Inpatient bariatric surgery among eligible black and white men and women in the United States, 1999-2010.

OBJECTIVES: We examined national trends in bariatric surgery for adults, focusing on differences in utilization by race and access to health care. METHODS: We analyzed subjects eligible for bariatric surgery in the National Hospital Discharge Survey and the National Health and Nutrition Examination Survey for 1999-2010. Primary outcome measures included population-based estimates and comparison of blacks and whites eligible for surgery with those who actually received it. RESULTS: A higher percentage of black than white women and of black than white men were eligible for bariatric surgery. But a higher proportion of eligible white women and men than black women and men received bariatric surgery. 69.8% of eligible white women and 72.9% of white women who received bariatric surgery had private health insurance, compared with 49.9% and 71.1% of black women. 71.4% of eligible white men and 75.9% of white men who received bariatric surgery had private health insurance, compared with 52.4% and 74.7% of black men. Among men eligibility and surgery rates were lower than for women of the same race, and significant differences were found by race in the same directions as for women. CONCLUSIONS: Eligible whites received bariatric surgery at higher levels than eligible blacks, apparently partly because of differences in insurance coverage.

Academic family physicians' perception of genetic testing and integration into practice: a CERA study.

BACKGROUND AND OBJECTIVES: Genetic testing for a variety of diseases is becoming more available to primary care physicians, but it is unclear how useful physicians perceive these tests to be. We examined academic family physicians' perception of and experiences with clinical genetic testing and direct-to-consumer genetic testing. METHODS: This study is an analysis of a survey conducted as part of the Council of Academic Family Medicine Educational Research Alliance (CERA). Academic family physicians in the United States and Canada were queried about their perception of genetic testing's utility, how frequently patients ask about genetic testing, and the importance of genetic testing in future practice and education of students and residents. RESULTS: The overall survey had a response rate of 45.1% (1,404/3,112). A majority (54.4%) of respondents felt that they were not knowledgeable about available genetic tests. Respondents perceived greater utility of genetic tests for breast cancer (94.9%) and hemochromatosis (74.9%) than for Alzheimer's disease (30.3%), heart disease (25.4%), or diabetes (25.2%). Individuals with greater self-perceived knowledge of genetic tests were more likely to feel that genetic testing would have a significant impact on their future practice (23.1%) than those with less knowledge (13.4%). Respondents had little exposure to direct-to-consumer genetic tests, but a majority felt that they were more likely to cause harm than benefit. CONCLUSIONS: Academic family physicians acknowledge their lack of knowledge about genetic tests. Educational initiatives may be useful in helping them incorporate genetic testing into practice and in teaching these skills to medical students and residents.

Factors affecting HPV vaccine use among recent family medicine residency graduates.

BACKGROUND AND OBJECTIVES: Many adolescents seek care by family physicians for well visits and have the opportunity for HPV vaccination during these visits. Limited information is available regarding what affects physicians in offering the vaccine. The purpose of this study was to examine factors that affect family physician administration of the HPV vaccine. METHODS: We used a mail survey of recent graduates from family medicine residencies affiliated with the South Carolina Area Health Education Consortium. RESULTS: The response rate was 51.3%. Almost 79% offer the HPV vaccine at least most of the time to their adolescent female patients in their practice. Approximately 83% of respondents reported supporting the use of the HPV vaccine in males, but less than 8% reported having actually offered the vaccine to males. Those physicians who are female (OR=8.95, 95% CI=1.56--51.3), practice full time in an office setting (OR=9.08, 95% CI=1.71--48.3), are involved in teaching (OR=8.86, 95% CI=1.75--44.9), and practice in a family medicine setting (OR=8.20, 95% CI=1.69-39.8) had greater odds of offering the vaccine. Those who currently practiced in the southeastern United States were less likely to offer the vaccine (OR=0.04, 95% CI=0.002--0.59). CONCLUSIONS: Recent graduates of family medicine training programs frequently offer the HPV vaccine to adolescent females. Multiple practice factors affected the odds of offering the vaccine. Though most respondents agree with using the vaccine in males, most do not offer it to males.

Preparation for practice in family medicine: before and after duty hours.

BACKGROUND AND OBJECTIVES: In July of 2003, the Accreditation Council for Graduate Medical Education (ACGME) adopted requirements limiting the duty hours of resident physicians. The impact of these restrictions on education and patient care activities is not clear. The purpose of this study is to examine the perception of graduates of family medicine residency programs immediately prior to and following implementation of duty hours regarding preparedness to practice and board certification status, as well as current patient care activities. METHODS: Surveys of graduates of family medicine residency programs in South Carolina were conducted. Preparation for practice and professional activities of program graduates prior to (1999--2003) and following (2005--2009) implementation of duty hours were compared. RESULTS: Response rates were 54.4% and 53.1%, respectively. No significant differences by survey years in the average age, gender, or race was noted. Recent graduates felt as well prepared for practice in most curricular areas except surgery (OR=0.50 [0.27, 0.91]) and performed similar procedures with the following exceptions: central line placement (OR=0.32 [0.11, 0.95]), flexible sigmoidoscopy (OR=0.12 [0.02, 0.80]), ICU care (OR=0.39 [0.22, 0.70]), and ventilator management (OR=0.54 [0.29, 0.99]). Higher proportion of recent graduates do not take after hours call (22.3% versus 8.6%). Similarly, fewer recent graduates care for patients in nursing homes (22.0% versus 44.9%) and hospitals (46.2% versus 68.0%). CONCLUSIONS: Implementation of resident duty hours appears to have little overall association with self-reported preparedness for practice. An association was noted in the patient care services and procedures performed.

IgA and IgG antineutrophil cytoplasmic antibody engagement of Fc receptor genetic variants influences granulomatosis with polyangiitis.

Granulomatosis with polyangiitis (Wegener's) is a rare autoimmune neutrophil-mediated vasculitis that can cause renal disease and mucosal manifestations. Antineutrophil cytoplasmic antibodies (ANCA) are present in many patients, vary in level over time, and induce neutrophil activation through engagement with Fc receptors (FcRs). Given roles for FcRs in ANCA-mediated neutrophil activation and IgA antibodies in mucosal immunity, we hypothesized that FcR genetics and previously unappreciated IgA ANCA affect clinical presentation. We assembled a total of 673 patients and 413 controls from two multicenter cohorts, performed ELISA and immunofluorescence assays to determine IgA and IgG ANCA positivity, and used Illumina, TaqMan, or Pyrosequencing to genotype eight haplotype-tagging SNPs in the IgA FcR (FCAR) and to determine NA1/NA2 genotype of FCGR3B, the most prevalent neutrophil IgG FcR. We evaluated neutrophil activation by measuring degranulation marker CD11b with flow cytometry or neutrophil extracellcular trap formation with confocal microscopy. Functional polymorphisms in FCGR3B and FCAR differed between patient groups stratified by renal involvement. IgA ANCA were found in ∼30% of patients and were less common in patients with severe renal disease. Neutrophil stimulation by IgA or IgG ANCA led to degranulation and neutrophil extracellcular trap formation in a FcR allele-specific manner (IgA:FCAR P = 0.008; IgG:FCGR3B P = 0.003). When stimulated with IgA and IgG ANCA together, IgG ANCA induced neutrophil activation was reduced (P = 0.0001). FcR genotypes, IgA ANCA, and IgG ANCA are potential prognostic and therapeutic targets for understanding the pathogenesis and presentation of granulomatosis with polyangiitis (Wegener's).