Publications by authors named "Miranda L Ritterman Weintraub"

21 Publications

  • Page 1 of 1

Disordered Eating, Body Image Dissatisfaction, and Associated Healthcare Utilization Patterns for Sexual Minority Youth.

J Adolesc Health 2021 May 27. Epub 2021 May 27.

Division of Adolescent Medicine, The Permanente Medical Group, Kaiser Permanente Northern California, San Leandro, California.

Purpose: To determine the prevalence of disordered eating behaviors (DEBs) and body image dissatisfaction (BID) according to sexual minority youth (SMY) status and describe healthcare utilization patterns by SMY status.

Methods: Retrospective data from 107,528 adolescents, who had a Well Check in Kaiser Permanente Northern California in 2016, were used to compare DEB and BID by SMY status. Multivariate logistic models were used to examine the associations of SMY, birth-assigned sex, age, race/ethnicity, and body mass index on DEB and BID. The utilization of specialized eating disorder (ED) medical and mental health services and general mental health services was described at one Kaiser Permanente Northern California facility.

Results: BID was reported in 20,763 (19.3%) adolescents, DEB in 1,458 (1.7%) adolescents, and 5,363 (5%) adolescents identified as SMY. SMY had higher odds of having DEB and BID than non-SMY, respectively (adjusted odds ratio 2.0 95% confidence interval [1.9-2.2] and adjusted odds ratio 3.8 [3.4-4.2]). Regardless of SMY status, adolescents with older age, female sex, nonwhite race, and elevated body mass index had higher odds of ED risk factors. SMY with ED risk factors had higher ED medical utilization than non-SMY with ED risk factors (4.6% vs. 1.6%). However, SMY status was not associated with utilization of specialized ED mental health services.

Conclusions: SMY had increased rates of DEB and BID but had underutilization of specialized ED mental health services. Future targeted efforts to prevent eating disorder-related mortality and morbidity for SMY should include targeted eating disorder screening and referral to specialized ED medical and mental health services.
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http://dx.doi.org/10.1016/j.jadohealth.2021.02.002DOI Listing
May 2021

Fetomaternal hemorrhage: evaluation of recurrence within a large integrated healthcare system.

Am J Obstet Gynecol 2021 May 4. Epub 2021 May 4.

Department of Pathology, Kaiser Permanente Oakland Medical Center, Oakland, CA.

Background: Fetomaternal hemorrhage is associated with severe fetal morbidity and mortality. The recurrence risk of fetomaternal hemorrhage is unknown.

Objective: We sought to establish the recurrence rate of fetomaternal hemorrhage in a large integrated healthcare system over a 10-year period.

Study Design: In this retrospective study within the Kaiser Permanente Northern California medical system, cases of fetomaternal hemorrhage were defined by either an elevated fetal hemoglobin level as determined by flow cytometry for a concerning pregnancy outcome (preterm delivery, perinatal demise, neonatal anemia, or transfusion within the first 2 days of life) or by perinatal demise with autopsy findings suggestive of fetomaternal hemorrhage. The outcomes of subsequent pregnancies were reviewed for features of recurrence.

Results: Within the 2008 to 2018 birth cohort of 375,864 pregnancies, flow cytometry testing for fetal hemoglobin levels was performed in 20,582 pregnancies. We identified 340 cases of fetomaternal hemorrhage (approximately 1 in 1100 births). Within the cohort of 340 affected pregnancies, perinatal loss was recorded for 80 (23.5%) pregnancies and 50 (14.7%) pregnancies delivered neonates who required transfusion. The affected patients had 225 subsequent pregnancies of which 210 were included in the analysis. Of these, 174 (82.9%) advanced beyond the threshold of viability and were delivered within our healthcare system. There was 1 case of recurrent fetomaternal hemorrhage identified. The recurrent case involved a spontaneous preterm delivery of an infant who was noted to have an elevated reticulocyte count but was clinically well.

Conclusion: Within our large integrated healthcare system, approximately 1 in 1100 pregnancies was affected by fetomaternal hemorrhage within a 10-year period, which is comparable with previous studies. We identified 1 case of recurrence, yielding a recurrence rate of 0.5%. This infant did not have features of clinically important fetomaternal hemorrhage. This information can inform counseling of patients with affected pregnancies.
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http://dx.doi.org/10.1016/j.ajog.2021.04.257DOI Listing
May 2021

Association of Adult Depression With Educational Attainment, Aspirations, and Expectations.

Prev Chronic Dis 2020 08 27;17:E94. Epub 2020 Aug 27.

Department of Public Health, School of Social Sciences, Humanities and Arts, University of California, Merced, Merced, California.

Introduction: Social factors across one's lifespan may contribute to the relationship between low educational attainment and depression, but this relationship has been understudied. Previous studies assessing the association between educational attainment and depression did not fully account for prior common determinants across the life course and possible interactions by sex or race/ethnicity. It is also unclear whether the link between educational attainment and depression is independent of the role of aspired educational attainment or expected educational attainment.

Methods: We used generalized linear log link models to examine the association between educational attainment at age 25 and depression at age 40 in the National Longitudinal Survey of Youth 1979 cohort, adjusting for confounders and mediators from childhood, adolescence, and adulthood.

Results: Members of each educational attainment group were less likely to be depressed at age 40 than those with less education. After adjusting for educational aspirations and educational expectations, the risk ratios became closer to the null. Neither sex nor race/ethnicity interacted with educational attainment. Additionally, low educational expectations in adolescence, but not low educational aspirations, was associated with a higher risk of depression at age 40.

Conclusion: Our study provides a nuanced understanding of the role of education, educational expectations, and educational aspirations as part of education's effect on risk of depression after controlling for a thorough set of confounders and mediators. Our findings may help advance the study of social determinants of depression.
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http://dx.doi.org/10.5888/pcd17.200098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478148PMC
August 2020

Minimally Invasive Intermetatarsal Nerve Decompression for Morton's Neuroma: A Review of 27 Cases.

J Foot Ankle Surg 2020 Nov - Dec;59(6):1186-1191. Epub 2020 May 23.

Research Director and Surgeon, Department of Podiatric Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA. Electronic address:

Minimally invasive nerve decompression for operative management of Morton's neuroma has been shown to be an effective alternative to neurectomy; however, little is known about postoperative outcomes. In this retrospective case series, we reviewed 27 procedures in 25 patients who underwent minimally invasive nerve decompression as primary surgical management for Morton's neuroma. Most subjects (22, or 88%) had 12 or more months of health plan enrollment postoperatively; 3 (12%) had 4 to 7 months of enrollment after the procedure. Postoperative patient satisfaction, complications and the need for a follow-up neurectomy were ascertained from medical record review. Additionally, demographic and clinical data were extracted from electronic sources. Patient satisfaction was unknown for 5 (18.5%) of the 27 procedures. Among the 22 (81.5%) procedures for which there were valid patient satisfaction data, patient satisfaction was excellent for 11 (50%); good for 2 (9.1%), and poor for 9 (40.9%). During the follow-up period, 5 (18.5%) patients required an open neurectomy. Among the 6 (22.2%) patients who presented without a Mulder's sign on physical exam preoperatively, 83% reported excellent results. Minimally invasive nerve decompression may not be as effective as previously seen; however, it may be indicated in patients presenting with absence of a Mulder's sign, a physically small or nascent neuroma.
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http://dx.doi.org/10.1053/j.jfas.2020.05.011DOI Listing
June 2021

Erratum: Erratum: Adverse Pregnancy Outcomes in Women with Sickle Cell Trait.

AJP Rep 2019 10 14;9(4):e389. Epub 2020 Jan 14.

Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, Oakland, California.

[This corrects the article DOI: 10.1055/s-0039-1695743.].
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http://dx.doi.org/10.1055/s-0040-1701199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960017PMC
October 2019

Identification of Sexual Minority Youth in Pediatric Primary Care Settings Within a Large Integrated Healthcare System Using Electronic Health Records.

J Adolesc Health 2020 02 23;66(2):255-257. Epub 2019 Nov 23.

Division of Adolescent Medicine, The Permanente Medical Group, Kaiser Permanente Northern California, California.

Purpose: The aim of the study was to estimate the prevalence of sexual minority youth (SMY) within an integrated health care system using a standardized questionnaire.

Methods: This study assessed SMY status in youth aged 12.5-18 years using a previsit Well Check questionnaire at Kaiser Permanente Northern California facilities in 2016. SMY was defined as self-reported attraction to the same sex or both sexes.

Results: A total of 93,817 youth (87.3%) self-reported sexual attraction, and 5% (n = 5,329) of respondents (N = 107,532) identified as SMY: 1.7% were attracted to same sex, and 3.2% were attracted to both sexes. There were youth who responded neither (1.5%) and unsure (2.4%). Females were 2.8 times (95% confidence interval 2.6-2.94) more likely to be SMY than males. SMY status significantly increased with age. Nonwhite youth were significantly less likely to be SMY compared with white youth.

Conclusions: This is the first study to examine SMY prevalence in pediatric primary care. Primary care providers can use previsit screening before preventive visits to identify and support sexual minority adolescents, facilitate family acceptance, and promote healthy behaviors with care coordination.
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http://dx.doi.org/10.1016/j.jadohealth.2019.10.003DOI Listing
February 2020

Adverse Pregnancy Outcomes in Women with Sickle Cell Trait.

AJP Rep 2019 10 11;9(4):e346-e352. Epub 2019 Nov 11.

Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, Oakland, California.

 To compare adverse pregnancy outcomes between women with sickle cell trait (SCT) and women with normal hemoglobin.  A retrospective cohort study of women who delivered within Kaiser Permanente Northern California between 2006 and 2013. Using hemoglobin electrophoretic profiles, we defined women with hemoglobin AS (HbAS) as having SCT and those with hemoglobin AA (HbAA) as having normal hemoglobin. Outcomes were pregnancy-induced hypertension (PIH), small for gestational age (SGA), gestational diabetes (GDM), and preterm delivery (PTD). Demographic and pregnancy outcome variations were assessed in bivariate analyses. Multivariable logistic regression modeling was used to estimate odds ratios for the association between primary outcomes and selected characteristics.  Of 31,840 eligible women, 868 (2.7%) had SCT. Women with SCT were more likely to have PIH (15.6% vs. 12.2%, p value = 0.003) and SGA (8.3% vs. 6.1%, p value = 0.008), less likely to have GDM (6.8% vs. 9.8%, p value = 0.003) and had similar PTD prevalence (8.1% vs. 7.6%, p value = 0.600). In multivariable analyses, SCT was not an independent predictor of these outcomes. Racial/ethnic minorities had higher adjusted odds of PIH, SGA, and GDM.  SCT alone does not appear to be associated with adverse pregnancy outcomes. Race/ethnicity is a risk factor for adverse pregnancy outcomes.
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http://dx.doi.org/10.1055/s-0039-1695743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6847694PMC
October 2019

A Clinical Risk Model to Predict Obstetric Anal Sphincter Injuries in Laboring Patients.

Female Pelvic Med Reconstr Surg 2020 08;26(8):520-525

From the Department of Obstetrics and Gynecology, Kaiser Permanente East Bay, Oakland Medical Center.

Objective: Our objective was to develop a risk stratification tool for predicting obstetric anal sphincter injury risk in women during labor.

Methods: In this retrospective cohort study of singleton deliveries within Kaiser Permanente Northern California, a predictive model for anal sphincter injury was developed within the 2013 birth cohort and validated in the 2014 birth cohort of 22,741 births. Predictors of obstetric anal sphincter injury were identified using multiple regression analysis and used to create a risk calculator tool based on effect size and clinical judgment.

Results: Duration of second stage of labor, vacuum delivery, history of anal sphincter injury, maternal and gestational ages, and maternal race and ethnicity were associated with elevated risk of anal sphincter injury. Using these risk factors, we developed a validated parity-stratified scoring system. Among nulliparous women, 116 (1.3%) had a score of zero, corresponding to a 0.9% risk, and 1024 (11.7%) had a score higher than 6, corresponding to a 27.5% risk of anal sphincter injury. Among the multiparous women, 1181 (8.4%) had a score of zero, corresponding to a 0.1% risk, and the 260 (1.9%) with a score higher than 10 had a 7.7% risk. The predictive ability of the score derived based on the 2013 data was applied to the 2014 data, and results showed that the predictive abilities were statistically similar, except for one subgroup: multiparous women with a total score of ≥10.

Conclusions: Our anal sphincter injury risk stratification tool effectively predicts individual risk and can inform clinician and patient decision making to minimize maternal birth trauma.
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http://dx.doi.org/10.1097/SPV.0000000000000777DOI Listing
August 2020

Osseous and Soft Tissue Complications Associated With Foot and Ankle Surgery in Patients With Rheumatoid Arthritis Taking a Variety of Antirheumatic Medications.

J Foot Ankle Surg 2019 May 16;58(3):508-513. Epub 2019 Mar 16.

Residency Director, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Foundation Hospital, Oakland, CA. Electronic address:

There are multiple antirheumatic drug modalities available to patients with symptomatic rheumatoid arthritis (RA) that function to suppress the overactive immune system, but the inflammatory and immune suppression may contribute to postoperative complications. The purpose of this study was to determine if antirheumatic medications increased the risk of both soft tissue and osseous postoperative complications in patients with RA who underwent foot and ankle surgery. We reviewed patients with RA, aged 18years and older, who underwent either an elective or a nonelective foot or ankle surgery involving an osseous procedure between 2009 and 2014. Chart review was conducted to document procedure type, active medications, and postoperative complications. Of the final 110 subjects meeting inclusion criteria, 31 (28%) patients had a postoperative complication (13 soft tissue, 9 osseous, and 9 both soft tissue and osseous). There was no statistically significant association between taking antirheumatic medications in the perioperative period and postoperative complications. Increased surgery duration and peripheral neuropathy were associated with a statistically significant increase in postoperative complications. Every 15 minutes of increased surgery time led to a 1.2-fold increase in complication risk. Nonelective procedures had a higher risk of soft tissue complications than did elective procedures (odds ratio 4.2, 95% confidence interval 1.1 to 16.0). Although there was no statistically significant association between the specific medication and complications, some medications trended toward statistical significance. When working with patients with RA, our findings suggest the importance of considering the risk of surgery duration and the potential risk of antirheumatic medications in the perioperative period.
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http://dx.doi.org/10.1053/j.jfas.2018.09.030DOI Listing
May 2019

The incidence and recovery rate of idiopathic vocal fold paralysis: a population-based study.

Eur Arch Otorhinolaryngol 2019 Jan 15;276(1):153-158. Epub 2018 Nov 15.

Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, 4th floor, Oakland, CA, 94611, USA.

Purpose: To determine the incidence and spontaneous recovery rate of idiopathic vocal fold paralysis (IVFP) and paresis (IVFp), and the impact of steroid treatment on rates of recovery.

Methods: This retrospective cohort study included all patients with IVFP or IVFp within a large integrated health-care system between January 1, 2008 and December 31, 2014. Patient demographics and clinical characteristics, including time to diagnosis, spontaneous recovery status, time to recovery, and treatment, were examined.

Results: A total of 264 patients were identified, 183 (69.3%) with IVFP and 81 (30.7%) with IVFp. Nearly all cases (96.6%) were unilateral and 89.8% of patients were over the age of 45. The combined (IVFP and IVFp) 7-year mean incidence was 1.04 cases per 100,000 persons each year with the highest 7-year mean annual incidence in white patients (1.60 per 100,000). The total rate of spontaneous recovery was 29.5%, where 21.2% had endoscopic evidence of resolution and 8.3% had clinical improvement in their voice without endoscopic confirmation. The median time to symptom resolution was 4.0 months. Use of steroids was not linked with spontaneous recovery in multivariable analyses.

Conclusion: The annual incidence of VFP (IVFP and IVFp) was 1.04 cases per 100,000 persons, with spontaneous recovery occurring in nearly a third of patients, regardless of steroid use.
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http://dx.doi.org/10.1007/s00405-018-5207-xDOI Listing
January 2019

Understanding functional and social risk characteristics of frail older adults: a cross-sectional survey study.

BMC Fam Pract 2018 10 19;19(1):170. Epub 2018 Oct 19.

Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.

Background: Frailty is a condition of increasing importance, given the aging adult population. With an anticipated shortage of geriatricians, primary care physicians will increasingly need to manage care for frail adults with complex functional risks and social-economic circumstances.

Methods: We used cross-sectional data from 4551 adults ages 65-90 who responded to the 2014/2015 cycle of the Kaiser Permanente Northern California Member Health Survey (MHS), a self-administered survey that covers multiple health and social characteristics, to create a deficits accumulation model frailty index, classify respondents as frail or non-frail, and then compare prevalence of functional health issues including Activities of Daily Living (ADL)/Instrumental Activities of Daily Living (IADL) and social determinants of health (SDOHs) by frailty status.

Results: The overall prevalence of frailty was 14.3%, higher for women than men, increased with age, and more common among those with low levels of education and income. Frail older adults were more likely than non-frail to have ≥ 3 chronic diseases (55.9% vs. 10.1%), obesity (32.7% vs. 22.8%), insomnia (36.4% vs. 8.8%), oral health problems (25.1% vs. 4.7%), balance or walking problems (54.2% vs. 4.9%), ≥ 1 fall (56.1% vs. 19.7%), to use ≥ 1 medication known to increase fall risk (56.7% vs. 26.0%), and to need help with ≥2 ADLs (15.8% vs. 0.8%) and ≥ 2 IADLs (38.4% vs. 0.8%). They were more likely to feel financial strain (26.9% vs. 12.6%) and to use less medication than prescribed (7.4% vs. 3.6%), less medical care than needed (8.3% vs 3.7%), and eat less produce (9.5% vs. 3.2%) due to cost. Nearly 20% of frail adults were unpaid caregivers for an adult with frailty, serious illness or disability.

Conclusions: This study examined the prevalence of frailty and identified modifiable and non-modifiable risk factors of health. The frail older adult population is heterogeneous and requires a patient-centered assessment of their circumstances by healthcare providers and caregivers to improve their quality of life, avoid adverse health events, and slow physical and mental decline. The characteristics identified in this study can be proactively used for the assessment of patient health, quality of life, and frailty prevention.
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http://dx.doi.org/10.1186/s12875-018-0851-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6195739PMC
October 2018

Alternative Treatment Utilization Before Hysterectomy for Benign Gynecologic Conditions at a Large Integrated Health System.

J Minim Invasive Gynecol 2019 Jul - Aug;26(5):847-855. Epub 2018 Aug 28.

Department of Obstetrics and Gynecology (Drs. Nguyen, Salyer, and Zaritsky), Kaiser Permanente Northern California, Oakland, California. Electronic address:

Study Objective: To investigate rates of utilization of alternative treatments before hysterectomy for benign gynecologic indications within a large integrated health care system.

Design: Retrospective cohort study of patients who underwent hysterectomies for benign gynecologic conditions between 2012 and 2014 (Canadian Task Force classification II-2).

Setting: Kaiser Permanente Northern California, a community-based integrated health system.

Patients: Women who underwent hysterectomy for a benign gynecologic condition between 2012 and 2014.

Interventions: From an eligible cohort of 6892 patients who underwent hysterectomy, a stratified random sample of 1050 patients were selected for chart review. Stratification was based on the proportion of indications for hysterectomy.

Measurements And Main Results: The primary outcome was the use of alternative treatments before hysterectomy. Alternative treatments included oral hormone treatment, leuprolide, medroxyprogesterone intramuscular injections, a levonorgestrel intrauterine device, hormonal subdermal implants, endometrial ablation, uterine artery embolization, hysteroscopy, and myomectomy. Of the 1050 charts reviewed, 979 (93.2%) met the criteria for inclusion in this study. The predominant indication for hysterectomy was symptomatic myomas (54.4%), followed by abnormal uterine bleeding (29.0%), endometriosis (5.8%), pelvic pain (3.1%), dysmenorrhea (3.4%), and other (4.3%). The major routes of hysterectomy were laparoscopy (68.7%) and vaginal hysterectomy (13.4%). Before hysterectomy, 81.2% of patients tried at least 1 type of alternative treatment (33.8% with 1 treatment and 47.4% with at least 2 treatments), and 99.3% of patients were counseled regarding alternative treatments. Compared with younger women age <40 years, women age 45 to 49 years were less likely to use alternative treatments before hysterectomy (adjusted odds ratio, 0.41; 95% confidence interval, 0.21-0.76). There were no variations in treatment rates by socioeconomic status or between major racial and ethnic groups. The final pathological analysis identified myomas as the most common pathology (n = 637; 65.1%); 96 patients (9.8%) had normal uterine pathology.

Conclusion: More than 80% of patients received alternative treatments before undergoing hysterectomy for a benign gynecologic condition. Additional investigation is warranted to assess alternative treatment use as it relates to preventing unnecessary hysterectomies.
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http://dx.doi.org/10.1016/j.jmig.2018.08.013DOI Listing
January 2020

Three-Year Morbidity and Mortality Rates After Nontraumatic Transmetatarsal Amputation.

J Foot Ankle Surg 2018 Sep - Oct;57(5):967-971. Epub 2018 Jul 10.

Research Director and Surgeon, Department of Podiatric Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA. Electronic address:

Patients requiring a nontraumatic transmetatarsal amputation (TMA) typically have multiple comorbidities that place them at high risk of postoperative complications and additional surgery. The present study identified the demographic, clinical, and surgical risk factors that predict complications after a nontraumatic TMA, including the incidence of 3-year mortality, proximal limb amputation, and lack of healing. The electronic medical records of patients who had undergone TMA within a Kaiser Permanente Northern California facility from March 2007 to January 2012 (n = 375) were reviewed. We used bivariate and multivariate analyses to examine the variations in the rates of TMA complications according to sex, age, race, and comorbid conditions, including nonpalpable pedal pulses, end-stage renal disease, coronary artery disease, hypertension, smoking status, and preoperative albumin <3.5 mg/dL. After a nontraumatic TMA, 136 (36.3%) patients had died within 3 years, 138 (36.8%) had required a more proximal limb amputation, and 83 (22.1%) had healed without complications. The patients with nonpalpable pedal pulses had 3 times the odds of requiring a proximal limb amputation (adjusted odds ratio [aOR] 3.07; 95% confidence interval [CI] 1.84 to 5.11), almost twice the odds of dying within 3 years (aOR 1.70; 95% CI 0.98 to 2.93), and >2 times the odds of not healing after the TMA (aOR 2.45; 95% CI 1.40 to 4.31). The patients with end-stage renal disease had 3 times the odds of dying within 3 years (aOR 3.10; 95% CI 1.69 to 5.70). The present findings can help us identify patients with an increased risk of postoperative complications after nontraumatic TMA, including patients with nonpalpable pedal pulses or end-stage renal disease, and suggest the vulnerability of this patient population.
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http://dx.doi.org/10.1053/j.jfas.2018.03.047DOI Listing
January 2019

Diagnostic Pathway of Oral Cavity Cancer in an Integrated Health Care System.

Perm J 2018 ;22:17-152

Head and Neck Surgeon at the Oakland Medical Center in CA.

Context: Survival for patients with oral cavity squamous cell carcinoma (OCSCC) has remained relatively stagnant despite advances in treatment. Few studies have examined why advanced-stage disease is diagnosed in 40% of patients with OCSCC nationally.

Objective: To characterize the diagnostic pathway of OCSCC in an integrated health care system.

Design: Retrospective study of patients with OCSCC (2007-2010).

Main Outcome Measures: Referral patterns and demographic, clinical, and tumor characteristics associated with time to diagnosis (diagnostic interval).

Results: Of 247 patients, 167 (68%) had early-stage (I/II) disease, 86 (35%) were referred by dentists, and 70 (28%) had a history of premalignancy. The median time (interquartile range) from symptom onset to care sought from a primary care physician (patient interval), from primary care physician to otolaryngologist, and from otolaryngologist to diagnosis was 8.6 (4.0-25.8), 1.0 (0.6-3.1), 0.0 (0.0-3.0) weeks, respectively. These intervals did not differ by demographic characteristics, clinical factors, or tumor stage. Prolonged diagnostic intervals were observed among patients with premalignant lesions.

Conclusion: The patient interval was the largest component of the total diagnostic interval. The subsequent professional workup proceeded relatively efficiently. Prolonged diagnostic interval in patients with premalignant lesions may reflect the natural history of malignant transformation rather than a delay in diagnosis. However, nearly one-fourth of these cases were diagnosed at an advanced stage; closer surveillance may represent an opportunity for diagnosis at an earlier stage. Surveillance for premalignant lesions and facilitating referrals from dentists may expedite the diagnosis and treatment of OCSCC. Further investigation is warranted.
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http://dx.doi.org/10.7812/TPP/17-152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5882182PMC
December 2018

Parent Involvement in the Pediatric Resident Applicant Interview.

Acad Pediatr 2018 08 19;18(6):605-608. Epub 2018 Mar 19.

Pediatric Residency Training Program, Kaiser Permanente Northern California, Department of Pediatrics, Oakland Medical Center, Oakland, CA.

Background: Parents and patients are actively involved in the clinical learning environment, yet scant literature exists about their involvement in the residency interview process. We aimed to pilot a process of including parents in resident interviews and to determine its value.

Methods: During the 2016-17 residency interview cycle, 22 parent volunteers, blinded to applicant credentials, conducted brief structured interviews with 118 applicants. We then surveyed all parents and applicants with the use of mixed methods: descriptive statistics to analyze 5-point Likert-type-scale responses, and content analysis to identify themes from open-ended questions. Although parent interviews were not used in ranking, we later compared final composite parent interview scores (1-10, with 10 being high) among the final rank and match list candidates.

Results: Response rates were high for both groups (parents 100%; resident applicants 98.3%). Parents felt strongly positive about meeting applicants (mean ± SD, 5.00 ± 0.00), the value of parent participation (4.90 ± 0.30), and their own experience (4.95 ± 0.22). Applicants felt positive about meeting parents (4.45 ± 0.70), the value of parent participation (3.92 ± 0.84), and their own experience (4.51 ± 0.67). Several themes emerged from both groups, with the most salient parent themes including the value of patient-centered perspectives and appreciation and joy of meeting applicants. Parent interview scores correlated with the final match list, with matched applicants scoring higher (9.08 vs 8.51; P = .05).

Conclusions: Involvement of parents in the pediatric residency interview process is achievable, is perceived positively by parents and applicants, and may provide valuable perspectives for consideration in residency selection.
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http://dx.doi.org/10.1016/j.acap.2018.02.017DOI Listing
August 2018

Risk Factors for the Development of Obstetric Anal Sphincter Injuries in Modern Obstetric Practice.

Obstet Gynecol 2018 02;131(2):290-296

Departments of Obstetrics & Gynecology and Graduate Medical Education, Kaiser Permanente Oakland Medical Center, and the Division of Research, Kaiser Permanente Northern California, Oakland, California; and the Department of Obstetrics & Gynecology, Kaiser Permanente Fremont Medical Center, Fremont, California.

Objective: To characterize the rate of obstetric anal sphincter injuries and identify key risk factors of obstetric anal sphincter injuries, including duration of the second stage of labor.

Methods: This retrospective cohort study included all singleton, term, cephalic vaginal deliveries within Kaiser Permanente Northern California between January 2013 and December 2014 (N=22,741). Incidence of obstetric anal sphincter injuries, defined as third- or fourth-degree perineal lacerations, was the primary outcome. Multiple logistic regression models were conducted to identify obstetric anal sphincter injury risk factors and high-risk subpopulations.

Results: The overall incidence rate of obstetric anal sphincter injuries was 4.9% (3.6% of women who delivered spontaneously vs 24.0% of women who had a vacuum-assisted vaginal delivery, P<.001, CI 18.1-22.6%). In bivariate and multivariate analyses, obstetric anal sphincter injury incidence was higher among women with second stage of labor longer than 2 hours, Asian race, nulliparity, vaginal birth after cesarean delivery, episiotomy, and vacuum delivery. Women with a vacuum-assisted vaginal delivery had four times the odds of obstetric anal sphincter injury (adjusted odds ratio [OR] 4.23, 95% CI 3.59-4.98) and those whose second stage of labor lasted at least 180 minutes vs less than 60 minutes had three times the odds of incurring obstetric anal sphincter injury (adjusted OR 3.20, 95% CI 2.62-3.89).

Conclusion: Vacuum-assisted vaginal delivery conferred the highest odds of obstetric anal sphincter injury followed by prolonged duration of the second stage of labor, particularly among certain subpopulations. Understanding these risk factors and their complex interactions can inform antepartum and intrapartum decision-making with the goal of reducing obstetric anal sphincter injury incidence.
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http://dx.doi.org/10.1097/AOG.0000000000002444DOI Listing
February 2018

Evaluating the Effectiveness of One-on-One Conversations to Increase Colorectal Cancer Screening in a Community-Based Clinical Setting.

J Am Osteopath Assoc 2018 Jan;118(1):26-33

Context: The American Cancer Society's 80% by 2018 initiative aims to increase at-home colorectal cancer (CRC) screening.

Objective: To assess the effectiveness of one-on-one conversations with patients about CRC screening on compliance with at-home fecal immunochemical tests (FITs).

Setting: Federally funded health care center serving a largely minority, urban, underserved population in Vallejo, California.

Methods: Patients aged 50 to 75 years were divided into 3 main intervention arms: (1) patients who received a one-on-one in-person consultation to discuss the need for CRC screening and the screening process, as well as a FIT; (2) patients who received a telephone call to discuss the need for CRC screening and the screening process before receiving a FIT in the mail; and (3) patients who were mailed a FIT with a letter explaining the importance of completing the FIT and instructions. The FITs were tracked to see if they were returned to the laboratory for processing, and the rates of return were compared in bivariate analyses using t and χ2 tests and in adjusted analyses using logistic regression with bootstrapping.

Results: A total of 3415 patients were included in the study. One-on-one conversations either in person (OR, 24.63; 95% CI, 19.28-31.46) or via telephone (OR, 14.74; 95% CI, 10.96-19.82) were more effective at getting patients to complete the at-home CRC screening than not having one-on-one conversations before receiving the FIT.

Conclusion: Patients may be more likely to complete at-home FITs to screen for CRC if they are first able to discuss the need for screening and the screening process with a health care professional.
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http://dx.doi.org/10.7556/jaoa.2018.005DOI Listing
January 2018

The diagnostic pathway of oropharyngeal squamous cell carcinoma in a large U.S. healthcare system.

Laryngoscope 2018 08 15;128(8):1867-1873. Epub 2017 Dec 15.

Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, Oakland, California, U.S.A.

Objective: To examine the current diagnostic pathway of oropharyngeal squamous cell carcinoma (OPSCC) and identify factors associated with time to diagnosis.

Methods: Retrospective cohort study of patients with OPSCC in an integrated healthcare system from January 1, 2013, to December 31, 2013. Patient demographics, tobacco and alcohol use, chief complaint, tumor stage, human papilloma virus (HPV) status, physician factors (diagnosis, antibiotic prescription, performance of endoscopic exam, biopsy), and time intervals were examined. Time variations by patient characteristics and physician practice were assessed.

Results: We identified 152 patients with OPSCC. Of those, 90% had stage III to IV disease. The cohort was largely male (85%), white (79%), with HPV-positive tumors (84%). Most common chief complaints were neck mass (52%) and sore throat (20%). Among those with neck a mass, 94% had HPV-positive tumors. Prescription of antibiotics was associated with longer time to first otolaryngology evaluation. Median time from symptom onset to first primary care physician (PCP) contact was 3.0 weeks; from PCP to otolaryngologist was 1.1 weeks, and from otolaryngologist to tissue diagnosis was 0.4 weeks. At the first otolaryngology visit, 82% underwent in-office flexible endoscopy and 58% had same-day biopsy, resulting in rapid time to tissue diagnosis. Diagnostic time intervals did not differ by HPV status.

Conclusion: The overall diagnostic process was efficient, although initial antibiotic treatment resulted in longer time to first otolaryngology visit. Tumor HPV status was associated with presenting findings but not time to diagnosis. The variation in diagnostic delay time and impact on survival outcomes is unknown and merits further investigation.

Level Of Evidence: 4. Laryngoscope, 1867-1873, 2018.
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http://dx.doi.org/10.1002/lary.27038DOI Listing
August 2018

Role of socioeconomic position in multiple sclerosis etiology.

Neurodegener Dis Manag 2015 Aug 21;5(4):333-43. Epub 2015 Aug 21.

Department of Public Health, Touro University California, CA 94592, USA.

Multiple sclerosis (MS) is a debilitating autoimmune disease with a prominent inflammatory component. There have been strides identifying genetic and environmental MS risk factors, though much of the disease risk remains unknown. Recent large observational studies suggest adverse socioeconomic position increases the risk for MS, however the mediating biological processes are not understood. We hypothesize a prominent role for stress response, both the autonomic nervous system and the hypothalamic-pituitary-adrenal axis, which become maladaptive under frequent or chronic stimulation resulting in a proinflammatory phenotype. Thus, adverse SEP and chronic stress may predispose individuals for MS.
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http://dx.doi.org/10.2217/nmt.15.22DOI Listing
August 2015

Weight status of Mexican immigrant women: a comparison with women in Mexico and with US-born Mexican American women.

Am J Public Health 2013 Sep 18;103(9):1634-40. Epub 2013 Jul 18.

University of California Berkeley School of Public Health, Berkeley, CA 94720, USA.

Objectives: We assessed the association between birthplace, residence, or years in the United States and actual weight (body mass index), perceived weight accuracy, or provider screens for overweight or obesity among Mexican immigrant women.

Methods: We used linked data from Health and Nutrition Examination Survey waves 2001-2006 and 2006 National Mexican Health and Nutrition Survey to compare 513 immigrants with 9527 women in Mexico and 342 US-born Mexican American women.

Results: Immigrants were more likely than women in Mexico to be obese and to perceive themselves as overweight or obese after adjustment for confounders. Recent immigrants had similar weight-related outcomes as women in Mexico. Immigrants were less likely to be obese than were US-born Mexican Americans. Within the overweight or obese population, reported provider screens were higher among immigrants than among women in Mexico, but lower than among US-born Mexican Americans. US residency of at least 5 years but less than 20 years and reporting insufficient provider screens elevated obesity risk.

Conclusions: Mexican-origin women in the United States and Mexico are at risk for overweight and obesity. We found no evidence of a "healthy immigrant" effect.
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http://dx.doi.org/10.2105/AJPH.2012.301171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3780668PMC
September 2013

Weight perceptions among overweight and obese women: a US-Mexico binational perspective.

Obesity (Silver Spring) 2011 Dec 30;19(12):2440-3. Epub 2011 Jun 30.

School of Public Health, University of California, Berkeley, California, USA.

We examined actual and perceived weight in nationally representative cohorts of adults in Mexico (n = 9,527) and the United States (n = 855) using data from the National Health and Nutrition Examination Survey (waves 2001-2006) and Mexican National Health and Nutrition Survey (2006). Actual weight was assessed by health technicians using BMI and perceived weight was collected through self-report. The prevalence of overweight or obesity (OO) in Mexican women was 72% and in Mexican-American women was 71%. OO Mexican-American women were more likely than OO Mexican women to label themselves as "overweight" (86% vs. 64%, P < 0.001), and this difference was significant while controlling for socio-demographic and weight-related variables. Among OO women from both populations, those who had been told by a health provider that they were OO were much more likely to perceive themselves as such (odds ratio = 5.3; 95% confidence intervals: 3.8-7.3). Significantly fewer OO women in Mexico than in the United States (13% vs. 42%, P < 0.0001) recalled having been screened for obesity by their health care provider. Weight misperceptions were common in both populations but more prevalent in Mexico, and low screening by health providers may be an important contributor to poor weight control in both countries.
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http://dx.doi.org/10.1038/oby.2011.194DOI Listing
December 2011
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