Studying the impact of translational genomic research: Lessons from eMERGE.

Two major goals of the Electronic Medical Record and Genomics (eMERGE) Network are to learn how best to return research results to patient/participants and the clinicians who care for them and also to assess the impact of placing these results in clinical care. Yet since its inception, the Network has confronted a host of challenges in achieving these goals, many of which had ethical, legal, or social implications (ELSIs) that required consideration. Here, we share impediments we encountered in recruiting participants, returning results, and assessing their impact, all of which affected our ability to achieve the goals of eMERGE, as well as the steps we took to attempt to address these obstacles. We divide the domains in which we experienced challenges into four broad categories: (1) study design, including recruitment of more diverse groups; (2) consent; (3) returning results to participants and their health care providers (HCPs); and (4) assessment of follow-up care of participants and measuring the impact of research on participants and their families. Since most phases of eMERGE have included children as well as adults, we also address the particular ELSI posed by including pediatric populations in this research. We make specific suggestions for improving translational genomic research to ensure that future projects can effectively return results and assess their impact on patient/participants and providers if the goals of genomic-informed medicine are to be achieved.

The prevalence of impostor phenomenon and its association with burnout amongst urologists.

OBJECTIVES: To characterise the prevalence of impostor phenomenon (IP; tendency for high-achieving individuals to perceive themselves as fraudulent in their successes) amongst attending staff in urology, to identify variables that predict more severe impostorism, and to study the association of IP with burnout. SUBJECTS AND METHODS: A survey composed of the Clance Impostor Phenomenon Scale (CIPS), demographic information, practice details, and burnout levels was e-mailed to urologists via urological subspecialty societies. Survey results were analysed to identify associations between IP severity, survey respondent characteristics, and symptoms of professional burnout. This study was conducted in the United States of America. RESULTS: A total of 614 survey responses were received (response rate 11.0%). In all, 40% (n = 213) of responders reported CIPS scores qualifying as either 'frequent' or 'intense' impostorism (i.e., scores of 61-100). On multivariable analysis, female gender, fewer years in practice (i.e., 0-2 years), and lower academic rank were all independently associated with higher CIPS scores (adjusted P < 0.05). Regarding burnout, 46% of responders reported burnout symptoms. On multivariable analysis, increase in CIPS score was independently associated with higher odds of burnout (odds ratio 1.06, 95% confidence interval 1.04-1.07; P < 0.001). CONCLUSION: Impostor phenomenon is prevalent in the urological community and is experienced more severely in younger and female urologists. IP is also independently associated with burnout. Increased female representation may improve IP amongst our female colleagues. More work is needed to determine strategies that are effective in mitigating feelings of IP and professional burnout amongst urologists, particularly those earlier in their careers.

Arrhythmias as Presentation of Genetic Cardiomyopathy.

There is increasing evidence regarding the prevalence of genetic cardiomyopathies, for which arrhythmias may be the first presentation. Ventricular and atrial arrhythmias presenting in the absence of known myocardial disease are often labelled as idiopathic, or lone. While ventricular arrhythmias are well-recognized as presentation for arrhythmogenic cardiomyopathy in the right ventricle, the scope of arrhythmogenic cardiomyopathy has broadened to include those with dominant left ventricular involvement, usually with a phenotype of dilated cardiomyopathy. In addition, careful evaluation for genetic cardiomyopathy is also warranted for patients presenting with frequent premature ventricular contractions, conduction system disease, and early onset atrial fibrillation, in which most detected genes are in the cardiomyopathy panels. Sudden death can occur early in the course of these genetic cardiomyopathies, for which risk is not adequately tracked by left ventricular ejection fraction. Only a few of the cardiomyopathy genotypes implicated in early sudden death are recognized in current indications for implantable cardioverter defibrillators which otherwise rely upon a left ventricular ejection fraction ≤0.35 in dilated cardiomyopathy. The genetic diagnoses impact other aspects of clinical management such as exercise prescription and pharmacological therapy of arrhythmias, and new therapies are coming into clinical investigation for specific genetic cardiomyopathies. The expansion of available genetic information and implications raises new challenges for genetic counseling, particularly with the family member who has no evidence of a cardiomyopathy phenotype and may face a potentially negative impact of a genetic diagnosis. Discussions of risk for both probands and relatives need to be tailored to their numeric literacy during shared decision-making. For patients presenting with arrhythmias or cardiomyopathy, extension of genetic testing and its implications will enable cascade screening, intervention to change the trajectory for specific genotype-phenotype profiles, and enable further development and evaluation of emerging targeted therapies.

The Media and Sexual Violence Among Adolescents: Findings from a Qualitative Study of Educators Across Vietnam.

Growing access to technology and media has presented new avenues of influence on youth attitudes and norms regarding sexuality and sexual violence, as well as new technological pathways through which to perpetrate sexual violence. The aim of this research was to understand contextual influences on and needs for scale-up of sexual violence prevention programming in the media-violence context of Vietnam. We conducted 45 interviews with high school teachers (n = 15), university lecturers (n = 15), and affiliates from youth-focused community service organizations (n = 15) from across Vietnam. Additionally, we conducted four sector-specific focus groups with a sub-sample of interview participants (k = 4, n = 22). Media and technology were brought up consistently in relation to sexual violence prevention and sexual health information. Key informants noted that, in Vietnam, generational differences in acceptability of sex and lack of comprehensive sexuality education intersect with new technological opportunities for exposure to sexual information and media. This creates a complex landscape that can promote sexual violence through priming processes, instigate mimicry of violent media, and presents new opportunities for the perpetration of sexual violence though technology. Development of comprehensive sexual education, including violence prevention education, is imperative, with consideration of age-specific needs for Vietnamese youth.

Development of the Vietnamese Rape Myths Acceptance Scales: A Web-Based Survey of Young Adults.

Rape myths-false but widely held beliefs that serve to deny and justify sexual aggression-present a major barrier to reporting and prevention of sexual violence in Vietnam and globally. Based on a parent study aimed at reducing sexual violence at two universities in Hanoi, we developed and assessed a contextualized measure of rape myths among young people in Vietnam. Items from previously validated rape myth acceptance (RMA) scales and data from qualitative research informed the development of 50 items, which were administered to Vietnamese 18-24-year-olds (n = 2,756 total, n = 1,798 cisgender women) via an anonymous link in February 2021. We used factor analysis to explore and test factor structure and multi-group factor analysis to assess measurement equivalence across gender. We calculated item-level discrimination and difficulty parameters and visualized information curves using item response theory analysis, informing the development of a short form. Four hypothesized subconstructs identified in the qualitative data emerged as factors: (1) "He didn't mean to"; (2) "She asked for it"; (3) "It wasn't really rape"; and (4) "Rape is a deviant event." A fifth factor, "She didn't protect herself," included four items from formative data. Confirming formative findings and prior literature, cisgender women had lower RMA than cisgender men, particularly on items related to victim-blaming. The Vietnamese Rape Myths Acceptance Scales were internally consistent and equivalent between cisgender men and women, capturing elements specific to the Vietnamese context and providing a tool for campus climate surveys and evaluations of sexual violence prevention programs.

The impact of intimate partner violence on PrEP adherence among U.S. Cisgender women at risk for HIV.

BACKGROUND: Cisgender women account for 1 in 5 new HIV infections in the United States, yet remain under-engaged in HIV prevention. Women experiencing violence face risk for HIV due to biological and behavioral mechanisms, and barriers to prevention, such as challenges to Pre-Exposure Prophylaxis for HIV Prevention (PrEP) adherence. In this analysis, we aim to characterize intimate partner violence (IPV) among cisgender heterosexual women enrolled in a PrEP demonstration project and assess the associations with PrEP adherence. METHODS: Adherence Enhancement Guided by Individualized Texting and Drug Levels (AEGiS) was a 48-week single-arm open-label study of PrEP adherence in HIV-negative cisgender women in Southern California (N = 130) offered daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC). From 6/2016 to 10/2018, women completed a survey reporting HIV risk behavior and experiences of any IPV (past 90-days) and IPV sub-types (past-year, lifetime) and biological testing for HIV/STIs at baseline, and concentrations of tenofovir-diphosphate (TFV-DP) in dried blood spots at weeks 4, 12, 24, 36, and 48. Outcomes were TFV-DP concentrations consistent with ≥ 4 or ≥ 6 doses/week at one or multiple visits. Multivariable logistic regression models were conducted to examine associations. RESULTS: Past-90-day IPV was reported by 34.4% of participants, and past-year and lifetime subtypes reported by 11.5-41.5%, and 21.5-52.3%, respectively. Women who engaged in sex work and Black women were significantly more likely to report IPV than others. Lifetime physical IPV was negatively associated with adherence at ≥ 4 doses/week at ≥ 3 of 5 visits, while other relationships with any IPV and IPV sub-types were variable. CONCLUSION: IPV is an indication for PrEP and important indicator of HIV risk; our findings suggest that physical IPV may also negatively impact long-term PrEP adherence. CLINICAL TRIALS REGISTRATION: NCT02584140 (ClinicalTrials.gov), registered 15/10/2015.

Most people share genetic test results with relatives even if the findings are normal: Family communication in a diverse population.

PURPOSE: With increasing utilization of genetic testing, sharing genetic information can become part of general family health communication while providing biological relatives with important information about their own genetic risk. Importantly, little is known about motivations for and barriers to family communication of genetic information in historically underserved populations. METHODS: Using mixed methods, we explored patient experiences with family communication in a study population of English- and Spanish-speaking adults aged 18 to 49 years, enriched for participants from historically underserved backgrounds. Risk screening for hereditary cancer guided genetic testing for cancer risk genes and other medically actionable findings. RESULTS: Most participants overall (91%), including most with normal findings (89%), shared or planned to share their results with relatives. Common motivations for sharing results were to give relatives information about their genetic risk and because the participant thought the results were interesting. Reasons for not sharing were limited contact with relatives, perceptions of limited clinical utility for relatives, and concern that discussion of genetic information was stigmatized or taboo. CONCLUSION: Results demonstrate high rates of sharing genetic information, indicate motivations for sharing go beyond facilitating genetic testing for relatives, and suggest general willingness to share genetic information as part of family health communication.

Characterization of Gender Differences in H-index Within Urological Subspecialties.

PURPOSE: Previous work in urology has shown that men have higher h-indices than women. However, the degree to which h-indices vary by gender within urological subspecialties has not been well defined. Herein, we assess gender differences in h-index among different subspecialties. MATERIALS AND METHODS: Demographics were recorded for academic urologists using residency program websites as of July 2021. Scopus was queried to identify h-indices. Gender differences in h-index were estimated from a linear mixed-effects regression model with fixed effects for gender, urological subspecialty, MD/PhD status, years since first publication, interactions of subspecialty with years since first publication, and interactions of subspecialty with gender and random effects for AUA section and institution nested within AUA section. The Holm method was used to adjust for multiplicity (7 hypothesis tests). RESULTS: Of 1,694 academic urologists from 137 institutions, 308 were women (18%). Median years since first publication was 20 for men (IQR 13, 29) and 13 for women (IQR 8, 17). Among all academic urologists, the median h-index was 8 points higher for men (15 [IQR 7, 27]) vs women (7 [IQR 5, 12]). There was no significant gender difference in h-index for any of the subspecialties after adjusting for urologist experience and after applying the Holm method for multiplicity correction. CONCLUSIONS: We were unable to demonstrate a gender difference in h-index after adjusting for urologist experience for any urological subspecialties. Future study is warranted as women become more senior members of the urological workforce.

Stigma manifestations in cardiomyopathy care impact outcomes for black patients: a qualitative study.

INTRODUCTION: Inequities in clinical care may contribute to racial disparities observed in studies of heart disease morbidity and cardiogenetic testing outcomes. There is a lack of research aimed at understanding the complexity of those inequities, but stigma likely contributes. This qualitative exploratory study helps close that gap in the literature by describing intersectional stigma manifestations perceived by the Black cardiomyopathy patient population at one academic medical center. METHODS: Qualitative interviews were conducted with 14 Black cardiomyopathy patients. Interviews aimed to elicit patients' experiences with discrimination related to diagnosis, symptoms, genetic testing, knowledge of genetic results, genetic counseling, providers' actions, and providers' communication. The interview guide was informed by The Health Stigma and Discrimination Framework. Data were also collected about participant demographics, type of cardiomyopathy, age of diagnosis, documentation of relevant family history, and completion of genetic counseling and/or genetic testing. RESULTS: More than half of participants reported intersectional stigma manifestations related to their race, age, and/or weight while receiving care from cardiologists, nurse practitioners, genetic counselors, or clinical support staff. Stigma manifestations included physical roughness during patient care, withholding diagnostically-relevant information from the patient, impersonal care, coercion, and use of offensive stereotyped language by providers. These stigma manifestations impacted access to care, uptake of genetic testing, timeline to diagnosis, patient emotion, patient-provider trust, and adherence to medical recommendations. CONCLUSIONS: This study provides nuanced qualitative descriptions of stigma manifestations that affect patient and clinical outcomes in cardiology care and genetic services in one medical center in the Southeastern United States. The results of this study suggest that provider bias and stigma manifestations have an adverse effect on cardiogenetic and clinical outcomes among Black cardiomyopathy patients. Clinical interventions are suggested to assist health professionals in providing culturally-competent and respectful care. These results help inform patient-provider communication, clinical policies, and evidence-based practice in cardiology care and genetics. Continued study of this topic across more institutions and with a larger sample size is needed to confirm the generalizability of the conclusions.

Preventing sexual violence in Vietnam: qualitative findings from high school, university, and civil society key informants across regions.

BACKGROUND: Sexual violence by young men against women is common, but efficacious primary prevention interventions tailored to men are limited in low- and middle-income settings like Vietnam. GlobalConsent, a web-based sexual violence prevention intervention tailored to university men in Hanoi, is efficacious. Implementation research is needed to understand facilitators and barriers to scaling GlobalConsent and prevention programs generally. We conducted qualitative research with key informants from three youth-focused organizational settings to understand the context of implementation in Vietnam. METHODS: Interviews with university (n = 15), high-school (n = 15) and non-governmental (n = 15) key informants focused on perceptions about sexual violence among young people and prevention programming. Four focus group discussions with 22 interviewed informants, following the Consolidated Framework for Implementation Research, asked about facilitators and barriers to implementing GlobalConsent. Narratives were transcribed, translated, and coded inductively and deductively to identify salient themes. RESULTS: Outer-setting influences included greater expectations for sex among young people alongside norms favoring men's sexual privilege, ostensibly ambiguous and lax laws on sexual violence, government ministries as bureaucratic but potential allies, external subject-matter experts, and the media. Inner-setting influences included variable cultures regarding openness to discuss sexual violence and equitable gender norms, variable departmental coordination, limited funding and 'red tape' especially in public institutions, inconsistent student access to technologies, and limited time and competing priorities among students and teachers. Several actors were considered influential, including institutional leaders, human-resource staff, the Youth Union, and student-facing staff. Important characteristics of individuals for implementation included subject-matter expertise, science or social science training, younger age, engagement in social justice related activities, and more open attitudes about sex. Regarding characteristics of sexual violence prevention programming, some participants preferred online formats for busy students while others suggested hybrid or in-person formats, peer education, and incentives. Participants generally accepted the content of GlobalConsent and suggested adding more content for women, ancillary support services, and adapted content for high-school students. CONCLUSIONS: Implementation of sexual violence prevention programs in youth-focused organizations in Vietnam requires multilevel strategies that connect outer-setting subject-matter experts with supportive inner-setting leaders and student-facing staff to overcome normative and organizational constraints, and thereby, to deliver institution-wide programming.

Integration of stakeholder engagement from development to dissemination in genomic medicine research: Approaches and outcomes from the CSER Consortium.

PURPOSE: There is a critical need for genomic medicine research that reflects and benefits socioeconomically and ancestrally diverse populations. However, disparities in research populations persist, highlighting that traditional study designs and materials may be insufficient or inaccessible to all groups. New approaches can be gained through collaborations with patient/community stakeholders. Although some benefits of stakeholder engagement are recognized, routine incorporation into the design and implementation of genomics research has yet to be realized. METHODS: The National Institutes of Health-funded Clinical Sequencing Evidence-Generating Research (CSER) consortium required stakeholder engagement as a dedicated project component. Each CSER project planned and carried out stakeholder engagement activities with differing goals and expected outcomes. Examples were curated from each project to highlight engagement strategies and outcomes throughout the research lifecycle from development through dissemination. RESULTS: Projects tailored strategies to individual study needs, logistical constraints, and other challenges. Lessons learned include starting early with engagement efforts across project stakeholder groups and planned flexibility to enable adaptations throughout the project lifecycle. CONCLUSION: Each CSER project used more than 1 approach to engage with relevant stakeholders, resulting in numerous adaptations and tremendous value added throughout the full research lifecycle. Incorporation of community stakeholder insight improves the outcomes and relevance of genomic medicine research.

An accessible, relational, inclusive, and actionable (ARIA) model of genetic counseling compared with usual care: Results of a randomized controlled trial.

PURPOSE: Effective approaches to communicate genomic information are needed to ensure equitable care. In a randomized controlled superiority trial, we tested a novel practice model that aims to make genetic counseling inclusive, by making the communication accessible, relational, and actionable (ARIA). METHODS: In total, 696 English- and Spanish-speaking patients aged 18 to 49 years, enriched for individuals from historically underserved backgrounds, were randomized in 1:1 ratio to ARIA or usual care. Primary outcomes were accuracy of recall, communication satisfaction, and perceived understanding. In total, 33 participants completed qualitative interviews. RESULTS: Recall and understanding were high for all participants. ARIA participants scored higher on the relationship scale of communication satisfaction (mean difference = 0.09, 95% CI = <0.01 to 0.17). Moderator analyses of communication satisfaction showed that those with lower health literacy reported less communication difficulty in ARIA and those using medical interpreters reported greater communication ease in ARIA. No significant difference was found on other primary and secondary outcomes. Qualitative data enhanced understanding of how and why ARIA can be effective. CONCLUSION: This study provides evidence that a genetic counseling intervention that focuses on specific communication skills to enhance relationship-building, patient engagement, and comprehension can be effective with all patients and may be especially valuable for patients of lower health literacy and Spanish-speakers who use a medical interpreter.

Defining Success after Anterior Urethroplasty: An Argument for a Universal Definition and Surveillance Protocol.

PURPOSE: A successful urethroplasty has been defined in different ways across studies. This variety in the literature makes it difficult to compare success rates and techniques across studies. We aim to evaluate the success of anterior urethroplasty based on different definitions of success in a single cohort. MATERIALS AND METHODS: Data were collected from a multi-institutional, prospectively maintained database. We included men undergoing first-time, single-stage, anterior urethroplasty between 2006 and 2020. Exclusion criteria included lack of followup, hypospadias, extended meatotomy, perineal urethrostomy, posterior urethroplasty and staged repairs. We compared 5 different ways to define a "failed" urethroplasty: 1) stricture retreatment, 2) anatomical recurrence on cystoscopy, 3) peak flow rate <15 ml/second, 4) weak stream on questionnaire and 5) failure by any of these measures. Kaplan-Meier survival curves were generated for each of the definitions. We also compared outcomes by stricture length, location and etiology. RESULTS: A total of 712 men met inclusion criteria, including completion of all types of followup. The 1- and 5-year estimated probabilities of success were "retreatment," 94% and 75%; "cystoscopy," 88% and 71%; "uroflow," 84% and 58%; "questionnaire," 67% and 37%; and "any failure," 57% and 23%. This pattern was inconsistent across stricture length, location and etiology. CONCLUSIONS: The estimated probability of success after first-time, anterior urethroplasty is highly dependent on the way success is defined. The variability in definitions in the literature has limited our ability to compare urethroplasty outcomes across studies.

A promoter variant in the OTC gene associated with late and variable age of onset hyperammonemia.

Ornithine transcarbamylase deficiency (OTCD) is an X-linked inborn error caused by loss of function variants in the OTC gene typically associated with severe neonatal hyperammonemia. Rare examples of late-onset OTCD have also been described. Here, we describe an OTC promoter variant, c.-106C>A, in a conserved HNF4a binding site, identified in two male siblings in Family 1 whose first and only recognized episodes of severe hyperammonemia occurred at ages 14 and 39 years, respectively. We identified the same OTC variant segregating in a large family with late-onset OTCD with variable expressivity (Family 2). We show that this OTC promoter variant reduces expression >5-fold in a dual-luciferase assay that tests promoter function. Addition of an upstream OTC enhancer increases expression of both the wild type and the c.-106C>A variant promoter constructs >5-fold with the mutant promoter still about fourfold lower than the wild type. Thus, in both contexts, the promoter variant results in substantially lower OTC expression. Under normal demand on urea cycle function, OTC expression in hemizygous males, although reduced, is sufficient to meet the demand for waste nitrogen excretion. However, in response to severe metabolic stress with attendant increased requirements on urea cycle function, the impaired promoter function results in inadequate OTC expression with resultant hyperammonemia. In the absence of precipitating events, hemizygotes with this allele are asymptomatic, explaining the late age of onset of hyperammonemia in affected individuals and the incomplete penetrance observed in some individuals in Family 2.

CDK19-related disorder results from both loss-of-function and gain-of-function de novo missense variants.

PURPOSE: To expand the recent description of a new neurodevelopmental syndrome related to alterations in CDK19. METHODS: Individuals were identified through international collaboration. Functional studies included autophosphorylation assays for CDK19 Gly28Arg and Tyr32His variants and in vivo zebrafish assays of the CDK19G28R and CDK19Y32H. RESULTS: We describe 11 unrelated individuals (age range: 9 months to 14 years) with de novo missense variants mapped to the kinase domain of CDK19, including two recurrent changes at residues Tyr32 and Gly28. In vitro autophosphorylation and substrate phosphorylation assays revealed that kinase activity of protein was lower for p.Gly28Arg and higher for p.Tyr32His substitutions compared with that of the wild-type protein. Injection of CDK19 messenger RNA (mRNA) with either the Tyr32His or the Gly28Arg variants using in vivo zebrafish model significantly increased fraction of embryos with morphological abnormalities. Overall, the phenotype of the now 14 individuals with CDK19-related disorder includes universal developmental delay and facial dysmorphism, hypotonia (79%), seizures (64%), ophthalmologic anomalies (64%), and autism/autistic traits (56%). CONCLUSION: CDK19 de novo missense variants are responsible for a novel neurodevelopmental disorder. Both kinase assay and zebrafish experiments showed that the pathogenetic mechanism may be more diverse than previously thought.

Application of the Consolidated Framework for Implementation Research to Facilitate Violence Screening in HIV Care Settings: a Review of the Literature.

PURPOSE OF REVIEW: This review summarizes the literature on violence screening practices within HIV care settings globally as well as identified salient multi-level barriers and facilitators for adopting and implementing violence screening within HIV care. We utilized the Consolidated Framework for Implementation Research (CFIR) to systematically identify multi-level factors related to violence screening within HIV services. RECENT FINDINGS: Across the 15 articles included, several highly salient CFIR constructs emerged as particularly relevant for violence screening adoption and implementation within HIV including inner setting factors, outer setting factors, as well as select constructs specific to characteristics of the violence screening process, the individuals charged with screening, and violence screening execution. This review underscores the importance of considering CFIR constructs to bolster successful violence screening implementation in HIV care settings. We describe several potential implementation strategies to overcome the most salient barriers identified across this limited body of summarized research.

Evaluation of surgical approaches for vesicovaginal fistulae repair: the case for transvaginal repair as the gold standard.

INTRODUCTION AND HYPOTHESIS: To highlight the success rates of two approaches of transvaginal vs. transabdominal closures for the vesicovaginal fistula (VVF) repair and to investigate the patient, fistula, and surgical factors relevant to surgical characteristics and successful outcomes. METHODS: Retrospective analysis of 66 consecutive patients who underwent VVF repair between 2005 and 2020. Fistula profile, operative data, and postoperative outcomes were analyzed. Primary outcome was success rate with regard to surgical approach. Secondary outcomes were to compare patients' and surgical characteristics with regard to surgical approach and correlate these characteristics relevant to surgical outcomes. RESULTS: A total of 66 women with a median age of 47 (27-82) years were included. Most (93.9%) of the VVFs were secondary to gynecological procedures. Thirteen (19.7%) patients had previous VVF repair. The median time from onset of leakage to surgical repair was 120 days. Forty-nine patients underwent transvaginal repair, whereas 17 (25.7%) women had abdominal repair. The success rates of transvaginal and abdominal techniques were 98% and 82%, respectively. Transvaginal approach had a significantly shorter operative time, less intraoperative blood loss, reduced hospital stay, and lower complication rates (p < 0.005). Age and time to surgery were positively and significantly correlated with surgical time [r (p value): 0.392 (0.003), (0.0386 (0.01)] and estimated blood loss [0.388 (0.002 and 0.410 (0.001)], respectively. CONCLUSION: Transvaginal repair of VVF is a technically feasible and successful approach with significantly better operative parameters and lower complications. Despite varied etiology and different surgical approach, age and time to surgery are the main factors that correlate with operative time and blood loss.

Racial and Ethnic Differences in COVID-19 Outcomes, Stressors, Fear, and Prevention Behaviors Among US Women: Web-Based Cross-sectional Study.

BACKGROUND: In the United States, racial and ethnic minorities are disproportionately affected by COVID-19, with persistent social and structural factors contributing to these disparities. At the intersection of race/ethnicity and gender, women of color may be disadvantaged in terms of COVID-19 outcomes due to their role as essential workers, their higher prevalence of pre-existing conditions, their increased stress and anxiety from the loss of wages and caregiving, and domestic violence. OBJECTIVE: The purpose of this study is to examine racial and ethnic differences in the prevalence of COVID-19 outcomes, stressors, fear, and prevention behaviors among adult women residing in the United States. METHODS: Between May and June 2020, women were recruited into the Capturing Women's Experiences in Outbreak and Pandemic Environments (COPE) Study, a web-based cross-sectional study, using advertisements on Facebook; 491 eligible women completed a self-administered internet-based cross-sectional survey. Descriptive statistics were used to examine racial and ethnic differences (White; Asian; Native Hawaiian or other Pacific Islander; Black; Hispanic, Latina, or Spanish Origin; American Indian or Alaskan Native; multiracial or some other race, ethnicity, or origin) on COVID-19 outcomes, stressors, fear, and prevention behaviors. RESULTS: Among our sample of women, 16% (73/470) reported COVID-19 symptoms, 22% (18/82) were concerned about possible exposure from the people they knew who tested positive for COVID-19, and 51.4% (227/442) knew where to get tested; yet, only 5.8% (27/469) had been tested. Racial/ethnic differences were observed, with racial/ethnic minority women being less likely to know where to get tested. Significant differences in race/ethnicity were observed for select stressors (food insecurity, not enough money, homeschooling children, unable to have a doctor or telemedicine appointment) and prevention behaviors (handwashing with soap, self-isolation if sick, public glove use, not leaving home for any activities). Although no racial/ethnic differences emerged from the Fear of COVID-19 Scale, significant racial/ethnic differences were observed for some of the individual scale items (eg, being afraid of getting COVID-19, sleep loss, and heart racing due to worrying about COVID-19). CONCLUSIONS: The low prevalence of COVID-19 testing and knowledge of where to get tested indicate a critical need to expand testing for women in the United States, particularly among racial/ethnic minority women. Although the overall prevalence of engagement in prevention behaviors was high, targeted education and promotion of prevention activities are warranted in communities of color, particularly with consideration for stressors and adverse mental health.

A Virtual Wellness and Learning Communities Program for Medical Students during the COVID-19 Pandemic.

OBJECTIVES: Numerous studies have demonstrated the high risk for burnout and mental illness in medical students. Because of the coronavirus disease 2019 (COVID-19) pandemic, our medical school transitioned to an all-virtual learning environment from March to June 2020, which raised concerns among student leaders and administrators, as reduced interpersonal attachments have known associations with decreased mental health. In an effort to facilitate student well-being during the pandemic, the Virtual Wellness and Learning Communities (VWLC) program was established. VWLC consisted of hour-long events that offered students the opportunity to engage with their peers online. METHODS: More than 20 events and workshops were conducted from March to June 2020, including trivia nights, song and guitar performances, sketching, video editing tutorials, chess lessons, yoga, and personal investing tips. An institutional review board-approved survey to assess the efficacy of the VWLC program was sent to medical student participants and nonparticipants. RESULTS: The overall response rate of this study was 43% (53/123). The response rate for students who attended a VWLC event was 51% (33/65), and the response rate for students who did not attend a VWLC event was 34% (20/58). Of all of the respondents, 85% (45/53) reported a decreased sense of connectivity with peers because of the pandemic, and 40% (21/53) reported a decrease in their sense of wellness. After attending a VWLC event, 79% (26/33) reported an increased sense of peer connectivity, 61% (20/33) reported improved wellness, and 55% (18/33) believed that these events should continue postpandemic to supplement in-person programming. Those who did not attend a virtual event stated that the main barriers to attending were unfamiliarity with attendees and screen fatigue. CONCLUSIONS: The COVID-19 pandemic has worsened medical student well-being and sense of community. VWLC programming may be an effective strategy for promoting medical student wellness and community while social distancing during the COVID-19 pandemic. To our knowledge, this is the first virtual wellness program for promotion of medical student mental health during the COVID-19 pandemic to be described in the literature.

Potentially avoidable hospitalizations after chemotherapy: Differences across medicare and the Veterans Health Administration.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) has released quality measures regarding potentially avoidable hospitalizations visits in the 30 days after receipt of outpatient chemotherapy. This study evaluated the proportions of patients treated by Medicare-reimbursed clinicians and Veterans Health Administration (VA) clinicians who experienced avoidable acute care in order to evaluate differences in health system performance. METHODS: This retrospective evaluation of Medicare and VA administrative data used a cohort of cancer decedents (fiscal years 2010-2014). Cohort members were veterans aged 66 years or older at death who were dually enrolled in Medicare and the VA. Chemotherapy was identified through International Classification of Diseases, Ninth Revision and Current Procedural Terminology (ICD-9) codes. CMS defines avoidable hospitalizations as those related to anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, or sepsis in the 30 days after chemotherapy. Following CMS guidance, this study compared the proportions of patients with potentially avoidable hospitalizations, using hierarchical generalized estimating equations. RESULTS: There were 27,443 patients who received outpatient chemotherapy. Patients receiving Medicare chemotherapy were significantly more likely to have potentially avoidable hospitalizations than patients receiving VA chemotherapy (adjusted odds ratio, 1.58; 95% confidence interval, 1.41-1.78; P < .001). In predicted estimates, 7.1% of Medicare-treated veterans had potentially avoidable hospitalizations in the 30 days after chemotherapy, compared with 4.6% of VA-treated veterans. CONCLUSIONS: Results indicate veterans with cancer receiving chemotherapy in the VA have higher quality care with respect to avoidable hospitalizations than veterans receiving chemotherapy through Medicare. As more veterans seek care in the private sector under the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, concerted efforts may be warranted to ensure that veterans do not experience a decline in care quality.