Extent of Follow-Up on Abnormal Cancer Screening in Multiple California Public Hospital Systems: A Retrospective Review.

BACKGROUND: Inequitable follow-up of abnormal cancer screening tests may contribute to racial/ethnic disparities in colon and breast cancer outcomes. However, few multi-site studies have examined follow-up of abnormal cancer screening tests and it is unknown if racial/ethnic disparities exist. OBJECTIVE: This report describes patterns of performance on follow-up of abnormal colon and breast cancer screening tests and explores the extent to which racial/ethnic disparities exist in public hospital systems. DESIGN: We conducted a retrospective cohort study using data from five California public hospital systems. We used multivariable robust Poisson regression analyses to examine whether patient-level factors or site predicted receipt of follow-up test. MAIN MEASURES: Using data from five public hospital systems between July 2015 and June 2017, we assessed follow-up of two screening results: (1) colonoscopy after positive fecal immunochemical tests (FIT) and (2) tissue biopsy within 21 days after a BIRADS 4/5 mammogram. KEY RESULTS: Of 4132 abnormal FITs, 1736 (42%) received a follow-up colonoscopy. Older age, Medicaid insurance, lack of insurance, English language, and site were negatively associated with follow-up colonoscopy, while Hispanic ethnicity and Asian race were positively associated with follow-up colonoscopy. Of 1702 BIRADS 4/5 mammograms, 1082 (64%) received a timely biopsy; only site was associated with timely follow-up biopsy. CONCLUSION: Despite the vulnerabilities of public-hospital-system patients, follow-up of abnormal cancer screening tests occurs at rates similar to that of patients in other healthcare settings, with colon cancer screening test follow-up occurring at lower rates than follow-up of breast cancer screening tests. Site-level factors have larger, more consistent impact on follow-up rates than patient sociodemographic traits. Resources are needed to identify health system-level factors, such as test follow-up processes or data infrastructure, that improve abnormal cancer screening test follow-up so that effective health system-level interventions can be evaluated and disseminated.

Rapid diagnosis of tuberculosis and multidrug resistance by the microscopic-observation drug-susceptibility assay.

RATIONALE: Mortality is exceedingly high and rapid among patients infected with HIV and tuberculosis (TB), in part because of limited access to appropriate TB diagnostics. The microscopic observation drug-susceptibility (MODS) assay is a simple, rapid, low-cost test for TB and multidrug-resistant (MDR) TB, but data in individuals infected with HIV and in Africa are limited. OBJECTIVES: To evaluate the MODS assay in a high-HIV-prevalence setting. METHODS: We performed a prospective diagnostic accuracy study of consecutive adults suspected to have TB from outpatient and inpatient settings at a district hospital in rural South Africa. Sputum was tested by concentrated smear microscopy; agar (Middlebrook 7H11) and liquid (mycobacterial growth indicator tube) culture; and the MODS assay. Drug-susceptibility testing (DST) was by indirect 1% proportion method and MODS. Reference standard for Mycobacterium tuberculosis detection was growth on Middlebrook or mycobacterial growth indicator tube culture; 1% proportion was the reference standard for isoniazid and rifampin DST. MEASUREMENTS AND MAIN RESULTS: Among 534 adults enrolled, 388 (73%) were HIV-positive, with a median CD4 count of 161 cells/mm(3) (interquartile range [IQR]: 72-307). TB was diagnosed by the reference standard culture in 113 (21%). MODS sensitivity was 85% (95% confidence interval [CI], 78-92%), and specificity was 97% (CI, 95-99%). MODS test performance did not differ by patients' HIV status (sensitivity 88% vs. 90%, specificity 97% vs. 100% for HIV-positive versus HIV-negative, respectively). For MDR-TB diagnosis (n = 11), sensitivity was 100% (one-sided CI, 68-100%) and specificity was 94% (CI, 82-98%). Median turnaround time for MDR-TB diagnosis was 7 days (IQR: 6-9) with MODS versus 70 days (IQR: 49-96) with indirect proportion method (P < 0.001). CONCLUSIONS: Among adult TB suspects predominantly infected with HIV, MODS provided high sensitivity and specificity for rapid diagnosis of TB and MDR-TB. Given the high mortality from TB and MDR-TB and prolonged opportunity for TB transmission before diagnosis, the MODS assay warrants serious consideration for use in similar high-HIV-prevalence, resource-limited settings.

Increasing drug resistance in extensively drug-resistant tuberculosis, South Africa.

We expanded second-line tuberculosis (TB) drug susceptibility testing for extensively drug-resistant Mycobacterium tuberculosis isolates from South Africa. Of 19 patients with extensively drug-resistant TB identified during February 2008-April 2009, 13 (68%) had isolates resistant to all 8 drugs tested. This resistance leaves no effective treatment with available drugs in South Africa.

Gender and the pre-clinical experiences of female medical students: a taxonomy.

CONTEXT: The number of women entering medical school has increased substantially in recent years. However, practising female doctors still report gender-associated professional challenges. We focused on female medical students to characterise how gender shapes the range of their professional experiences during the pre-clinical years of medical school. METHODS: We conducted a qualitative study from 2006 to 2007 using in-depth interviews with 12 Year 3 female medical students at a private New England medical school who had completed their pre-clinical years of training. All transcripts were analysed using a grounded theory approach; the code structure was developed through a process of inductive reasoning. Coding team members coded all transcripts line by line, using a constant comparative method of analysis. RESULTS: The resulting taxonomy identifies three domains that capture the recurrent gender-associated experiences of our participants: (i) observations of the effect of gender on pre-clinical educational experiences through instructor, student and institutional behaviour; (ii) responses to observations of gender-based occurrences in terms of emotional reactions and strategic responses, and (iii) gender-associated expectations for the clinical years and beyond brought about by a heightened awareness of gender. Participants reported subtle as well as overt gender-based experiences and emotional consequences of both. CONCLUSIONS: Female medical students continue to report numerous gender-based experiences during their pre-clinical training. Such experiences have both emotional and educational consequences and institutions should develop multifaceted approaches to address the full spectrum of gender-based experiences that affect medical students.

Research Beyond the Ivory Tower: Partnering with Safety-Net Health Systems for Equity.

Safety-net health systems serve primarily low-income, racially/ethnically diverse patients who bear a disproportionate burden of disease and high social needs. Many safety-net institutions are publicly funded and are under-resourced to deliver high-quality and timely care. Further, little clinical and translational research includes safety-net populations due to lack of funding, structure to support research, and low prioritization. However, we argue that US health care as a whole will lose key insights across all levels of translational medicine-T1-T4 research, if safety-net health systems do not participate in research. Solutions such as targeted funds for safety-net research, consortium arrangements for research infrastructure, and increasing ways for clinician-researchers to have their primary home in safety-net settings are suggested to fill this gap. Achieving health equity in the U.S. is contingent upon safety-net inclusion in research to advance knowledge and develop, test, and evaluate innovations applicable across all patient populations.

Extensively drug-resistant Mycobacterium tuberculosis from aspirates, Rural South Africa.

The yield from aspirating lymph nodes and pleural fluid for diagnosing extensively drug-resistant (XDR) tuberculosis is unknown. Mycobacterium tuberculosis was cultured from lymph node or pleural fluid aspirates of 21 patients; 7 (33%) cultures grew XDR M. tuberculosis. Additive diagnostic yield for XDR M. tuberculosis was found in parallel culture of sputum and fluid aspirate.

Blood cultures for the diagnosis of multidrug-resistant and extensively drug-resistant tuberculosis among HIV-infected patients from rural South Africa: a cross-sectional study.

BACKGROUND: The yield of mycobacterial blood cultures for multidrug-resistant (MDR) and extensively drug-resistant tuberculosis (XDR-TB) among drug-resistant TB suspects has not been described. METHODS: We performed a retrospective, cross-sectional analysis to determine the yield of mycobacterial blood cultures for MDR-TB and XDR-TB among patients suspected of drug-resistant TB from rural South Africa. Secondary outcomes included risk factors of Mycobacterium tuberculosis bacteremia and the additive yield of mycobacterial blood cultures compared to sputum culture. RESULTS: From 9/1/2006 to 12/31/2008, 130 patients suspected of drug-resistant TB were evaluated with mycobacterial blood culture. Each patient had a single mycobacterial blood culture with 41 (32%) positive for M. tuberculosis, of which 20 (49%) were XDR-TB and 8 (20%) were MDR-TB. One hundred fourteen (88%) patients were known to be HIV-infected. Patients on antiretroviral therapy were significantly less likely to have a positive blood culture for M. tuberculosis (p = 0.002). The diagnosis of MDR or XDR-TB was made by blood culture alone in 12 patients. CONCLUSIONS: Mycobacterial blood cultures provided an additive yield for diagnosis of drug-resistant TB in patients with HIV from rural South Africa. The use of mycobacterial blood cultures should be considered in all patients suspected of drug-resistant TB in similar settings.

"I'm too used to it": a longitudinal qualitative study of third year female medical students' experiences of gendered encounters in medical education.

Although the number of women entering medical school has been steadily rising in the U.S.A., female medical students continue to report instances of sexual harassment and gender discrimination. The full spectrum of such experiences and their effect on the professional identity formation of female students over time remains largely unknown. To investigate these experiences, we interviewed 12 third year female medical students at a private New England medical school over several points during the 2006-2007 academic year. Using theoretical frameworks of gender performance and the centrality of student-patient and student-supervisor relationships, we were better able to understand how female medical students interpret the role of 'woman doctor' and the effect of negative and positive gendered interactions on the evolution of their professional identity. We found that participants quickly learned how to confront and respond to inappropriate behavior from male patients and found interactions with female patients and supervisors particularly rewarding. However, they did not feel equipped to respond to the unprofessional behavior of male supervisors, resulting in feelings of guilt and resignation over time that such events would be a part of their professional identity. The rapid acculturation to unprofessional behavior and resignation described by participants has implications for not only professional identity formation of female students but specialty choices and issues of future physician workforce.

The effect of gender on the clinical clerkship experiences of female medical students: results from a qualitative study.

PURPOSE: To characterize how female medical students perceive the role of gender within their medical education during the transition to the clinical curriculum. METHOD: In 2006-2007, the authors conducted a qualitative study consisting of in-depth interviews with 12 third-year female medical students completing their first clinical clerkship. Participants were purposefully selected from a single New England medical school to represent a range of ages, ethnicities, and prior life experiences. RESULTS: Participants (1) struggled to define their role on the wards and often defaulted to stereotypical gender roles, (2) perceived differences in the nature of their workplace relationships compared with the nature of male medical students' workplace relationships, (3) had gendered expectations of male and female physicians that shaped their interactions with clinical supervisors, (4) felt able to negotiate uncomfortable situations with patients but felt unable to negotiate uncomfortable situations with supervisors and attendings, and (5) encountered a "gender learning curve" on the wards that began to shape their self-view as future female physicians. CONCLUSIONS: Despite increased numbers of women in medicine, issues of gender continue to have a substantial impact on the medical education of female students. Institutions can design interventions about gender issues in medicine that expand beyond a focus on sexual harassment to address the complex ways in which students are affected by issues of gender.