrease clinician time spent charting, time to finalize encounter notes, and clinician's perceived documentation time.

Method: This 15-month single-center observational study was carried out with 3 study periods: pre-scribe, with-scribe, and scribe-withheld. Time spent in EHR was extracted by our EHR vendor. Participants completed surveys regarding time spent documenting. Six clinicians (5 physicians, 1 nurse practitioner) participated in this study to trial the implementation of medical scribes.

Results: EHR time data was collected for 4329 patient visits (2232 pre-scribe, 1888 with-scribe, 209 scribe-withheld periods). Comparing pre-scribe versus with-scribe periods, documentation time per patient decreased by 3-minutes 28-seconds per patient (pre-scribe IQR: 6, with-scribe IQR: 3, p=0.028); note timeliness decreased from 0.96 days to 0.26 days (pre-scribe IQR: 0.22, with-scribe IQR: 0.11, p=0.028); and clinicians' estimates of time spent in the EHR decreased by 1.2 hours per clinic session (pre-scribe IQR: 0.5, with-scribe IQR: 0.5, p=0.031).

Conclusions: Medical scribes in an outpatient pediatric setting result in: 1) decreased time spent charting, 2) reduced time to final sign clinic notes, and 3) decrease in clinician's perceived time spent documenting.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2021.05.004DOI Listing
May 2021

Contraceptive Procedures in Internal Medicine Clinics and Resident Education: a Qualitative Study of Implementation Methods, Barriers, and Facilitators.

J Gen Intern Med 2021 May 6. Epub 2021 May 6.

Department of Public Health Sciences, Pennsylvania State University, Hershey, PA, USA.

Background: Long-acting reversible contraceptives (LARCs) such as intrauterine devices (IUDs) and implants are highly effective and increasingly popular. Internal Medicine (IM) clinics and residency curricula do not routinely include LARCs, which can limit patient access to these methods. In response, internists are integrating LARCs into IM practices and residency training.

Objective: This study examines the approaches, facilitators, and barriers reported by IM faculty to incorporating LARCs into IM clinics and resident education.

Design: We interviewed faculty who were prior or current LARC providers and/or teachers in 15 IM departments nationally. Each had implemented or attempted to implement LARC training for residents in their IM practice. Semi-structured interviews were used.

Participants: Eligible participants were a convenience sample of clinicians identified as key informants at each institution.

Approach: We used inductive thematic coding analysis to identify themes in the transcribed interviews.

Key Results: Fourteen respondents currently offered LARCs in their clinic and 12 were teaching these procedures to residents. LARC integration into IM clinics occurred in 3 models: (1) a dedicated procedure or women's health clinic, (2) integration into existing IM clinical sessions, or (3) an interdisciplinary IM and family medicine or gynecology clinic. Balancing clinical and educational priorities was a common theme, with chosen LARC model(s) reflecting the desired priority balance at a given institution. Most programs incorporated a mix of educational modalities, with opportunities based upon resident interest and desired educational goals. Facilitators and barriers related to clinical (equipment, workflow), educational (curriculum, outcomes), or process considerations (procedural volume, credentialing). Participants reported that support from multiple stakeholders including patients, residents, leadership, and other departments was necessary for success.

Conclusion: The model for integration of LARCs into IM clinics and resident education depends upon the clinical resources, patient needs, stakeholder support, and educational goals of the program.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11606-021-06832-3DOI Listing
May 2021

The Stanford stereotactic radiosurgery experience on 7000 patients over 2 decades (1999-2018): looking far beyond the scalpel.

J Neurosurg 2021 Apr 2:1-17. Epub 2021 Apr 2.

Departments of1Neurosurgery and.

Objective: The CyberKnife (CK) has emerged as an effective frameless and noninvasive method for treating a myriad of neurosurgical conditions. Here, the authors conducted an extensive retrospective analysis and review of the literature to elucidate the trend for CK use in the management paradigm for common neurosurgical diseases at their institution.

Methods: A literature review (January 1990-June 2019) and clinical review (January 1999-December 2018) were performed using, respectively, online research databases and the Stanford Research Repository of patients with intracranial and spinal lesions treated with CK at Stanford. For each disease considered, the coefficient of determination (r2) was estimated as a measure of CK utilization over time. A change in treatment modality was assessed using a t-test, with statistical significance assessed at the 0.05 alpha level.

Results: In over 7000 patients treated with CK for various brain and spinal lesions over the past 20 years, a positive linear trend (r2 = 0.80) in the system's use was observed. CK gained prominence in the management of intracranial and spinal arteriovenous malformations (AVMs; r2 = 0.89 and 0.95, respectively); brain and spine metastases (r2 = 0.97 and 0.79, respectively); benign tumors such as meningioma (r2 = 0.85), vestibular schwannoma (r2 = 0.76), and glomus jugulare tumor (r2 = 0.89); glioblastoma (r2 = 0.54); and trigeminal neuralgia (r2 = 0.81). A statistically significant difference in the change in treatment modality to CK was observed in the management of intracranial and spinal AVMs (p < 0.05), and while the treatment of brain and spine metastases, meningioma, and glioblastoma trended toward the use of CK, the change in treatment modality for these lesions was not statistically significant.

Conclusions: Evidence suggests the robust use of CK for treating a wide range of neurological conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2020.9.JNS201484DOI Listing
April 2021

Impact of the Early Phase of the COVID-19 Pandemic on US Healthcare Workers: Results from the HERO Registry.

J Gen Intern Med 2021 05 10;36(5):1319-1326. Epub 2021 Mar 10.

Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.

Background: The HERO registry was established to support research on the impact of the COVID-19 pandemic on US healthcare workers.

Objective: Describe the COVID-19 pandemic experiences of and effects on individuals participating in the HERO registry.

Design: Cross-sectional, self-administered registry enrollment survey conducted from April 10 to July 31, 2020.

Setting: Participants worked in hospitals (74.4%), outpatient clinics (7.4%), and other settings (18.2%) located throughout the nation.

Participants: A total of 14,600 healthcare workers.

Main Measures: COVID-19 exposure, viral and antibody testing, diagnosis of COVID-19, job burnout, and physical and emotional distress.

Key Results: Mean age was 42.0 years, 76.4% were female, 78.9% were White, 33.2% were nurses, 18.4% were physicians, and 30.3% worked in settings at high risk for COVID-19 exposure (e.g., ICUs, EDs, COVID-19 units). Overall, 43.7% reported a COVID-19 exposure and 91.3% were exposed at work. Just 3.8% in both high- and low-risk settings experienced COVID-19 illness. In regression analyses controlling for demographics, professional role, and work setting, the risk of COVID-19 illness was higher for Black/African-Americans (aOR 2.32, 99% CI 1.45, 3.70, p < 0.01) and Hispanic/Latinos (aOR 2.19, 99% CI 1.55, 3.08, p < 0.01) compared with Whites. Overall, 41% responded that they were experiencing job burnout. Responding about the day before they completed the survey, 53% of participants reported feeling tired a lot of the day, 51% stress, 41% trouble sleeping, 38% worry, 21% sadness, 19% physical pain, and 15% anger. On average, healthcare workers reported experiencing 2.4 of these 7 distress feelings a lot of the day.

Conclusions: Healthcare workers are at high risk for COVID-19 exposure, but rates of COVID-19 illness were low. The greater risk of COVID-19 infection among race/ethnicity minorities reported in the general population is also seen in healthcare workers. The HERO registry will continue to monitor changes in healthcare worker well-being during the pandemic.

Trial Registration: ClinicalTrials.gov identifier NCT04342806.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11606-020-06529-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946335PMC
May 2021

A robotically assisted 3D printed quality assurance lung phantom for Calypso.

Phys Med Biol 2021 Apr 6;66(7). Epub 2021 Apr 6.

Department of Radiation Oncology, School of Medicine, Stanford University, Stanford, California, United States of America.

. Radiation dose delivered to targets located near the upper-abdomen or in the thorax are significantly affected by respiratory-motion. Relatively large-margins are commonly added to compensate for this motion, limiting radiation-dose-escalation. Internal-surrogates of target motion, such as a radiofrequency (RF) tracking system, i.e. CalypsoSystem, are used to overcome this challenge and improve normal-tissue sparing. RF tracking systems consist of implanting transponders in the vicinity of the tumor to be tracked using radiofrequency-waves. Unfortunately, although the manufacture provides a universal quality-assurance (QA) phantom, QA-phantoms specifically for lung-applications are limited, warranting the development of alternative solutions to fulfil the tests mandated by AAPM's TG142. Accordingly, our objective was to design and develop a motion-phantom to evaluate Calypso for lung-applications that allows the CalypsoBeacons to move in different directions to better simulate trulung-motion.A Calypso lung QA-phantom was designed, and 3D-printed. The design consists of three independent arms where the transponders were attached. A pinpoint-chamber with a buildup-cap was also incorporated. A 4-axis robotic arm was programmed to drive the motion-phantom to mimic breathing. After acquiring a four-dimensional-computed-tomography (4DCT) scan of the motion-phantom, treatment-plans were generated and delivered on a Varian TrueBeamwith Calypso capabilities. Stationary and gated-treatment plans were generated and delivered to determine the dosimetric difference between gated and non-gated treatments. Portal cine-images were acquired to determine the temporal-accuracy of delivery by calculating the difference between the observed versus expected transponders locations with the known speed of the transponders' motion.Dosimetric accuracy is better than the TG142 tolerance of 2%. Temporal accuracy is greater than, TG142 tolerance of 100 ms for beam-on, but less than 100 ms for beam-hold.The robotic QA-phantom designed and developed in this study provides an independent phantom for performing Calypso lung-QA for commissioning and acceptance testing of Calypso for lung treatments.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1088/1361-6560/abebaaDOI Listing
April 2021

Technical Note: Performance of CyberKnife tracking using low-dose CT and kV imaging.

Med Phys 2020 Dec 28;47(12):6163-6170. Epub 2020 Oct 28.

Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA.

Purpose: To investigate the effects of CT protocol and in-room x-ray technique on CyberKnife (Accuray Inc.) tracking accuracy by evaluating end-to-end tests.

Methods: End-to-end (E2E) tests were performed for the different tracking methods (6D skull, fiducial, spine, and lung) using an anthropomorphic head phantom (Accuray Inc.) and thorax phantom (CIRS Inc.). Bolus was added to the thorax phantom to simulate a large patient and to evaluate the performance of lung tracking in a more realistic condition. The phantoms were scanned with a Siemens Sensation Open 24 slice CT at low dose (120 kV, 70 mAs, 1.5 mm slice thickness) and high dose (120 kV, 700 mAs, 1.5 mm slice thickness) to generate low-dose and high-dose digitally reconstructed radiographs (DRRs). The difference in initial phantom alignment, Δ(Align), and in total targeting accuracy, E2E, were obtained for all tracking methods with low- and high-dose DRRs. Additionally, Δ(Align) was determined for different in-room x-ray imaging techniques (0.5 to 50 mAs and 100 to 140 kV) using a low-dose lung tracking plan.

Results: Low-dose CT scans produced images with high noise; however, for these phantoms the targets could be easily delineated on all scans. End-to-end results were less than 0.95 mm for all tracking methods and all plans. The greatest difference in initial alignment Δ(Align) and E2E results between low- and high-dose CT protocols was 0.32 and 0.24 mm, respectively. Similar results were observed with a large thorax phantom. Tracking using different in-room x-ray imaging techniques (mAs) corresponding to low exposures (resulting in high image noise) or high exposure (resulting in image saturation) had alignment accuracy Δ(Align) greater than 1 mm.

Conclusions: End-to-end targeting accuracy within tolerance (<0.95 mm) was obtained for all tracking methods using low-dose CT protocols, suggesting that CT protocol should be set by target contouring needs. Additionally, high tracking accuracy was achieved for in-room x-ray imaging techniques that produce high-quality images.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/mp.14537DOI Listing
December 2020

ZAP-X: A Novel Radiosurgical Device for the Treatment of Trigeminal Neuralgia.

Cureus 2020 May 27;12(5):e8324. Epub 2020 May 27.

Department of Neurosurgery, Stanford University School of Medicine, Stanford, USA.

Introduction The treatment of trigeminal neuralgia (TN) is one of the most demanding of all radiosurgery procedures, requiring accurate delivery and sharp dose fall off. ZAP-X®, a new, innovative frameless radiosurgical device, maybe an attractive platform for the treatment of TN and other functional brain disorders. Here, we compared the dosimetry of ZAP-X plans for a single patient to that generated by a well-established dedicated radiosurgery device, the CyberKnife. Methods Radiosurgery plans that delineated the cranial nerve from a single patient's fused computed tomography and magnetic resonance imaging (CT-MR) data set were planned on both the ZAP-X and CyberKnife, with the latter serving as a validated benchmark. The same target and treatment planning constraints were applied. Plans were evaluated by a physician with experience treating TN and a medical physicist. The ZAP-X treatment plan used two isocenters delivered through 4-mm collimators based on a non-isocentric plan that delivered 29,441 MU through 81 beams. The CyberKnife plans used a 5-mm collimator for a non-isocentric plan that delivered 17,880 MU through 88 beams. Results Based on visual inspection, the isodose volumes covered by ZAP-X and CyberKnife were similar at the prescription isodose (70% and 80%, respectively, with a maximum dose (Dmax) of 7500 cGy. The conformality index was better for the CyberKnife as compared to ZAP-X. However, the irradiated volumes were smaller at the 50%, 20%, and 10% isodoses for ZAP-X (0.12 cc, 0.57 cc, and 1.69 for ZAP-X; 0.18 cc, 0.91 cc, and 3.41 cc for CyberKnife). In particular, the 20% and 10% isodose volumes were much smaller for ZAP-X, especially on the axial and sagittal planes. Conclusions ZAP-X treatment planning for TN compares favorably with equivalent planning on CyberKnife. The brain volumes containing the 20% and 10% isodoses are smaller using ZAP-X, thus relatively sparing critical structures close to the target, including the Gasserian ganglion and brainstem. This feature could be of clinical relevance by potentially reducing treatment-related complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7759/cureus.8324DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325335PMC
May 2020

Medication for Abortion and Miscarriage in Primary Care: Important and Possible for General Internists.

J Gen Intern Med 2020 08;35(8):2256-2257

Department of Medicine, Division of General Internal Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11606-020-05919-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7259738PMC
August 2020

The Impact of Medical Scribes on Relative Value Units in a Pediatric Primary Care Practice.

Acad Pediatr 2021 04 20;21(3):542-547. Epub 2020 May 20.

Department of Pediatrics, Penn State College of Medicine (BH Levi, P Jhaveri, D Abdulahad, and BN Fogel), Hershey, Pa; Penn State College of Medicine (P Jhaveri), Hershey, Pa.

Objective: Our study assessed the impact of adding medical scribes to an academic pediatric primary practice by measuring the relationship between work relative value units (wRVUs) and use of the medical scribe.

Methods: This is a retrospective comparative study on the effect of medical scribes on average wRVUs per patient encounter. wRVUs were abstracted from procedure codes in the billing system.

Results: Six clinicians performed 2277 patient visits included in the study over 2 different time periods during 2017 and 2018. The first period was without the use of medical scribes and the second period included scribes. Average clinician wRVU production per visit increased by 7.68% (P < .001) with medical scribes over the previous period without them.

Conclusions: This study shows that scribes contribute to improving the wRVU per visit in a primary pediatric practice. This finding is consistent with other research showing that scribes help increase volume and improve wRVUs for specialists who perform complex procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2020.05.009DOI Listing
April 2021

Clinical impact of the VOLO optimizer on treatment plan quality and clinical treatment efficiency for CyberKnife.

J Appl Clin Med Phys 2020 May 25;21(5):38-47. Epub 2020 Mar 25.

Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA.

With the recent CyberKnife treatment planning system (TPS) upgrade from Precision 1.0 to Precision 2.0, the new VOLO optimizer was released for plan optimization. The VOLO optimizer sought to overcome some of the limitations seen with the Sequential optimizer from previous TPS versions. The purpose of this study was to investigate the clinical impact of the VOLO optimizer on treatment plan quality and clinical treatment efficiency as compared to the Sequential optimizer. Treatment plan quality was evaluated in four categories of patients: Brain Simple (BS), Brain Complex (BC), Spine Complex (SC), and Prostate (PC). A total of 60 treatment plans were compared using both the Sequential and VOLO optimizers with Iris and MLC collimation with the same clinical constraints. Metrics evaluated included estimated treatment time, monitor units (MUs) delivered, conformity index (CI), and gradient index (GI). Furthermore, the clinical impact of the VOLO optimizer was evaluated through statistical analysis of the patient population treated during the 4 months before (n = 297) and 4 months after (n = 285) VOLO introduction. Significant MU and time reductions were observed for all four categories planned. MU reduction ranged from -14% (BS Iris) to -52% (BC MLC), and time reduction ranged from -11% (BS Iris) to -22% (BC MLC). The statistical analysis of patient population before and after VOLO introduction for patients using 6D Skull tracking with fixed cone, 6D Skull tracking with Iris, and Xsight Spine tracking with Iris were -4.6%, -22.2%, and -17.8% for treatment time reduction, -1.1%, -22.0%, and -28.4% for beam reduction and -3.2%, -21.8%, and -28.1% for MU reduction, respectively. The VOLO optimizer maintains or improves the plan quality while decreases the plan complexity and improves treatment efficiency. We anticipate an increase in patient throughput with the introduction of the VOLO optimizer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/acm2.12851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286021PMC
May 2020

What Women Want: Factors Impacting Contraceptive Satisfaction in Privately Insured Women.

Womens Health Issues 2020 Mar - Apr;30(2):93-97. Epub 2020 Jan 3.

Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Division of General Internal Medicine, Pennsylvania State Hershey Medical Center, Hershey, Pennsylvania.

Purpose: To identify factors associated with high contraceptive method satisfaction among privately insured, adult women in Pennsylvania.

Methods: We used cross-sectional survey data collected in 2014 from 874 privately insured women participating in the MyNewOptions study who were currently using contraception. Binomial logistic regression assessed the relationship of contraceptive attributes, attitudes, and sociodemographic variables with contraceptive method satisfaction.

Findings: More than one-half of the analytic sample (53%) was "very satisfied" with their current contraceptive method. The strongest predictors of high method satisfaction were having a method that was easy to use (adjusted odds ratio [aOR], 2.65; 95% confidence interval [CI], 1.79-3.91), high perceived method effectiveness (aOR, 2.52; 95% CI, 1.68-3.78), cost not being a factor in method selection (aOR, 2.88; 95% CI, 2.08-4.00), and not being troubled by side effects (aOR, 2.27; 95% CI, 1.54-3.34). In contrast with previous studies, long-acting reversible contraception (i.e., intrauterine devices and contraceptive implant) was not independently associated with high method satisfaction, but other hormonal methods were (versus nonprescription methods; aOR, 2.48; 95% CI, 1.65-3.75).

Conclusions: The strongest predictors of high method satisfaction were having a method that was easy to use and effective and for which cost was not a factor in method selection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.whi.2019.11.003DOI Listing
August 2020

General Internists as Change Agents: Opportunities and Barriers to Leadership in Health Systems and Medical Education Transformation.

J Gen Intern Med 2020 06 2;35(6):1865-1869. Epub 2020 Jan 2.

Division of General Internal Medicine, Penn State College of Medicine, Hershey, PA, USA.

Health systems are increasingly engaging in mission development around the quadruple aim of patient experience of care, population health, cost of care, and work-life balance of clinicians. This integrated approach is closely aligned with the education principles and competencies of health systems science (HSS), which includes population health, high-value care, leadership, teamwork, collaboration, and systems thinking. Influenced by health outcomes research, the systems-based practice competency, and the Clinical Learning Environment Review, many medical schools and residency programs are taking on the challenge of comprehensively incorporating these HSS competencies into the education agenda. General internal medicine physicians, inclusive of hospitalists, geriatricians, and palliative and primary care physicians, are at the frontlines of this transformation and uniquely positioned to contribute to and lead health system transformation, role model HSS competencies for trainees, and facilitate the education of a new workforce equipped with HSS skills to accelerate change in healthcare. Although GIM faculty are positioned to be early adopters and leaders in evolving systems of care and education, professional development and changes with academic health systems are required. This Perspective article explores the conceptualization and opportunities to effectively link GIM with healthcare and medical education transformation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11606-019-05611-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280380PMC
June 2020

Reproductive Life Planning and Contraceptive Action Planning for Privately Insured Women: The MyNewOptions Study.

Perspect Sex Reprod Health 2019 12 9;51(4):219-227. Epub 2019 Dec 9.

Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, PA.

Context: Although reproductive life planning (RLP) is recommended in federal and clinical guidelines and may help insured women make personalized contraceptive choices, it has not been systematically evaluated for effectiveness.

Methods: In 2014, some 984 privately insured women aged 18-40 who were not intending to become pregnant in the next year were randomly assigned to receive RLP, RLP with contraceptive action planning (RLP+) or information only (the control group). Women's contraceptive use, prescription contraceptive use, method adherence, switching to a more effective method, method satisfaction and contraceptive self-efficacy were assessed at six-month intervals during the two-year follow-up period. Differences between groups were identified using binomial logistic regression, linear regression and generalized estimating equation models.

Results: During the follow-up period, the proportion of women using any contraceptive method increased from 89% to 96%, and the proportion using a long-acting reversible contraceptive or sterilization increased from 8% to 19%. Contraceptive adherence was high (72-76%) in all three groups. In regression models, the sole significant finding was that women in the RLP+ group were more likely than those in the RLP group to use a prescription method (odds ratio, 1.3). No differences were evident between the intervention groups and the control group in overall contraceptive use, contraceptive adherence, switching to a more effective method, method satisfaction or contraceptive self-efficacy.

Conclusions: The study does not provide evidence that web-based RLP influences contraceptive behaviors in insured women outside of the clinical setting. Further research is needed to identify strategies to help women of reproductive age identify contraceptive methods that meet their needs and preferences.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1363/psrh.12123DOI Listing
December 2019

ACA's Contraceptive Coverage Requirement: Measuring Use And Out-Of-Pocket Spending.

Health Aff (Millwood) 2019 09;38(9):1537-1541

Douglas L. Leslie is a professor of public health sciences and psychiatry and director of the Center for Applied Studies in Health Economics, Penn State College of Medicine.

Following the implementation of the Affordable Care Act's contraceptive coverage requirement, privately insured women's out-of-pocket spending for contraception declined and their use of long-acting reversible contraceptives (LARCs) increased. Claims data through 2016 show a continued increase in LARC insertions but an increase in out-of-pocket spending for intrauterine devices.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1377/hlthaff.2018.05484DOI Listing
September 2019

Successful use of frameless stereotactic radiosurgery for treatment of recurrent brain metastases in an 18-month-old child.

Int J Neurosci 2019 Dec 20;129(12):1234-1239. Epub 2019 Aug 20.

Department of Radiation Oncology, Stanford University , Stanford , CA , USA.

There are very few reported cases of stereotactic radiosurgery (SRS) delivered in children under 3 years of age. We report an 18-month-old boy with metastatic recurrence of undifferentiated round cell sarcoma to the brain which was treated with chemotherapy, resection and robotic frameless SRS. Frameless SRS was delivered without technical difficulties, acute adverse events, or clinical sequelae 1.5 months post-radiation. Longer term follow-up will be needed to evaluate local tumor control and effects on neurocognitive development, endocrine function and growth. This report adds to the literature of the few reported cases of successfully attempted SRS in very young children.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/00207454.2019.1655015DOI Listing
December 2019

Factors Associated with New Uptake of Long-Acting Reversible Contraceptives Since the Affordable Care Act Among Privately Insured Women in Pennsylvania.

Womens Health Issues 2019 Sep - Oct;29(5):370-375. Epub 2019 Jul 20.

Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania; Division of General Internal Medicine, Penn State College of Medicine, Hershey, Pennsylvania.

Background: The Affordable Care Act eliminated out-of-pocket costs for contraceptives, including highly effective long-acting reversible contraception (LARC), for most insured women. Patient characteristics associated with new LARC uptake after the Affordable Care Act have not been well-studied. We hypothesized that awareness of no-cost intrauterine device (IUD) coverage would be associated with new LARC use.

Methods: Data included were from 883 women not using a LARC at baseline who participated in the MyNewOptions study, a 2-year study of privately insured women in Pennsylvania. Multivariable analysis assessed whether the following baseline characteristics predicted new LARC use over 2 years: awareness of no-cost IUD coverage, future pregnancy intention, baseline contraceptive use, contraceptive attitudes, and sociodemographic characteristics.

Results: At baseline, 54.4% of participants were using prescription methods; 21.1% nonprescription methods; 12.1% natural family planning, withdrawal, or spermicide alone; and 12.5% no method. A minority (7.2%) was aware of no-cost coverage for IUDs. Over 2 years, 7.2% of participants became new LARC users, but awareness of no-cost coverage for IUDs was not associated with new LARC use (adjusted odds ratio, 0.84; 95% confidence interval, 0.27-2.55). New LARC use was associated with already using prescription methods, not intending pregnancy within the next 5 years, prior unintended pregnancy, and desire to change method if cost were not a factor.

Conclusions: Among privately insured women, wanting to switch methods if cost were not a factor was associated with new LARC uptake, although awareness of no-cost IUD coverage was not. Providing women with information about their contraceptive coverage benefits may help women to seek and obtain the methods better aligned with their personal needs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.whi.2019.06.004DOI Listing
June 2020

Optimizing beam models for dosimetric accuracy over a wide range of treatments.

Phys Med 2019 Feb 24;58:47-53. Epub 2019 Jan 24.

Department of Radiation Oncology, University of California San Francisco, 1600 Divisadero Street, Suite H1031, San Francisco, CA 94115, United States.

This work presents a systematic approach for testing a dose calculation algorithm over a variety of conditions designed to span the possible range of clinical treatment plans. Using this method, a TrueBeam STx machine with high definition multi-leaf collimators (MLCs) was commissioned in the RayStation treatment planning system (TPS). The initial model parameters values were determined by comparing TPS calculations with standard measured depth dose and profile curves. The MLC leaf offset calibration was determined by comparing measured and calculated field edges utilizing a wide range of MLC retracted and over-travel positions. The radial fluence was adjusted using profiles through both the center and corners of the largest field size, and through measurements of small fields that were located at highly off-axis positions. The flattening filter source was adjusted to improve the TPS agreement for the output of MLC-defined fields with much larger jaw openings. The MLC leaf transmission and leaf end parameters were adjusted to optimize the TPS agreement for highly modulated intensity-modulated radiotherapy (IMRT) plans. The final model was validated for simple open fields, multiple field configurations, the TG 119 C-shape target test, and a battery of clinical IMRT and volumetric-modulated arc therapy (VMAT) plans. The commissioning process detected potential dosimetric errors of over 10% and resulted in a final model that provided in general 3% dosimetric accuracy. This study demonstrates the importance of using a variety of conditions to adjust a beam model and provides an effective framework for achieving high dosimetric accuracy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejmp.2019.01.011DOI Listing
February 2019

Taking Aim at Contraceptive Coverage - The Trump Administration's Attacks on Reproductive Rights.

N Engl J Med 2019 Mar 30;380(11):993-995. Epub 2019 Jan 30.

From the Division of General Internal Medicine, Department of Medicine (C.H.C.), the Department of Public Health Sciences (C.H.C., C.S.W.), and the Department of Obstetrics and Gynecology (C.H.C., C.S.W.), Penn State College of Medicine, Hershey, PA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1056/NEJMp1815738DOI Listing
March 2019

Fast calculation of nanodosimetric quantities in treatment planning of proton and ion therapy.

Phys Med Biol 2018 Nov 28;63(23):235015. Epub 2018 Nov 28.

Department of Radiation Oncology, University of California, San Francisco, CA, United States of America. Author to whom any correspondence should be addressed.

Details of the pattern of ionization formed by particle tracks extends knowledge of dose effects on the nanometer scale. Ionization detail (ID), frequently characterized by ionization cluster size distributions (ICSD), is obtained through time-consuming Monte Carlo (MC) track-structure simulations. In this work, TOPAS-nBio was used to generate a highly precise database of biologically significant ID quantities, sampled with randomly oriented 2.3 nm diameter cylinders, 3.4 nm (10 base pairs) long, inside a chromatin-size cylinder, irradiated by 1-1000 MeV/u ions of Z  =  1-8. A macroscopic method developed to utilize the database using condensed-history MC was used to calculate distributions of the ICSD first moment [Formula: see text] and cumulative probability [Formula: see text] in a 20  ×  20  ×  40 cm water phantom irradiated with proton and carbon spread-out Bragg peak (SOBP) of 10.5 cm range, 2 cm width. Results were verified against detailed MC track-structure simulations using phase space scored at several depths. ID distributions were then obtained for intensity modulated proton and carbon radiotherapy plans in a digitized anthropomorphic phantom of a base of skull tumor to demonstrate clinical application of this approach. The database statistical uncertainties were 0.5% (3 standard deviations). Fluence-averaged ID as implemented proved unsuitable for macroscopic calculation. E -averaged ID agreed with track-structure results within 0.8% for protons. For carbon, maximum absolute differences of 2.9%  ±  1.6% and 5.6%  ±  1.9% for [Formula: see text], 1.7%  ±  0.8% and 1.9%  ±  0.4% (1 standard deviation) for [Formula: see text], were found in the plateau and SOBP, respectively, up to 11.5%  ±  5.6% in the tail region. Macroscopic ID calculation was demonstrated for a realistic treatment plan. Computation times with or without ID calculation were comparable in all cases. Pre-calculated nanodosimetric data may be used for condensed-history MC for nanodosimetric ID-based treatment planning in ion radiotherapy in the future. The macroscopic approach developed has the calculation speed of condensed-history MC while approaching the accuracy of full track structure simulations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1088/1361-6560/aaeeeeDOI Listing
November 2018

High Self-Efficacy Is Associated with Prescription Contraceptive Use.

Womens Health Issues 2018 Nov - Dec;28(6):509-513. Epub 2018 Aug 18.

Department of Medicine, Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Department Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania.

Objectives: In the United States, 45% of pregnancies continue to be unintended. Although many previous studies have focused on external barriers to contraceptive use such as cost or access, fewer studies have evaluated internal barriers such as individual characteristics. We hypothesize that high self-efficacy for contraception will be associated with use of more effective contraceptive methods.

Study Design: The analytic sample is 861 privately insured Pennsylvania women aged 18 to 40 years not intending pregnancy for 12 months at enrollment. Contraceptive self-efficacy (high vs. low) was measured using an eight-item scale. The association of self-efficacy with prescription contraceptive use was determined using multivariable logistic regression adjusting for future pregnancy intention, history of unintended pregnancy, number of live births, non-White race, frequency of sexual intercourse, marital status, and age group.

Results: Prescription contraceptive use was higher among those with high self-efficacy (adjusted odds ratio, 1.75; 95% confidence interval, 1.29-2.37).

Conclusions: Women with high self-efficacy for contraception had an increased use of prescription contraceptive methods compared with nonprescription methods. Strategies for encouraging effective contraceptive choices in women with low contraceptive self-efficacy should be further studied.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.whi.2018.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6345511PMC
January 2019

A model for academic institution support for community-engaged research.

J Clin Transl Sci 2017 Oct 16;1(5):320-321. Epub 2017 Nov 16.

College of Nursing, Penn State University, State College, PA, University Park, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/cts.2017.295DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915808PMC
October 2017

The Impact of the Affordable Care Act on Contraceptive Use and Costs among Privately Insured Women.

Womens Health Issues 2018 May - Jun;28(3):219-223. Epub 2018 Mar 13.

Division of General Internal Medicine, Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania.

Objectives: The Affordable Care Act (ACA) contraceptive coverage mandate issued in August 2012 requires most private health insurance plans to cover all U.S. Food and Drug Administration-approved contraceptive methods without cost sharing. We evaluate the impact of this policy on out-of-pocket costs and use of long-acting reversible contraceptives (LARCs) and other prescription methods through 2014.

Methods: Data from Truven Health MarketScan were used to examine out-of-pocket costs and contraceptive use patterns for all reversible prescription contraceptives before and after the implementation of the contraceptive mandate for privately insured women ages 13 to 45. Costs were estimated by combining copayment, coinsurance, and deductible payments for both contraception and insertion fees for LARCs. Contraceptive use rates were examined and multivariable logistic regression analysis of LARC insertions before and after the ACA was conducted.

Results: Out-of-pocket costs for all reversible contraceptives, including LARCs, decreased sharply after the ACA contraceptive mandate. The greatest proportion of women in each year was oral contraceptive users (24.3%-26.1%). Rates of new LARC insertions increased significantly after the ACA, when controlling for cohort year, age group, geographic region, and rural versus urban setting (adjusted odds ratio, 1.03; 95% confidence interval, 1.02-1.04).

Conclusions: Our study adds to the current literature with the inclusion of 2014 data and confirms previous findings of a post-ACA decrease in out-of-pocket contraceptive costs. In addition, there was a small but statistically significant increase in LARC insertions after the ACA. This finding indicates the importance of reduced cost sharing for increasing use of the most effective contraceptives.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.whi.2018.01.005DOI Listing
October 2018

Correcting TG 119 confidence limits.

Med Phys 2018 Mar 19;45(3):1001-1008. Epub 2018 Feb 19.

Department of Radiation Oncology, University of California, San Francisco, CA, 94115, USA.

Purpose: Task Group 119 (TG-119) has been adopted for evaluating the adequacy of intensity-modulated radiation therapy (IMRT) commissioning and for establishing patient-specific IMRT quality assurance (QA) passing criteria in clinical practice. TG-119 establishes 95% confidence limits (CLs), which help clinics identify systematic IMRT QA errors and identify outliers. In TG-119, the 95% CLs are established by fitting the Gamma Γ analysis passing rate results to an assumed distribution, then calculating the limit in which 95% of the data fall. CLs for a given dataset will depend greatly on the type of distribution used, and those determined by following the TG-119 guidelines are only valid if the underlying data follows a Gaussian distribution. Gaussian distributions assume symmetry about the mean, which would imply the possibility of negative Γ analysis failing rates. This study demonstrates that the gamma distribution is a more reasonable assumption for establishing CLs than the Gaussian distribution used in TG-119. Thus, the gamma distribution is suggested as a replacement to the conventional Gaussian statistical model used in TG-119.

Materials And Methods: The moments estimator (ME) for the gamma family is used to obtain the CLs of the failing rates for all Γ analysis criteria. To demonstrate the congruence of the gamma distribution, the root mean squared error and the CL values for the MEs of the gamma and the Gaussian families were compared.

Results: In this study, the empirical 95% CLs generated using 302 plans represent the ground truth, which resulted in a 91.83% passing rate using 3%/3 mm error local criteria. The gamma distribution underestimates the 95% CL by 0.09%, while the Gaussian distribution overestimates the 95% CL by 4.12%.

Conclusions: Although IMRT QA equipment may vary between clinics, the mathematical formalism presented in this study applies to any combination of planning and delivery systems. This study has demonstrated that a gamma distribution should be favored over a Gaussian distribution when establishing CLs for IMRT QA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/mp.12759DOI Listing
March 2018

Measuring oral contraceptive adherence using self-report versus pharmacy claims data.

Contraception 2017 Dec 4;96(6):453-459. Epub 2017 Sep 4.

Division of General Internal Medicine, Penn State College of Medicine; Department of Public Health Sciences, Penn State College of Medicine.

Objective: Proportion of Days Covered (PDC) is a measure of medication adherence that uses prescription claims data to describe the proportion of days that the patient possessed medication. The objective of this study is to compare PDC and self-report as measures of oral contraceptive pills (OCPs) adherence and to identify individual-level predictors of adherence.

Study Design: In a sample of 384 OCP users, self-report was compared with PDC as measures of adherence over the past 3 months. Patient-level variables were examined for associations with adherence using multivariable logistic regression models.

Results: High adherence, defined as missing ≤1 pill per month, was 76%, 68% and 54% as measured by self-report, PDC and both measures, respectively. Younger women (ages 18-25 and 26-33 years) were significantly less likely to have high adherence on both measures than women in the 34-40 age group [adjusted odds ratio (OR) 0.20, 95% confidence interval (CI) 0.08-0.51 and adjusted OR 0.26, 95% CI 0.11-0.62, respectively). Other predictors of high adherence on both self-report and PDC measures included being in a relationship (adjusted OR 2.30, 95% CI 1.14-4.64, compared with unpartnered women), Protestant religion (adjusted OR 2.08, 95% CI 1.07-4.06, compared with women with no religious affiliation) and higher contraceptive self-efficacy (adjusted OR 1.63, 95% CI 1.03-2.58).

Conclusion: PDC derived from pharmacy claims, or a combination of PDC and self-report measures, may be an alternative to self-report alone for measuring OCP adherence.

Implications: PDC may be a potential tool for measuring women's adherence to OCPs and should be validated in future studies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.contraception.2017.08.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6540974PMC
December 2017

Association of Iron Deficiency Anemia With Hearing Loss in US Adults.

JAMA Otolaryngol Head Neck Surg 2017 04;143(4):350-354

Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey.

Importance: Hearing loss in the US adult population is linked to hospitalization, poorer self-reported health, hypertension, diabetes, and tobacco use. Because iron deficiency anemia (IDA) is a common and easily correctable condition, further understanding of the association between IDA and all types of hearing loss in a population of US adults may help to open new possibilities for early identification and appropriate treatment.

Objective: To evaluate the association between sensorineural hearing loss (SNHL) and conductive hearing loss and IDA in adults aged 21 to 90 years in the United States.

Design, Setting, And Participants: The prevalence of IDA and hearing loss (International Classification of Diseases, Ninth Revision codes 389.1 [SNHL], 389.0 [conductive hearing loss], and 389 [combined hearing loss]) was identified in this retrospective cohort study at the Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. Iron deficiency anemia was determined by low hemoglobin and ferritin levels for age and sex in 305 339 adults aged 21 to 90 years. Associations between hearing loss and IDA were evaluated using χ2 testing, and logistic regression was used to model the risk of hearing loss among those with IDA. The study was conducted from January 1, 2011, to October 1, 2015.

Main Outcomes And Measures: Hearing loss.

Results: Of 305 339 patients in the study population, 132 551 were men (43.4%); mean (SD) age was 50.1 (18.5) years. There was a 1.6% (n = 4807) prevalence of combined hearing loss and 0.7% (n = 2274) prevalence of IDA. Both SNHL (present in 26 of 2274 individuals [1.1%] with IDA; P = .005) and combined hearing loss (present in 77 [3.4%]; P < .001) were significantly associated with IDA. Logistic regression analysis confirmed increased odds of SNHL (adjusted odds ratio [OR], 1.82; 95% CI, 1.18-2.66) and combined hearing loss (adjusted OR, 2.41; 95% CI, 1.90-3.01) among adults with IDA, after adjusting for sex.

Conclusions And Relevance: Iron deficiency anemia was associated with SNHL and combined hearing loss in a population of adult patients. Further research is needed to better understand the potential links between IDA and hearing loss and whether screening and treatment of IDA in adults could have clinical implications in patients with hearing loss.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaoto.2016.3631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787694PMC
April 2017

Exploring the Topics Discussed During a Conversation Card Game About Death and Dying: A Content Analysis.

J Pain Symptom Manage 2016 11 17;52(5):655-662. Epub 2016 Sep 17.

Medicine and Humanities, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.

Context: Substantive discussions between loved ones are necessary for effective advance care planning. Although multiple tools are currently in use for promoting conversations, the content and clinical relevance of the conversations they stimulate is unknown.

Objective: To describe the content and clinical relevance of conversations that occur during a nonfacilitated end-of-life conversation game.

Methods: Using convenience sampling, we scheduled adult volunteers to participate in an end-of-life conversation game (2-6 individuals per game; n = 68). Participants discussed 20 questions about death, dying, or end-of-life issues. Games lasted up to two hours and were audio-recorded, transcribed, and analyzed using a conventional qualitative content analysis approach to identify emerging themes.

Results: Participants (n = 68) were primarily Caucasian (94%), females (68%), with mean age of 51.3 years (SD 0.7). Seventeen games were analyzed. Four primary themes emerged during game conversations: 1) the importance of people, relationships, and the roles played during end-of-life decision making, 2) values, beliefs, and preferences related to end-of-life care and the dying period, 3) considerations about preparing for the aftermath of one's death, and 4) the relevance of stories or experiences for informing one's own end-of-life preferences.

Conclusions: Topics discussed during a nonfacilitated end-of-life conversation game are substantive and address important issues for advance care planning.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpainsymman.2016.03.021DOI Listing
November 2016

Does body mass index or weight perception affect contraceptive use?

Contraception 2017 01 9;95(1):59-64. Epub 2016 Sep 9.

Division of General Internal Medicine, Department of Medicine, Penn State College of Medicine, Hershey, PA 17033, USA; Department of Public Health Sciences, Pennsylvania State College of Medicine, Hershey, PA 17033, USA. Electronic address:

Objective: Overweight and obese women may avoid contraceptive methods they believe are associated with weight gain. The objective of this study was to examine the role of weight and weight perception on contraceptive use.

Study Design: Using cross-sectional data from the MyNewOptions study, we analyzed contraceptive use among 987 privately insured, sexually active women aged 18-40 years. Contraception was categorized into three groups: (1) long-acting reversible contraceptives (LARCs), (2) non-LARC prescription methods and (3) nonprescription methods/no method. Multinomial logistic regression was used to model the effect of body mass index category and weight perception on contraceptive use while controlling for pregnancy intentions, sexual behavior and sociodemographic characteristics.

Results: Eighty-three (8.4%) women were using LARCs, 490 (49.6%) women were using non-LARC prescription methods and 414 (42.0%) were using nonprescription methods or no method. In the adjusted multinomial model, overweight [adjusted odds ratio (aOR) 3.84, 95% confidence interval (CI) 1.85-7.98) and obese women (aOR 2.82, 95% CI 1.18-6.72) were significantly more likely to use LARCs compared to normal-weight women. There were greater adjusted odds of overweight and obese women using nonprescription methods/no method compared with non-LARC prescription methods, but this finding did not reach statistical significance. Weight perception was not associated with contraceptive use.

Conclusion: In this study sample, overweight and obese women were more likely to use LARCs than normal-weight women. It will be important to further understand how weight influences women and providers' views on contraception in order to better assist women with individualized, patient-centered contraceptive decision making.

Implications: Overweight and obese women may be reluctant to use contraceptive methods they believe are associated with weight gain (i.e., pills, shot), but how that affects contraceptive use is unclear. Compared with normal-weight women, overweight and obese women in this study were more likely to use LARCs than non-LARC prescription methods.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.contraception.2016.09.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6333300PMC
January 2017

Optimizing hemoglobin thresholds for detection of iron deficiency among reproductive-age women in the United States.

Transl Res 2017 02 18;180:68-76. Epub 2016 Aug 18.

Department of Pediatrics, Penn State College of Medicine, Hershey, Pa; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pa.

Iron deficiency (ID) affects 9%-16% of US women with well-documented morbidity in academic performance, mood, and concentration. Current ID screening depends on the detection of low hemoglobin (ie, anemia, <12.0 g/dL). However, anemia is a late-stage indicator of ID. The study hypothesis was that using higher hemoglobin thresholds would optimize ID screening. The objective was to assess the sensitivity and specificity of hemoglobin to detect ID among nonpregnant, reproductive-age women of 12-49 years and to determine if psychometric characteristics varied by age and race. This cross-sectional study used National Health and Nutrition Examination Survey 2003-2010 data. ID was defined as body iron, calculated using ferritin and transferrin receptors. Logistic regression and receiver operating characteristic (ROC) curves were used to model the predictive probability of ID by hemoglobin values. ID prevalence by body iron was 11.5% (n = 6602). Using <12.0 g/dL, hemoglobin had a sensitivity of 42.9% (95% confidence interval [CI] = 39.4%, 46.4%) and specificity of 95.5% (95% CI = 95.0%, 96.0%) for ID. The ROC curve was optimized at the hemoglobin threshold of <12.8 g/dL with the sensitivity and specificity of 71.3% (95% CI = 68.0%, 74.5%) and 79.3% (95% CI = 78.2%, 80.3%), respectively. The probability of ID at this threshold was 13.5% (95% CI = 11.3%, 15.9%). Hemoglobin better predicted ID among older (22-49 years) vs younger (12-21 years) women (c-index 0.87 vs 0.77, P < 0.001). Among nonpregnant, reproductive-age women, current hemoglobin thresholds are insufficient to exclude ID. A threshold of <12.8 g/dL improves the detection of ID.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.trsl.2016.08.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5253089PMC
February 2017

Non-local total-variation (NLTV) minimization combined with reweighted L1-norm for compressed sensing CT reconstruction.

Phys Med Biol 2016 09 2;61(18):6878-6891. Epub 2016 Sep 2.

Department of Radiation Oncology, University of California San Francisco, San Francisco, CA 94115, USA.

The compressed sensing (CS) technique has been employed to reconstruct CT/CBCT images from fewer projections as it is designed to recover a sparse signal from highly under-sampled measurements. Since the CT image itself cannot be sparse, a variety of transforms were developed to make the image sufficiently sparse. The total-variation (TV) transform with local image gradient in L1-norm was adopted in most cases. This approach, however, which utilizes very local information and penalizes the weight at a constant rate regardless of different degrees of spatial gradient, may not produce qualified reconstructed images from noise-contaminated CT projection data. This work presents a new non-local operator of total-variation (NLTV) to overcome the deficits stated above by utilizing a more global search and non-uniform weight penalization in reconstruction. To further improve the reconstructed results, a reweighted L1-norm that approximates the ideal sparse signal recovery of the L0-norm is incorporated into the NLTV reconstruction with additional iterates. This study tested the proposed reconstruction method (reweighted NLTV) from under-sampled projections of 4 objects and 5 experiments (1 digital phantom with low and high noise scenarios, 1 pelvic CT, and 2 CBCT images). We assessed its performance against the conventional TV, NLTV and reweighted TV transforms in the tissue contrast, reconstruction accuracy, and imaging resolution by comparing contrast-noise-ratio (CNR), normalized root-mean square error (nRMSE), and profiles of the reconstructed images. Relative to the conventional NLTV, combining the reweighted L1-norm with NLTV further enhanced the CNRs by 2-4 times and improved reconstruction accuracy. Overall, except for the digital phantom with low noise simulation, our proposed algorithm produced the reconstructed image with the lowest nRMSEs and the highest CNRs for each experiment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1088/0031-9155/61/18/6878DOI Listing
September 2016

Can Playing an End-of-Life Conversation Game Motivate People to Engage in Advance Care Planning?

Am J Hosp Palliat Care 2017 Sep 12;34(8):754-761. Epub 2016 Jul 12.

5 Department of Pediatrics and Humanities, Pennsylvania State University College of Medicine, Hershey, PA, USA.

Background: Advance care planning (ACP) involves several behaviors that individuals undertake to prepare for future medical care should they lose decision-making capacity. The goal of this study was to assess whether playing a conversation game could motivate participants to engage in ACP.

Methods: Sixty-eight English-speaking, adult volunteers (n = 17 games) from communities around Hershey, Pennsylvania, and Lexington, Kentucky, played a conversation card game about end-of-life issues. Readiness to engage in 4 ACP behaviors was measured by a validated questionnaire (based on the transtheoretical model) immediately before and 3 months postgame and a semistructured phone interview. These behaviors were (1) completing a living will; (2) completing a health-care proxy; (3) discussing end-of-life wishes with loved ones; and (4) discussing quality versus quantity of life with loved ones.

Results: Participants' (n = 68) mean age was 51.3 years (standard deviation = 0.7, range: 22-88); 94% of the participants were caucasian and 67% were female. Seventy-eight percent of the participants engaged in ACP behaviors within 3 months of playing the game (eg, updating documents, discussing end-of-life issues). Furthermore, 73% of the participants progressed in stage of change (ie, readiness) to perform at least 1 of the 4 behaviors. Scores on measures of decisional balance and processes of change increased significantly by 3 months postintervention.

Conclusion: This pilot study found that individuals who played a conversation game had high rates of performing ACP behaviors within 3 months. These findings suggest that using a game format may be a useful way to motivate people to perform important ACP behaviors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1049909116656353DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055477PMC
September 2017