Publications by authors named "Yingjie Weng"

36 Publications

Merits of Surgical Comanagement of Patients With Hip Fracture by Dedicated Orthopaedic Hospitalists.

J Am Acad Orthop Surg Glob Res Rev 2021 Mar 10;5(3). Epub 2021 Mar 10.

From the Division of Hospital Medicine, Department of Medicine, Stanford University School of Medicine, CA (Dr. Rohatgi, Dr. Kittle, and Dr. Ahuja), and the Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, CA (Mr. Weng).

Background: Rotating medical consultants, hospitalists or geriatricians, are involved in the care of patients with hip fracture, often after medical complications have already occurred. In August 2012, we implemented a unique surgical comanagement (SCM) model in which the same Internal Medicine hospitalists are dedicated year-round to the orthopaedic surgery service. We examine whether this SCM model was associated with a decrease in medical complications, length of stay, and inpatient mortality in patients with hip fracture admitted at our institution, compared with the previous model.

Methods: We included 2,252 admissions to the orthopaedic surgery service with a hip fracture between 2009 and 2018 (757 pre-SCM and 1495 post-SCM). We adjusted for age, Charlson comorbidity score, and operating time in all regression analyses.

Results: Mean Charlson comorbidity score (1.6 versus 1.2) and median case mix index (2.1 versus 1.9) were higher in the post-SCM group. A 32% decrease was observed in the odds of having ≥1 medical complication(s) (odds ratio, 0.68 [95% confidence interval, 0.50 to 0.91], P = 0.009) post-SCM. No change was observed in length of stay or inpatient mortality despite an increase in medical complexity post-SCM.

Conclusion: Having dedicated orthopaedic hospitalists may contribute to fewer medical complications in patients with hip fracture.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954368PMC
March 2021

Perceptions of Support Among Transgender and Gender-Expansive Adolescents and Their Parents.

J Adolesc Health 2021 Feb 21. Epub 2021 Feb 21.

Division of Pediatric Endocrinology, Stanford University School of Medicine, Stanford, California. Electronic address:

Purpose: To capture and compare the perspectives of parents and their transgender and gender expansive (TGE) adolescents during pivotal moments of gender identity development and to report the level of adjustment during these parental experiences.

Methods: We utilized a mixed-methods approach and interviewed 36 parents and 23 TGE adolescents at our Gender Clinic. Parents retrospectively identified "pivotal moments" in their child's gender identity development and rated their levels of support and adjustment. Adolescents independently rated their parent's level of support during these moments to allow for comparative analyses.

Results: The supportive behavior most frequently identified by parents was connecting the adolescent to services, while adolescents considered their parents' use of the affirmed name or pronouns to be most supportive. We found a positive correlation between the parents' perceptions of support and those of TGE adolescents during pivotal moments (r = 0.4, p < 0.001). Adolescents rated the degree of parental support to be 3.73 points (95% confidence interval: [2.67,4.8], p < 0.001) higher on a Likert scale than corresponding ratings provided by parents in a generalized estimating equation model. Parents experienced moderate need for adjustment during these moments.

Conclusions: Providers may use these findings to guide parents toward gender affirmative behaviors that may protect against negative mental health outcomes.
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http://dx.doi.org/10.1016/j.jadohealth.2020.11.021DOI Listing
February 2021

Handheld Ultrasound Device Usage and Image Acquisition Ability Among Internal Medicine Trainees: A Randomized Trial.

J Grad Med Educ 2021 Feb 29;13(1):76-82. Epub 2021 Dec 29.

Background: There is insufficient knowledge about how personal access to handheld ultrasound devices (HUDs) improves trainee learning with point-of-care ultrasound (POCUS).

Objective: To assess whether HUDs, alongside a yearlong lecture series, improved trainee POCUS usage and ability to acquire images.

Methods: Internal medicine intern physicians (n = 47) at a single institution from 2017 to 2018 were randomized 1:1 to receive personal HUDs (n = 24) for patient care/self-directed learning vs no-HUDs (n = 23). All interns received a repeated lecture series on cardiac, thoracic, and abdominal POCUS. Main outcome measures included self-reported HUD usage rates and post-intervention assessment scores using the Rapid Assessment of Competency in Echocardiography (RACE) scale between HUD and no-HUD groups.

Results: HUD interns reported performing POCUS assessments on patients a mean 6.8 (SD 2.2) times per week vs 6.4 (SD 2.9) times per week in non-HUD arm ( = .66). There was no relationship between the number of self-reported examinations per week and a trainee's post-intervention RACE score (rho = 0.022, = .95). HUD interns did not have significantly higher post-intervention RACE scores (median HUD score 17.0 vs no-HUD score 17.8; = .72). Trainee confidence with cardiac POCUS did not correlate with RACE scores.

Conclusions: Personal HUDs without direct supervision did not increase the amount of POCUS usage or improve interns' acquisition abilities. Interns who reported performing more examinations per week did not have higher RACE scores. Improved HUD access and lectures without additional feedback may not improve POCUS mastery.
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http://dx.doi.org/10.4300/JGME-D-20-00355.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901629PMC
February 2021

Lung Ultrasound Findings in Patients Hospitalized With COVID-19.

J Ultrasound Med 2021 Mar 5. Epub 2021 Mar 5.

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

Objectives: Lung ultrasound (LUS) can accurately diagnose several pulmonary diseases, including pneumothorax, effusion, and pneumonia. LUS may be useful in the diagnosis and management of COVID-19.

Methods: This study was conducted at two United States hospitals from 3/21/2020 to 6/01/2020. Our inclusion criteria included hospitalized adults with COVID-19 (based on symptomatology and a confirmatory RT-PCR for SARS-CoV-2) who received a LUS. Providers used a 12-zone LUS scanning protocol. The images were interpreted by the researchers based on a pre-developed consensus document. Patients were stratified by clinical deterioration (defined as either ICU admission, invasive mechanical ventilation, or death within 28 days from the initial symptom onset) and time from symptom onset to their scan.

Results: N = 22 patients (N = 36 scans) were included. Eleven (50%) patients experienced clinical deterioration. Among N = 36 scans, only 3 (8%) were classified as normal. The remaining scans demonstrated B-lines (89%), consolidations (56%), pleural thickening (47%), and pleural effusion (11%). Scans from patients with clinical deterioration demonstrated higher percentages of bilateral consolidations (50 versus 15%; P = .033), anterior consolidations (47 versus 11%; P = .047), lateral consolidations (71 versus 29%; P = .030), pleural thickening (69 versus 30%; P = .045), but not B-lines (100 versus 80%; P = .11). Abnormal findings had similar prevalences between scans collected 0-6 days and 14-28 days from symptom onset.

Discussion: Certain LUS findings may be common in hospitalized COVID-19 patients, especially for those that experience clinical deterioration. These findings may occur anytime throughout the first 28 days of illness. Future efforts should investigate the predictive utility of these findings on clinical outcomes.
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http://dx.doi.org/10.1002/jum.15683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014702PMC
March 2021

Clinical trials in a COVID-19 pandemic: Shared infrastructure for continuous learning in a rapidly changing landscape.

Clin Trials 2021 Feb 3:1740774520988298. Epub 2021 Feb 3.

Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.

Background: Clinical trials, conducted efficiently and with the utmost integrity, are a key component in identifying effective vaccines, therapies, and other interventions urgently needed to solve the COVID-19 crisis. Yet launching and implementing trials with the rigor necessary to produce convincing results is a complicated and time-consuming process. Balancing rigor and efficiency involves relying on designs that employ flexible features to respond to a fast-changing landscape, measuring valid endpoints that result in translational actions and disseminating findings in a timely manner. We describe the challenges involved in creating infrastructure with potential utility for shared learning.

Methods: We have established a shared infrastructure that borrows strength across multiple trials. The infrastructure includes an endpoint registry to aid in selecting appropriate endpoints, a registry to facilitate establishing a Data & Safety Monitoring Board, common data collection instruments, a COVID-19 dedicated design and analysis team, and a pragmatic platform protocol, among other elements.

Results: The authors have relied on the shared infrastructure for six clinical trials for which they serve as the Data Coordinating Center and have a design and analysis team comprising 15 members who are dedicated to COVID-19. The authors established a pragmatic platform to simultaneously investigate multiple treatments for the outpatient with adaptive features to add or drop treatment arms.

Conclusion: The shared infrastructure provides appealing opportunities to evaluate disease in a more robust manner with fewer resources and is especially valued during a pandemic where efficiency in time and resources is crucial. The most important element of the shared infrastructure is the pragmatic platform. While it may be the most challenging of the elements to establish, it may provide the greatest benefit to both patients and researchers.
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http://dx.doi.org/10.1177/1740774520988298DOI Listing
February 2021

Testing Hypnotizability by Phone: Development and Validation of the Remote Hypnotic Induction Profile (rHIP).

Int J Clin Exp Hypn 2021 Jan-Mar;69(1):94-111

PGSP-Stanford Psy.D. Consortium, Palo Alto University , California, USA.

Standard hypnotizability scales require physical contact or direct observation by tester and participant. The authors addressed this limitation by developing and testing the remote Hypnotic Induction Profile (rHIP), a hypnotizability test derived from the Hypnotic Induction Profile that is completed by telephone. To assess the validity of the rHIP, 56 volunteers naïve to hypnotizability testing completed both the HIP and the rHIP, with order of testing randomized. Results indicate a strong correlation between HIP and rHIP scores,  =.71(0.53-0.84), <.0001, and good concordance, difference =.03(-0.53, 0.59), =.91, independent of testing order. The rHIP had few complications. Possible advantages of using the rHIP include improving patient expectancy prior to scheduling a hypnosis session, increasing access to hypnotizability testing for remote interventions, and obviating resource-intensive in-person hypnotizability screening for trials that exclude subjects with certain scores.
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http://dx.doi.org/10.1080/00207144.2021.1827937DOI Listing
January 2021

Impact of the program on reproductive, maternal, newborn and child health and nutrition in Bihar, India: early results from a quasi-experimental study.

J Glob Health 2020 Dec 19;10(2):021002. Epub 2020 Dec 19.

Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, D.C., USA.

Background: The Government of Bihar (GoB) in India, the Bill and Melinda Gates Foundation and several non-governmental organisations launched the program aimed to support the GoB to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide. Here we summarise changes in indicators attained during the initial two-year pilot phase (2012-2013) of implementation in eight focus districts of approximately 28 million population, aimed to inform subsequent scale-up.

Methods: The quasi-experimental impact evaluation included statewide household surveys at two time points during the pilot phase: January-April 2012 ("baseline") including an initial cohort of beneficiaries and January-April 2014 ("midline") with a new cohort. The two arms were: 1) eight intervention districts, and 2) a comparison arm comprised of the remaining 30 districts in Bihar where interventions were not implemented. We analysed changes in indicators across the RMNCHN continuum of care from baseline to midline in intervention and comparison districts using a difference-in-difference analysis.

Results: Indicators in the two arms were similar at baseline. Overall, 40% of indicators (20 of 51) changed significantly from baseline to midline in the comparison districts unrelated to ; two-thirds (n = 13) of secular indicator changes were in a direction expected to promote health. Statistically significant impact attributable to the program was found for 10% (five of 51) of RMNCHN indicators. Positive impacts were most prominent for mother's behaviours in contraceptive utilisation.

Conclusions: The program had limited impact in improving health-related outcomes during the first two-year period covered by this evaluation. The program's theories of change and action were not powered to observe statistically significant differences in RMNCHN indicators within two years, but rather aimed to help inform program improvements and scale-up. Evaluation of large-scale programs such as using theory-informed, equity-sensitive (including gender), mixed-methods approaches can help elucidate causality and better explain pathways through which supply- and demand-side interventions contribute to changes in behaviour among the actors involved in the production of population-level health outcomes. Evidence from Bihar indicates that deep structural constraints in health system organisation and delivery of interventions pose substantial limitations on behaviour change among health care providers and beneficiaries.

Study Registration: ClinicalTrials.gov number NCT02726230.
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http://dx.doi.org/10.7189/jogh.10.021002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757842PMC
December 2020

Trends in reproductive, maternal, newborn and child health and nutrition indicators during five years of piloting and scaling-up of interventions in Bihar, India.

J Glob Health 2020 Dec;10(2):021003

Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.

Background: The program in Bihar implemented household and community-level interventions to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) in two phases: a first phase of intensive ancillary support to governmental implementation and innovation testing by non-government organisation (NGO) partners in eight focus districts (2012-2014), followed by a second phase of state-wide government-led implementation with techno-managerial assistance from NGOs (2014 onwards). This paper examines trends in RMNCHN indicators in the program's implementation districts from 2012-2017.

Methods: Eight consecutive rounds of cross-sectional Community-based Household Surveys conducted by CARE India in 2012-2017 provided comparable data on a large number of indicators of frontline worker (FLW) performance, mothers' behaviours, and facility-based care and outreach service delivery across the continuum of maternal and child care. Logistic regression, considering the complex survey design and sample weights generated by that design, was used to estimate trends using survey rounds 2-5 for the first phase in the eight focus districts and rounds 6-9 for the second phase in all 38 districts statewide, as well as the overall change from round 2-9 in focus districts. To aid in contextualising the results, indicators were also compared amongst the formerly focus and the non-focus districts at the beginning of the second phase.

Results: In the first phase, the levels of 34 out of 52 indicators increased significantly in the focus districts, including almost all indicators of FLW performance in antenatal and postnatal care, along with mother's birth preparedness, some breastfeeding practices, and immunisations. Between the two phases, 33 of 52 indicators declined significantly. In the second phase, the formerly focus districts experienced a rise in the levels of 14 of 50 indicators and a decline in the levels of 14 other indicators. There was a rise in the levels of 22 out of 50 indicators in the non-focus districts in the second phase, with a decline in the levels of 13 other indicators.

Conclusions: Improvements in indicators were conditional on implementation support to program activities at a level of intensity that was higher than what could be achieved at scale so far. Successes during the pilot phase of intensive support suggests that RMNCHN can be improved statewide in Bihar with sufficient investments in systems performance improvements.

Study Registration: ClinicalTrials.gov number NCT02726230.
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http://dx.doi.org/10.7189/jogh.10.021003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757843PMC
December 2020

Interobserver Agreement of Lung Ultrasound Findings of COVID-19.

J Ultrasound Med 2021 Jan 11. Epub 2021 Jan 11.

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

Background: Lung ultrasound (LUS) has received considerable interest in the clinical evaluation of patients with COVID-19. Previously described LUS manifestations for COVID-19 include B-lines, consolidations, and pleural thickening. The interrater reliability (IRR) of these findings for COVID-19 is unknown.

Methods: This study was conducted between March and June 2020. Nine physicians (hospitalists: n = 4; emergency medicine: n = 5) from 3 medical centers independently evaluated n = 20 LUS scans (n = 180 independent observations) collected from patients with COVID-19, diagnosed via RT-PCR. These studies were randomly selected from an image database consisting of COVID-19 patients evaluated in the emergency department with portable ultrasound devices. Physicians were blinded to any patient information or previous LUS interpretation. Kappa values (κ) were used to calculate IRR.

Results: There was substantial IRR on the following items: normal LUS scan (κ = 0.79 [95% CI: 0.72-0.87]), presence of B-lines (κ = 0.79 [95% CI: 0.72-0.87]), ≥3 B-lines observed (κ = 0.72 [95% CI: 0.64-0.79]). Moderate IRR was observed for the presence of any consolidation (κ = 0.57 [95% CI: 0.50-0.64]), subpleural consolidation (κ = 0.49 [95% CI: 0.42-0.56]), and presence of effusion (κ = 0.49 [95% CI: 0.41-0.56]). Fair IRR was observed for pleural thickening (κ = 0.23 [95% CI: 0.15-0.30]).

Discussion: Many LUS manifestations for COVID-19 appear to have moderate to substantial IRR across providers from multiple specialties utilizing differing portable devices. The most reliable LUS findings with COVID-19 may include the presence/count of B-lines or determining if a scan is normal. Clinical protocols for LUS with COVID-19 may require additional observers for the confirmation of less reliable findings such as consolidations.
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http://dx.doi.org/10.1002/jum.15620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013417PMC
January 2021

Evaluation of a large-scale reproductive, maternal, newborn and child health and nutrition program in Bihar, India, through an equity lens.

J Glob Health 2020 Dec 19;10(2):021011. Epub 2020 Dec 19.

Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.

Background: Despite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India.

Methods: Utilising survey-weighted logistic regression, we estimated programmatic impact using difference-in-difference estimators from Mathematica data collected at the beginning (2012, n = 10 174) and after two years of program implementation (2014, n = 9611). We also examined changes in disparities over time using eight rounds of Community-based Household Surveys (CHS) (2012-2017, n = 48 349) collected by CARE India.

Results: At baseline for the Mathematica data, least marginalised women generally performed desired health-related behaviours more frequently than the most marginalised. After two years, most disparities persisted. Disparities increased for skilled birth attendant identification [+16.2% (most marginalised) vs +32.6% (least marginalized),  < 0.01) and skin-to-skin care (+14.8% vs +20.4%,  < 0.05), and decreased for immediate breastfeeding (+10.4 vs -4.9,  < 0.01). For the CHS data, odds ratios compared the most to the least marginalised women as referent. Results demonstrated that disparities were most significant for indicators reliant on access to care such as delivery in a facility (OR range: 0.15 to 0.48) or by a qualified doctor (OR range: 0.08 to 0.25), and seeking care for complications (OR range: 0.26 to 0.64).

Conclusions: Disparities observed at baseline generally persisted throughout program implementation. The most significant disparities were observed amongst behaviours dependent upon access to care. Changes in disparities largely were due to improvements for the least marginalised women without improvements for the most marginalised. Equity-based assessments of programmatic impacts, including those of universal health approaches, must be undertaken to monitor disparities and to ensure equitable and sustainable benefits for all.

Study Registration: ClinicalTrials.gov number NCT02726230.
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http://dx.doi.org/10.7189/jogh.10.021011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759017PMC
December 2020

Health layering of self-help groups: impacts on reproductive, maternal, newborn and child health and nutrition in Bihar, India.

J Glob Health 2020 Dec 19;10(2):021007. Epub 2020 Dec 19.

Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.

Background: Self-help group (SHG) interventions have been widely studied in low and middle income countries. However, there is little data on specific impacts of health layering, or adding health education modules upon existing SHGs which were formed primarily for economic empowerment. We examined three SHG interventions from 2012-2017 in Bihar, India to test the hypothesis that health-layering of SHGs would lead to improved health-related behaviours of women in SHGs.

Methods: A model for health layering of SHGs - - was developed by the non-governmental organisation (NGO), Project Concern International, in 64 blocks of eight districts. Layering included health modules, community events and review mechanisms. The health layering model was adapted for use with government-led SHGs, called JEEViKAHL, in 37 other blocks of Bihar. Scale-up of government-led SHGs without health layering (JEEViKA) occurred contemporaneously in 433 other blocks, providing a natural comparison group. Using Community-based Household Surveys (CHS, rounds 6-9) by CARE India, 62 reproductive, maternal, newborn and child health and nutrition (RMNCHN) and sanitation indicators were examined for SHGs with health layering ( SHGs and JEEViKA+HL SHGs) compared to those without. We calculated mean, standard deviation and odds ratios of indicators using surveymeans and survey logistic regression.

Results: In 2014, 64% of indicators were significantly higher in members compared to non-members residing in the same blocks. During scale up, from 2015-17, half (50%) of indicators had significantly higher odds in health layered SHG members ( or JEEViKA+HL) in 101 blocks compared to SHG members without health layering (JEEViKA) in 433 blocks.

Conclusions: Health layering of SHGs was demonstrated by an NGO-led model (), adapted and scaled up by a government model (JEEViKA+HL), and associated with significant improvements in health compared to non-health-layered SHGs (JEEViKA). These results strengthen the evidence base for further layering of health onto the SHG platform for scale-level health change.

Study Registration: ClinicalTrials.gov number NCT02726230.
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http://dx.doi.org/10.7189/jogh.10.021007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759023PMC
December 2020

Health impact of self-help groups scaled-up statewide in Bihar, India.

J Glob Health 2020 Dec 19;10(2):021006. Epub 2020 Dec 19.

Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.

Background: The objective of this study was to assess the impact of self-help groups (SHGs) and subsequent scale-up on reproductive, maternal, newborn, child health, and nutrition (RMNCHN) and sanitation outcomes among marginalised women in Bihar, India from 2014-2017.

Methods: We examined RMNCHN and sanitation behaviors in women who were members of any SHGs compared to non-members, without differentiating between types of SHGs. We analysed annual surveys across 38 districts of Bihar covering 62 690 women who had a live birth in the past 12 months. All analyses utilised data from Community-based Household Surveys (CHS) rounds 6-9 collected in 2014-2017 by CARE India as part of the Bihar Technical Support Program funded by the Bill & Melinda Gates Foundation. We examined 66 RMNCHN and sanitation indicators using survey logistic regression; the comparison group in all cases was age-comparable women from the geographic contexts of the SHG members but who did not belong to SHGs. We also examined links between discussion topics in SHGs and changes in relevant behaviours, and stratification of effects by parity and mother's age.

Results: SHG members had higher odds compared to non-SHG members for 60% of antenatal care indicators, 22% of delivery indicators, 70% of postnatal care indicators, 50% of nutrition indicators, 100% of family planning and sanitation indicators and no immunisation indicators measured. According to delivery platform, most FLW performance indicators (80%) had increased odds, followed by maternal behaviours (57%) and facility care and outreach service delivery (22%) compared to non-SHG members. Self-report of discussions within SHGs on specific topics was associated with increased related maternal behaviours. Younger SHG members (<25 years) had attenuated health indicators compared to older group members (≥25 years), and women with more children had more positive indicators compared to women with fewer children.

Conclusions: SHG membership was associated with improved RMNCHN and sanitation indicators at scale in Bihar, India. Further work is needed to understand the specific impacts of health layering upon SHGs. Working through SHGs is a promising vehicle for improving primary health care.

Study Registration: ClinicalTrials.gov number NCT02726230.
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http://dx.doi.org/10.7189/jogh.10.021006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7761401PMC
December 2020

Impact of mHealth interventions for reproductive, maternal, newborn and child health and nutrition at scale: BBC Media Action and the program in Bihar, India.

J Glob Health 2020 Dec 19;10(2):021005. Epub 2020 Dec 19.

Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.

Background: Mobile health (mHealth) tools have potential for improving the reach and quality of health information and services through community health workers in low- and middle-income countries. This study evaluates the impact of an mHealth tool implemented at scale as part of the statewide reproductive,maternal, newborn and child health and nutrition (RMNCHN) program in Bihar, India.

Methods: Three survey-based data sets were analysed to compare the health-related knowledge, attitudes and behaviours amongst childbearing women exposed to the Mobile and Dr. Anita mHealth tools during their visits with frontline workers compared with those who were unexposed.

Results: An evaluation by Mathematica (2014) revealed that exposure to Mobile and Dr. Anita recordings were associated with significantly higher odds of consuming iron-folic acid tablets (odds ratio (OR) = 2.3, 95% confidence interval (CI) = 1.8-3.1) as well as taking a set of three measures for delivery preparedness (OR = 2.8, 95% CI = 1.9-4.2) and appropriate infant complementary feeding (OR = 1.9, 95% CI = 1.0-3.5). CARE India's Community-based Household Surveys (2012-2017) demonstrated significant improvements in early breastfeeding (OR = 1.64, 95% CI = 1.5-1.78) and exclusive breastfeeding (OR = 1.46, 95% CI = 1.33-1.62) in addition to birth preparedness practices. BBC Media Action's Usage & Engagement Survey (2014) demonstrated a positive association between exposure to Mobile and Dr. Anita and exclusive breastfeeding (58% exposed vs 43% unexposed,  < 0.01) as well as maternal respondents' trust in their frontline worker.

Conclusions: Significant improvements in RMNCHN-related knowledge and behaviours were observed for Bihari women who were exposed to Mobile and Dr. Anita. This analysis is unique in its rigorous evaluation across multiple data sets of mHealth interventions implemented at scale. These results can help inform global understanding of how best to use mHealth tools, for whom, and in what contexts.

Study Registration: ClinicalTrials.gov number NCT02726230.
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http://dx.doi.org/10.7189/jogh.10.021005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758913PMC
December 2020

Factors Associated with Hospital-Acquired Delirium in Patients 18-65 Years Old.

J Gen Intern Med 2021 Apr 8;36(4):1147-1149. Epub 2021 Jan 8.

, Stanford, USA.

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http://dx.doi.org/10.1007/s11606-020-06378-wDOI Listing
April 2021

Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of .

J Glob Health 2020 Dec;10(2):021001

CARE India, Patna, India.

In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Lessons for primary health care performance improvement - seeks to provide a broad description of and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.
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http://dx.doi.org/10.7189/jogh.10.021001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757841PMC
December 2020

Enhancing Social Initiations Using Naturalistic Behavioral Intervention: Outcomes from a Randomized Controlled Trial for Children with Autism.

J Autism Dev Disord 2021 Jan 2. Epub 2021 Jan 2.

Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, 401 Quarry Road, Stanford, CA, 94305-5719, USA.

Deficits in social skills are common in children with Autism Spectrum Disorder (ASD), and there is an urgent need for effective social skills interventions, especially for improving interactions with typically developing peers. This study examined the effects of a naturalistic behavioral social skills intervention in improving social initiations to peers through a randomized controlled trial. Analyses of multimethod, multi-informant measures indicated that children in the active group (SIMI) demonstrated greater improvement in the types of initiations which were systematically prompted and reinforced during treatment (i.e., behavior regulation). Generalization to joint attention and social interaction initiation types, as well as collateral gains in broader social functioning on clinician- and parent-rated standardized measures were also observed.
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http://dx.doi.org/10.1007/s10803-020-04787-8DOI Listing
January 2021

Reduction in Osteoarthritis Risk After Treatment With Ticagrelor Compared to Clopidogrel: A Propensity Score-Matching Analysis.

Arthritis Rheumatol 2020 11 3;72(11):1829-1835. Epub 2020 Oct 3.

Stanford University, Stanford, California.

Objective: Osteoarthritis (OA) is a common cause of joint pain and disability, and effective treatments are lacking. Extracellular adenosine has antiinflammatory effects and can prevent and treat OA in animal models. Ticagrelor and clopidogrel are both used in patients with coronary artery disease, but only ticagrelor increases extracellular adenosine levels. This study was undertaken to determine whether treatment with ticagrelor was associated with a lower risk of OA.

Methods: We conducted a 1:2 propensity score-matching analysis using data from 2011-2017 in the Optum Clinformatics Data Mart. Patients who had received either ticagrelor or clopidogrel for ≥90 days were included in our study, and patients with a prior diagnosis of OA or inflammatory arthritis were excluded. OA was identified using International Classification of Diseases codes. The primary outcome was the time to diagnosis of OA after treatment with ticagrelor versus clopidogrel.

Results: Our propensity score-matched cohort consisted of 7,007 ticagrelor-treated patients and 14,014 clopidogrel-treated patients, with a median number of days receiving treatment of 287 and 284, respectively. For both groups, the mean age was 64 years, and 73% of the patients were male. Multivariate Cox regression analysis estimated a hazard ratio for developing OA of 0.71 (95% confidence interval 0.64-0.79) (P < 0.001) after treatment with ticagrelor compared to clopidogrel.

Conclusion: Treatment with ticagrelor was associated with a 29% lower risk of developing OA compared to treatment with clopidogrel over 5 years of follow-up. We hypothesize that the reduction in OA seen in patients who received ticagrelor may in part be due to increased extracellular adenosine levels.
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http://dx.doi.org/10.1002/art.41412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722213PMC
November 2020

Direct versus indirect bypass procedure for the treatment of ischemic moyamoya disease: results of an individualized selection strategy.

J Neurosurg 2020 Jun 12:1-12. Epub 2020 Jun 12.

1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine.

Objective: The only effective treatment for ischemic moyamoya disease (iMMD) is cerebral revascularization by an extracranial to intracranial bypass. The preferred revascularization method remains controversial: direct versus indirect bypass. The purpose of this study was to test the hypothesis that method choice should be personalized based on angiographic, hemodynamic, and clinical characteristics to balance the risk of perioperative major stroke against treatment efficacy.

Methods: Patients with iMMD were identified retrospectively from a prospectively maintained database. Those with mild to moderate internal carotid artery or M1 segment stenosis, preserved cerebrovascular reserve, intraoperative M4 segment anterograde flow ≥ 8 ml/min, or the absence of frequent and severe transient ischemic attacks (TIAs) or stroke had been assigned to indirect bypass. The criteria for direct bypass were severe ICA or M1 segment stenosis or occlusion, impaired cerebrovascular reserve or steal phenomenon, intraoperative M4 segment retrograde flow or anterograde flow < 8 ml/min, and the presence of frequent and severe TIAs or clinical strokes. The primary study endpoint was MRI-confirmed symptomatic stroke ≤ 7 days postoperatively resulting in a decline in the modified Rankin Scale (mRS) score from preoperatively to 6 months postoperatively. As a secondary endpoint, the authors assessed 6-month postoperative DSA-demonstrated revascularization, which was classified as < 1/3, 1/3-2/3, or > 2/3 of the middle cerebral artery territory.

Results: One hundred thirty-eight patients with iMMD affecting 195 hemispheres revascularized in the period from March 2016 to June 2018 were included in this analysis. One hundred thirty-three hemispheres were revascularized with direct bypass and 62 with indirect bypass. The perioperative stroke rate was 4.7% and 6.8% in the direct and indirect groups, respectively (p = 0.36). Degree of revascularization was higher in the direct bypass group (p = 0.03). The proportion of patients improving to an mRS score 0-1 (from preoperatively to 6 months postoperatively) tended to be higher in the direct bypass group, although the difference between the two bypass groups was not statistically significant (p = 0.27).

Conclusions: The selective use of an indirect bypass procedure for iMMD did not decrease the perioperative stroke rate. Direct bypass provided a significantly higher degree of revascularization. The authors conclude that direct bypass is the treatment of choice for iMMD.
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http://dx.doi.org/10.3171/2020.3.JNS192847DOI Listing
June 2020

Timing and Predictors of Subspecialty Career Choice Among Internal Medicine Residents: A Retrospective Cohort Study.

J Grad Med Educ 2020 Apr;12(2):212-216

Background: Internal medicine residents face numerous career options after residency training. Little is known about when residents make their final career choice.

Objective: We assessed the timing and predictive factors of final career choices among internal medicine residents at graduation, including demographics, pre-residency career preferences, and rotation scheduling.

Methods: We conducted a retrospective study of graduates of an academic internal medicine residency program from 2014 to 2017. Main measures included demographics, rotation schedules, and self-reported career choices for residents at 5 time points: recruitment day, immediately after Match Day, end of postgraduate year 1 (PGY-1), end of PGY-2, and at graduation.

Results: Of the 138 residents eligible for the study, 5 were excluded based on participation in a fast-track program for an Accreditation Council for Graduate Medical Education subspecialty fellowship. Among the remaining 133 residents, 48 (36%) pursued general internal medicine fields and 78 (59%) pursued fellowship training. Career choices from recruitment day, Match Day, and PGY-1 were only weakly predictive of the career choice. Many choices demonstrated low concordance throughout training, and general medicine fields (primary care, hospital medicine) were frequently not decided until after PGY-2. Early clinical exposure to subspecialty rotations did not predict final career choice.

Conclusions: Early career choices before and during residency training may have low predictability toward final career choices upon graduation in internal medicine. These choices may continue to have low predictability beyond PGY-2 for many specialties. Early clinical exposure may not predict final career choice for subspecialties.
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http://dx.doi.org/10.4300/JGME-D-19-00556.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161324PMC
April 2020

Improvement in Patient Safety May Precede Policy Changes: Trends in Patient Safety Indicators in the United States, 2000-2013.

J Patient Saf 2020 Mar 25. Epub 2020 Mar 25.

From the Department of Medicine, Center for Biomedical Informatics Research, Stanford University, Stanford, California.

Objectives: Quality and safety improvement are global priorities. In the last two decades, the United States has introduced several payment reforms to improve patient safety. The Agency for Healthcare Research and Quality (AHRQ) developed tools to identify preventable inpatient adverse events using administrative data, patient safety indicators (PSIs). The aim of this study was to assess changes in national patient safety trends that corresponded to U.S. pay-for-performance reforms.

Methods: This is a retrospective, longitudinal analysis to estimate temporal changes in 13 AHRQ's PSIs. National inpatient sample from the AHRQ and estimates were weighted to represent a national sample. We analyzed PSI trends, Center for Medicaid and Medicare Services payment policy changes, and Inpatient Prospective Payment System regulations and notices between 2000 and 2013.

Results: Of the 13 PSIs studied, 10 had an overall decrease in rates and 3 had an increase. Joinpoint analysis showed that 12 of 13 PSIs had decreasing or stable trends in the last 5 years of the study. Central-line blood stream infections had the greatest annual decrease (-31.1 annual percent change between 2006 and 2013), whereas postoperative respiratory failure had the smallest decrease (-3.5 annual percent change between 2005 and 2013). With the exception of postoperative hip fracture, significant decreases in trends preceded federal payment reform initiatives.

Conclusions: National in-hospital patient safety has significantly improved between 2000 and 2015, as measured by PSIs. In this study, improvements in PSI trends often proceeded policies targeting patient safety events, suggesting that intense public discourses targeting patient safety may drive national policy reforms and that these improved trends may be sustained by the Center for Medicare and Medicaid Services policies that followed.
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http://dx.doi.org/10.1097/PTS.0000000000000615DOI Listing
March 2020

Surgical Comanagement by Hospitalists: Continued Improvement Over 5 Years.

J Hosp Med 2020 04 11;15(4):232-235. Epub 2020 Feb 11.

Division of Hospital Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.

Surgical comanagement (SCM), in which surgeons and hospitalists share responsibility of care for surgical patients, has been increasingly utilized. In August 2012, we implemented SCM in Orthopedic and Neurosurgery services in which the same Internal Medicine hospitalists are dedicated year round to each of these surgical services to proactively prevent and manage medical conditions. In this article, we evaluate if SCM was associated with continued improvement in patient outcomes between 2012 and 2018 in Orthopedic and Neurosurgery services at our institution. We conducted regression analysis on 26,380 discharges to assess yearly change in our outcomes. Since 2012, the odds of patients with ≥1 medical complication decreased by 3.8% per year (P = .01), the estimated length of stay decreased by 0.3 days per year (P < .0001), and the odds of rapid response team calls decreased by 12.2% per year (P = .001). Estimated average direct cost savings were $3,424 per discharge.
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http://dx.doi.org/10.12788/jhm.3363DOI Listing
April 2020

Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial.

J Hosp Med 2020 Feb 11;15(2):e1-e6. Epub 2020 Feb 11.

Department of Medicine, Stanford University School of Medicine, Stanford, California.

Background: Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage.

Objective: This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS.

Methods: Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures.

Results: Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores.

Conclusions: Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.
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http://dx.doi.org/10.12788/jhm.3351DOI Listing
February 2020

Use of mobile technology by frontline health workers to promote reproductive, maternal, newborn and child health and nutrition: a cluster randomized controlled Trial in Bihar, India.

J Glob Health 2019 Dec;9(2):0204249

Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.

Background: mHealth technology holds promise for improving the effectiveness of frontline health workers (FLWs), who provide most health-related primary care services, especially reproductive, maternal, newborn, child health and nutrition services (RMNCHN), in low-resource - especially hard-to-reach - settings. Data are lacking, however, from rigorous evaluations of mHealth interventions on delivery of health services or on health-related behaviors and outcomes.

Methods: The Information Communication Technology-Continuum of Care Service (ICT-CCS) tool was designed for use by community-based FLWs to increase the coverage, quality and coordination of services they provide in Bihar, India. It consisted of numerous mobile phone-based job aids aimed to improve key RMNCHN-related behaviors and outcomes. ICT-CCS was implemented in Saharsa district, with cluster randomization at the health sub-center level. In total, evaluation surveys were conducted with approximately 1100 FLWs and 3000 beneficiaries who had delivered an infant in the previous year in the catchment areas of intervention and control health sub-centers, about half before implementation (mid-2012) and half two years afterward (mid-2014). Analyses included bivariate and difference-in-difference analyses across study groups.

Results: The ICT-CCS intervention was associated with more frequent coordination of AWWs with ASHAs on home visits and greater job confidence among ASHAs. The intervention resulted in an 11 percentage point increase in FLW antenatal home visits during the third trimester ( = 0.04). In the post-implementation period, postnatal home visits during the first week were increased in the intervention (72%) vs the control (60%) group ( < 0.01). The intervention also resulted in 13, 12, and 21 percentage point increases in skin-to-skin care ( < 0.01), breastfeeding immediately after delivery ( < 0.01), and age-appropriate complementary feeding ( < 0.01). FLW supervision and other RMNCHN behaviors were not significantly impacted.

Conclusions: Important improvements in FLW home visits and RMNCHN behaviors were achieved. The ICT-CCS tool shows promise for facilitating FLW effectiveness in improving RMNCHN behaviors.
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http://dx.doi.org/10.7189/jogh.09.020424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6875677PMC
December 2019

Development and validation of a predictive model for American Society of Anesthesiologists Physical Status.

BMC Health Serv Res 2019 Nov 21;19(1):859. Epub 2019 Nov 21.

Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, California, 94025, USA.

Background: The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes.

Methods: Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator.

Results: Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.
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http://dx.doi.org/10.1186/s12913-019-4640-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868867PMC
November 2019

Trajectory analysis for postoperative pain using electronic health records: A nonparametric method with robust linear regression and K-medians cluster analysis.

Health Informatics J 2020 06 17;26(2):1404-1418. Epub 2019 Oct 17.

Stanford University, USA.

Postoperative pain scores are widely monitored and collected in the electronic health record, yet current methods fail to fully leverage the data with fast implementation. A robust linear regression was fitted to describe the association between the log-scaled pain score and time from discharge after total knee replacement. The estimated trajectories were used for a subsequent K-medians cluster analysis to categorize the longitudinal pain score patterns into distinct clusters. For each cluster, a mixture regression model estimated the association between pain score and time to discharge adjusting for confounding. The fitted regression model generated the pain trajectory pattern for given cluster. Finally, regression analyses examined the association between pain trajectories and patient outcomes. A total of 3442 surgeries were identified with a median of 22 pain scores at an academic hospital during 2009-2016. Four pain trajectory patterns were identified and one was associated with higher rates of outcomes. In conclusion, we described a novel approach with fast implementation to model patients' pain experience using electronic health records. In the era of big data science, clinical research should be learning from all available data regarding a patient's episode of care instead of focusing on the "average" patient outcomes.
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http://dx.doi.org/10.1177/1460458219881339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012003PMC
June 2020

Effects of team-based goals and non-monetary incentives on front-line health worker performance and maternal health behaviours: a cluster randomised controlled trial in Bihar, India.

BMJ Glob Health 2019 26;4(4):e001146. Epub 2019 Aug 26.

Department of Pediatrics and Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, USA.

Introduction: We evaluated the impact of a 'Team-Based Goals and Incentives' (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition.

Methods: This study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention's team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year.

Results: The TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid (IFA) tablets (7 PP, p=0.02), but non-significant changes in other health behaviours related to the trial's goals. Improvements were seen in selected attitudes related to coordination and teamwork among FLWs, and in the provision of advice to beneficiaries (ranging from 8 to 14 PP) related to IFA, cord care, breast feeding, complementary feeding and family planning.

Conclusion: Results suggest that combining an integrated set of team-based coverage goals and targets, small non-cash incentives for teams who meet targets and team building to motivate FLWs resulted in improvements in FLW coordination and teamwork, and in the quality and quantity of FLW-beneficiary interactions. These improvements represent programmatically meaningful steps towards improving health behaviours and outcomes.

Trial Registration Number: NCT03406221.
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http://dx.doi.org/10.1136/bmjgh-2018-001146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6730593PMC
August 2019

Community Pediatric Hospitalist Workload: Results from a National Survey.

J Hosp Med 2019 11 16;14(11):682-685. Epub 2019 Aug 16.

University of Chicago, Pritzker School of Medicine, Chicago, Illinois.

As a newly recognized subspecialty, understanding programmatic models for pediatric hospital medicine (PHM) programs is vital to lay the groundwork for a sustainable field. Although variability has been described within university-based PHM programs, there remains no national benchmark for community-based PHM programs. In this report, we describe the workload, clinical services, employment, and perception of sustainability of 70 community-based PHM programs in 29 states through a survey of community site leaders. The median hours for a full-time hospitalist was 1,882 hours/year with those employed by community hospitals working 8% more hours/year and viewing appropriate morning pediatric census as 20% higher than those employed by university institutions. Forty-three out of 70 (63%) site leaders perceived their programs as sustainable, with no significant difference by employer structure. Future studies should further explore root causes for workload discrepancies between community and academic employed programs along with establishing potential standards for PHM program development.
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http://dx.doi.org/10.12788/jhm.3263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827543PMC
November 2019

Utility of a Quantitative Approach Using Diffusion Tensor Imaging for Prognostication Regarding Motor and Functional Outcomes in Patients With Surgically Resected Deep Intracranial Cavernous Malformations.

Neurosurgery 2020 05;86(5):665-675

Stanford Stroke Center, Department of Neurosurgery, Stanford University School of Medicine, Stanford, California.

Background: Resection of deep intracranial cavernous malformations (CMs) is associated with a higher risk of neurological deterioration and uncertainty regarding clinical outcomes.

Objective: To examine diffusion tractography imaging (DTI) data evaluating the corticospinal tract (CST) in relation to motor and functional outcomes in patients with surgically resected deep CMs.

Methods: Perilesional CST was characterized as disrupted, displaced, or normal. Mean fractional anisotropy (FA) values were obtained for whole ipsilateral CST and in 3 regions: subcortical (proximal), perilesional, and distally. Mean FA values in anatomically equivalent regions in the contralateral CST were obtained. Clinical and radiological data were collected independently. Multivariable regression analysis was used for statistical analysis.

Results: A total of 18 patients [brainstem (15) and thalamus/basal ganglia (3); median follow-up: 270 d] were identified over 2 yr. The CST was identified preoperatively as disrupted (6), displaced (8), and normal (4). Five of 6 patients with disruption had weakness. Higher preoperative mean FA values for distal ipsilateral CST segment were associated with better preoperative lower (P < .001), upper limb (P = .004), postoperative lower (P = .005), and upper limb (P < .001) motor examination. Preoperative mean FA values for distal ipsilateral CST segment (P = .001) and contralateral perilesional CST segment (P < .001) were negatively associated with postoperative modified Rankin scale scores.

Conclusion: Lower preoperative mean FA values for overall and defined CST segments corresponded to worse patient pre- and postoperative motor examination and/or functional status. FA value for the distal ipsilateral CST segment has prognostic potential with respect to clinical outcomes.
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http://dx.doi.org/10.1093/neuros/nyz259DOI Listing
May 2020