Predictors of Human Papillomavirus Vaccine Completion Among Female and Male Vaccine Initiators in Family Planning Centers.

OBJECTIVES: We estimated human papillomavirus (HPV) vaccine series completion and examined predictors of completion among adolescents and young adults in a large family planning network. METHODS: Our retrospective cohort study of vaccine completion within 12 months and time to completion used electronic health record data from 119 Planned Parenthood health centers in 11 US states for 9648 patients who initiated HPV vaccination between January 2011 and January 2013. RESULTS: Among vaccine initiators, 29% completed the series within 12 months. Patients who were male, younger than 22 years, or non-Hispanic Black or who had public insurance were less likely to complete within 12 months and completed more slowly than their counterparts. Gender appeared to modify the effect of public versus private insurance on completion (adjusted hazard ratio = 0.76 for women and 0.95 for men; relative excess risk due to interaction = 0.41; 95% confidence interval = 0.09, 0.73). CONCLUSIONS: Completion was low yet similar to previous studies conducted in safety net settings.

Emergency airway management in the prone position: an observational mannequin-based simulation study.

INTRODUCTION: Accidental extubation during prone position can be a life-threatening emergency requiring rapid establishment of the airway. However, there is limited evidence of the best airway rescue method for this potentially catastrophic emergency. The aim of this study was to determine the most effective method to recover the airway in case of accidental extubation during prone positioning by comparing three techniques (supraglottic airway, video laryngoscopy, and fiber-optic bronchoscopy) in a simulated environment. METHODS: Eleven anesthesiologists and 12 anesthesia fellows performed the simulated airway management using 3 different techniques on a mannequin positioned prone in head pins. Time required for definitive airway management and the success rates were measured. RESULTS: The success rates of airway rescue were 100% with the supraglottic airway device (SAD), 69.6% with the video laryngoscope (CMAC), and 91.3% with the FOB. The mean (SD) time to insertion was 18.1 (4.8) s for the supraglottic airway, 78.3 (32.0) s for the CMAC, and 57.3 (24.6) s for the FOB. There were significant differences in the time required for definitive airway management between the SAD and FOB (t = 5.79, p < 0.001, 95% CI = 25.92-52.38), the SAD and CMAC (t = 8.90, p < 0.001, 95% CI = 46.93-73.40), and the FOB and CMAC (t = 3.11, p = 0.003, 95% CI = 7.78-34.25). CONCLUSION: The results of this simulation-based study suggest that the SAD I-gel is the best technique to manage accidental extubation during prone position by establishing a temporary airway with excellent success rate and shorter procedure time. When comparing techniques for securing a definitive airway, the FOB was more successful than the CMAC.

Reasons for PrEP Discontinuation After Navigation at Sexual Health Clinics: Interactions Among Systemic Barriers, Behavioral Relevance, and Medication Concerns.

BACKGROUND: Pre-exposure prophylaxis (PrEP) for HIV prevention requires engagement throughout the PrEP care continuum. Using data from a PrEP navigation program, we examine reasons for PrEP discontinuation. SETTING: Participants were recruited from New York City Health Department Sexual Health Clinics with PrEP navigation programs. METHODS: Participants completed a survey and up to 3 interviews about PrEP navigation and use. This analysis includes 94 PrEP initiators that were PrEP-naive before their clinic visit, started PrEP during the study, and completed at least 2 interviews. Interview transcripts were reviewed to assess reasons for PrEP discontinuation. RESULTS: Approximately half of PrEP initiators discontinued PrEP during the study period (n = 44; 47%). Most participants (71%) noted systemic issues (insurance or financial problems, clinic or pharmacy logistics, and scheduling barriers) as reasons for discontinuation. One-third cited medication concerns (side effects, potential long-term side effects, and medication beliefs; 32%) and behavioral factors (low relevance of PrEP because of sexual behavior change; 34%) as contributing reasons. Over half (53.5%) highlighted systemic issues alone, while an additional 19% attributed discontinuation to systemic issues in combination with other factors. Of those who discontinued, approximately one-third (30%) restarted PrEP during the follow-up period, citing resolution of systemic issues or behavior change that increased PrEP relevance. CONCLUSIONS: PrEP continuation is dependent on interacting factors and often presents complex hurdles for patients to navigate. To promote sustained engagement in PrEP care, financial, clinic, and pharmacy barriers must be addressed and counseling and navigation should acknowledge factors beyond sexual risk that influence PrEP use.

Clinic-Level Strategies for Mitigating Structural and Interpersonal HIV Pre-Exposure Prophylaxis Stigma.

Uptake of and persistence on pre-exposure prophylaxis (PrEP) in the United States have been limited. The potential of new PrEP modalities to increase access will be hindered if underlying structural and interpersonal barriers-including, insurance coverage, initiation and maintenance clinical protocols, provider bias, stigma, and lack of trust in health care-are not adequately addressed. We conducted in-person and telephone-based recorded interviews with 32 US-based clinical and nonclinical PrEP providers spanning the PrEP implementation continuum (clinicians, counselors, and support staff). Providers were recruited at biomedical HIV prevention conferences and networks to explore barriers to and strategies for PrEP implementation. Providers provided care to clients spanning adolescents to adulthood and a variety of genders across all geographic regions of the United States. To directly mitigate stigma, providers called for clinic-level interventions to normalize and universalize PrEP education and services, counseling and other services that center patients' lived experiences and circumstance, staffing and community engagement models that value patients, and implementation of specific programs and processes that facilitate access to services. To address disparities in access, PrEP implementation should acknowledge the interconnectedness of stigma and structural barriers to care.

A randomized controlled trial comparing autologous radiolabeled in vivo platelet (PLT) recoveries and survivals of 7-day-stored PLT-rich plasma and buffy coat PLTs from the same subjects.

BACKGROUND: A recent review concluded that there was inadequate evidence to show a difference between buffy coat (BC) and platelet (PLT)-rich plasma (PRP) PLT concentrates prepared from whole blood. We hypothesized that 7-day-stored BC-PLTs would have superior autologous recoveries and survivals compared to PRP-PLTs and that both would meet the Food and Drug Administration (FDA) criteria for poststorage viability. STUDY DESIGN AND METHODS: This was a randomized, crossover study design in healthy subjects who provided informed consent. Each participant donated a unit of whole blood on two occasions. In random order, either BC-PLTs or PC-PLTs were prepared after a 20 ± 2 °C overnight hold of the whole blood. PLTs were stored under standard conditions. On Day 7, fresh PLTs were prepared from 43 mL of autologous whole blood. The fresh PLTs paired with either BC-PLTs or PRP-PLTs were alternately labeled with (111) In or (51) Cr and simultaneously reinfused to determine recoveries and survivals. In vitro assays were performed on Days 1 and 7. RESULTS: Fourteen subjects completed the study at two sites. No differences in poststorage PLT viabilities were observed between BC-PLTs and PRP-PLTs; recovery differences averaged 3.7 ± 2.4% (± SE, p = 0.15) and survival differences averaged 0.48 ± 0.56 days (p = 0.41). Neither type of PLTs met the current FDA criteria for either poststorage PLT recoveries or survivals. CONCLUSION: We were unable to demonstrate that single-unit BC-PLTs stored for 7 days have superior poststorage viability compared to PRP-PLTs. Failure to meet the minimum FDA criteria for poststorage PLT viability raises questions regarding the acceptance thresholds of these metrics.

Airway Management With a Stereotactic Headframe In Situ-A Mannequin Study.

BACKGROUND: Stereotactic headframe-based imaging is often needed for target localization during surgery for insertion of deep brain stimulators. A major concern during this surgery is the need for emergency airway management while an awake or sedated patient is in the stereotactic headframe. The aim of our study was to determine the ease of emergency airway management with a stereotactic headframe in situ. MATERIALS AND METHODS: We conducted an observational study using a mannequin. A Leksell stereotactic headframe was placed on a mannequin in the operating room and the frame was fixed to the operating room table. Anesthesia personnel were asked to insert a #4 laryngeal mask and then to intubate the mannequin, using both direct (DL) and video laryngoscopy (VL). In addition, participants were asked to perform the same airway techniques in the mannequin without the headframe. Data were analyzed for time taken for airway management using different devices with and without the headframe. In addition, we compared the time taken to secure the airway between different participant groups. RESULTS: Thirty anesthesia personnel (7 residents, 12 fellows, and 11 consultants) participated in the study. With the headframe in situ, 97% of participants were able to insert a laryngeal mask on their first attempt; 93% and 97% of participants were able to intubate the mannequin using DL and VL respectively on their first attempt. Without the stereotactic headframe, all participants were able to insert the laryngeal mask and intubate on the first attempt. The average time taken to insert a laryngeal mask and intubate the mannequin using DL and VL with the headframe in situ was 39.3, 58.6, and 54.8 seconds, respectively. CONCLUSIONS: Our study showed that both laryngeal mask insertion and tracheal intubation can be performed with a stereotactic headframe in situ. A laryngeal mask is the quickest airway device to insert and can be inserted while the mannequin is in the standard surgical position. Further study is needed to validate the results in patients.

Attitudes toward comparative effectiveness research and patient engagement among reproductive health clinicians.

AIM: To assess reproductive health clinicians' knowledge of and attitudes toward comparative effectiveness research (CER), patient-centered outcomes research (PCOR) and patient engagement in research. MATERIALS & METHODS: Web-based survey of reproductive health clinicians. RESULTS: Among 103 responding clinicians, familiarity with CER and PCOR was moderate (35 and 44%, respectively). Once definitions were provided, most respondents agreed with the potential positive impacts of CER and patient engagement (65-87%), the importance of PCOR (95-99%) and that their patients might be interested in engaging in research as more than subjects (93%). CONCLUSION: We found positive attitudes toward PCOR and CER, and a range of experiences with patient engagement in research. There may be untapped potential for PCOR and CER in the reproductive health field.

Mental practice: a simple tool to enhance team-based trauma resuscitation.

INTRODUCTION: Effective trauma resuscitation requires the coordinated efforts of an interdisciplinary team. Mental practice (MP) is defined as the mental rehearsal of activity in the absence of gross muscular movements and has been demonstrated to enhance acquiring technical and procedural skills. The role of MP to promote nontechnical, team-based skills for trauma has yet to be investigated. METHODS: We randomized anaesthesiology, emergency medicine, and surgery residents to two-member teams randomly assigned to either an MP or control group. The MP group engaged in 20 minutes of MP, and the control group received 20 minutes of Advanced Trauma Life Support (ATLS) training. All teams then participated in a high-fidelity simulated adult trauma resuscitation and received debriefing on communication, leadership, and teamwork. Two blinded raters independently scored video recordings of the simulated resuscitations using the Mayo High Performance Teamwork Scale (MHPTS), a validated team-based behavioural rating scale. The Mann-Whitney U-test was used to assess for between-group differences. RESULTS: Seventy-eight residents provided informed written consent and were recruited. The MP group outperformed the control group with significant effect on teamwork behaviour as assessed using the MHPTS: r=0.67, p<0.01. CONCLUSIONS: MP leads to improvement in team-based skills compared to traditional simulation-based trauma instruction. We feel that MP may be a useful and inexpensive tool for improving nontechnical skills instruction effectiveness for team-based trauma care.

Knowledge of HPV and HPV Vaccine among Women Ages 19 to 26.

OBJECTIVE: To describe knowledge about human papillomavirus (HPV) and HPV vaccination among women ages 19 to 26 seeking a variety of services at reproductive health centers. A secondary objective was to identify common sources of HPV information. METHODS: Ten reproductive health centers enrolled 365 women ages 19 to 26 in a randomized, controlled trial to determine the effect of automated reminder messages on HPV vaccine completion. Using responses from a 61-item self-administered baseline questionnaire completed before initiating the HPV vaccine, this subanalysis assessed participants' knowledge regarding HPV and the HPV vaccine. RESULTS: Knowledge of HPV prevention, transmission, and disease outcomes among the study population was highly variable. The mean HPV knowledge score was 11.0 of a possible 19 (SD = 3.8). Most participants (77%) had heard of the HPV vaccine before completing the questionnaire and indicated that their primary sources of information about the vaccine were television ads (61%), health care providers (52%), and friends (45%). CONCLUSIONS: Despite a relatively high awareness of the vaccine, specific knowledge regarding HPV and the HPV vaccine varied substantially and participant scores highlighted knowledge gaps among vaccine-eligible young women. Media, health care providers, and friends were identified by participants as sources of information and may influence their knowledge of HPV and the HPV vaccine.

Staying on track: a cluster randomized controlled trial of automated reminders aimed at increasing human papillomavirus vaccine completion.

OBJECTIVES: To evaluate whether automated reminders increase on-time completion of the three-dose human papillomavirus (HPV) vaccine series. METHODS: Ten reproductive health centers enrolled 365 women aged 19-26 to receive dose one of the HPV vaccine. Health centers were matched and randomized so that participants received either routine follow-up (control) or automated reminder messages for vaccine doses two and three (intervention). Intervention participants selected their preferred method of reminders - text, e-mail, phone, private Facebook message, or standard mail. We compared vaccine completion rates between groups over a period of 32 weeks. RESULTS: The reminder system did not increase completion rates, which overall were low at 17.2% in the intervention group and 18.9% in the control group (p=0.881). Exploratory analyses revealed that participants who completed the series on-time were more likely to be older (OR=1.15, 95% CI 1.01-1.31), report having completed a four-year college degree or more (age-adjusted OR=2.51, 95% CI 1.29-4.90), and report three or more lifetime sexual partners (age-adjusted OR=3.45, 95% CI 1.20-9.92). CONCLUSIONS: The study intervention did not increase HPV vaccine series completion. Despite great public health interest in HPV vaccine completion and reminder technologies, completion rates remain low.

Pseudolipomatosis in hysteroscopically resected tissues from the gynecologic tract: pathologic description and frequency.

Pseudolipomatosis is an artifactual microscopic change in tissues that resembles fatty infiltration, most often described in the gastrointestinal tract. The fatlike spaces represent air or gas bubbles that enter the mucosa through microscopic ruptures secondary to gaseous insufflation. We report a series of cases of pseudolipomatosis encountered in gynecologic tissues removed during hysteroscopic procedures, a finding not previously described. We identified 300 consecutive hysteroscopic procedures performed at our institution from 2006 to 2008. Patients' medical records were reviewed to collect pertinent clinical data. Slides from all cases were systematically reviewed. The diagnosis of pseudolipomatosis was established by consensus. Twenty-eight cases of pseudolipomatosis, representing 9.3% of patients who under went hysteroscopy, were identified. Pseudolipomatosis was found in 9 endometrial curettings or biopsy tissues, 8 endometrial or endocervical polyps, 8 uterine fibroids, 2 fallopian tubes, and 1 endocervical biopsy. The type of distention medium used and length of hysteroscopic procedure did not differ significantly between cases with and without pseudolipomatosis. Pseudolipomatosis vacuoles varied in distribution from crowded clusters to sparsely scattered and solitary. Occasionally, vacuoles were found in vascular channels. Vacuoles were round or ovoid, unilocular, and variable in size. Immunohistochemical staining for adipocyte and endothelial markers were negative. We hypothesize that pseudolipomatosis derives from air that is almost invariably introduced into the uterus during media insufflation for hysteroscopy, creating a bubble under pressure. The air enters tissues either through lining microruptures or during the biopsy procedure. Pseudolipomatosis is a relatively common, easily overlooked finding in hysteroscopically derived specimens that may be misdiagnosed when prominent.