Facilitators and barriers to using telemedicine for gender-affirming care in gender-diverse youth: A qualitative study.

INTRODUCTION: Access to gender-affirming care (GAC) is limited for gender-diverse (GD) youth, with the potential for further limitations given the current political climate. GAC has been shown to improve the mental health of GD youth and telemedicine (TM) could increase access to GAC. With limited data on the acceptability and feasibility of TM for GAC among GD youth, we sought to further explore their perspectives on the use of TM in their care. METHODS: We used a semi-structured interview guide, with prompts developed to explore participants' knowledge of TM, identify factors that influenced use, and advantages or disadvantages of use. RESULTS: Thirty GD participants aged 13-21 years old participated in TM. While TM was not the preferred option for medical visits, it was recognized as a practical option for providing GAC. Various actual and perceived disadvantages noted by youth included, technical issues interrupting the visit, not receiving care equivalent to that of an in-person visit, having to see themselves on the screen, family members interrupting visits, and meeting new staff while connecting to a TM visit. The advantages, however, were an increased autonomy and convenience of TM, especially when used for specific aspects of GAC. DISCUSSION: The use of TM in GAC could be optimized by limiting camera use, eliminating/reducing staff involvement, being sensitive to privacy issues, and alternating TM with in-person visits. Clinicians should be cognizant of patient preferences and concerns and be flexible with visit types.

Recognition of infants at high risk for vertical HIV transmission at delivery in rural Western Cape Province, South Africa.

Background: Despite South Africa's substantial reduction in vertical HIV transmission (VHT), national paediatric HIV elimination is not yet attained. National and Western Cape Province (WC) HIV guidelines recommend enhanced postnatal prophylaxis for infants at high risk for VHT, identified in the WC 2015/2016 guidelines by any single high-risk criterion (maternal antiretroviral therapy (ART) <12 weeks, absent/ unsuppressed maternal HIV viral load (HIV-VL) <12 weeks before/including delivery, spontaneous preterm labour, prolonged rupture of membranes, chorioamnionitis). Accuracy of high-risk infant identification is unknown. Objectives: Primarily, to determine the proportion of infants at high risk for VHT, the accuracy of labour-ward risk classification, the criteria determining high-risk statuses and the criteria missed among unrecognised high-risk infants; secondarily, to determine maternal factors associated with high-risk infants. Methods: Infants born to women living with HIV at a rural regional hospital (May 2016 - April 2017) were retrospectively evaluated using data from the labour ward VHT register, standardised maternity case records, National Health Laboratory Service database and WC Provincial Health Data Centre. The study-derived risk status for each infant was determined using documented presence/absence of risk criteria and compared with labour ward assigned risk to determine accuracy. Proportions of high-risk and unrecognised high-risk infants with each high-risk criterion were determined. Maternal characteristics associated with having a high-risk infant were evaluated using multivariable logistic regression. Results: For liveborn infants, labour ward assigned risk classifications were 40% (n=75/188) high risk, 50% (n=94/188) low risk and 10% (n=19/188) unclassified. Study-derived risk was high risk for 69% (n=129/188) and low risk for 31% (n=59/188), yielding a high-risk classification sensitivity of 51% (95% confidence interval (CI) 42 - 60) and specificity of 69% (95% CI 56 - 80). Absent/unsuppressed HIVVL <12 weeks before delivery accounted for 83% (n=119/143) of study-derived high-risk exposures and 81% (n=60/74) of missed high-risk exposures. Fewer mothers of high-risk infants had >4 antenatal visits (38% v. 81%, p<0.01) and first antenatal visit <20 weeks' gestation (57% v. 77%, p=0.01). Only the number of antenatal visits remained associated with having a high-risk infant after adjusting for gestation at first visit and timing of HIV diagnosis and ART initiation: each additional antenatal visit conferred a 39% (95% CI 25 - 50) reduction in the odds of having a high-risk infant. Conclusion: Labour ward risk classification failed to recognise half of high-risk infants. Infant high-risk status as well as non-detection thereof were driven by suboptimal maternal HIV-VL monitoring. Reinforcing visit frequency later in pregnancy may improve antenatal HIV-VL monitoring, and point-of-care HIV-VL monitoring at delivery could improve recognition of virally unsuppressed mothers and their high-risk infants.

Recognition of infants at high risk for vertical HIV transmission at delivery in rural Western Cape Province, South Africa

Despite South Africa's substantial reduction in vertical HIV transmission (VHT), national paediatric HIV elimination is not yet attained. National and Western Cape Province (WC) HIV guidelines recommend enhanced postnatal prophylaxis for infants at high risk for VHT, identified in the WC 2015/2016 guidelines by any single high-risk criterion (maternal antiretroviral therapy (ART) <12 weeks, absent/ unsuppressed maternal HIV viral load (HIV-VL) <12 weeks before/including delivery, spontaneous preterm labour, prolonged rupture of membranes, chorioamnionitis). Accuracy of high-risk infant identification is unknown. Objectives. Primarily, to determine the proportion of infants at high risk for VHT, the accuracy of labour-ward risk classification, the criteria determining high-risk statuses and the criteria missed among unrecognised high-risk infants; secondarily, to determine maternal factors associated with high-risk infants. Methods. Infants born to women living with HIV at a rural regional hospital (May 2016 - April 2017) were retrospectively evaluated using data from the labour ward VHT register, standardised maternity case records, National Health Laboratory Service database and WC Provincial Health Data Centre. The study-derived risk status for each infant was determined using documented presence/absence of risk criteria and compared with labour ward assigned risk to determine accuracy. Proportions of high-risk and unrecognised high-risk infants with each high-risk criterion were determined. Maternal characteristics associated with having a high-risk infant were evaluated using multivariable logistic regression. Results. For liveborn infants, labour ward assigned risk classifications were 40% (n=75/188) high risk, 50% (n=94/188) low risk and 10% (n=19/188) unclassified. Study-derived risk was high risk for 69% (n=129/188) and low risk for 31% (n=59/188), yielding a high-risk classification sensitivity of 51% (95% confidence interval (CI) 42 - 60) and specificity of 69% (95% CI 56 - 80). Absent/unsuppressed HIVVL <12 weeks before delivery accounted for 83% (n=119/143) of study-derived high-risk exposures and 81% (n=60/74) of missed high-risk exposures. Fewer mothers of high-risk infants had >4 antenatal visits (38% v. 81%, p<0.01) and first antenatal visit <20 weeks' gestation (57% v. 77%, p=0.01). Only the number of antenatal visits remained associated with having a high-risk infant after adjusting for gestation at first visit and timing of HIV diagnosis and ART initiation: each additional antenatal visit conferred a 39% (95% CI 25 - 50) reduction in the odds of having a high-risk infant. Conclusion. Labour ward risk classification failed to recognise half of high-risk infants. Infant high-risk status as well as non-detection thereof were driven by suboptimal maternal HIV-VL monitoring. Reinforcing visit frequency later in pregnancy may improve antenatal HIV-VL monitoring, and point-of-care HIV-VL monitoring at delivery could improve recognition of virally unsuppressed mothers and their high-risk infants

Stereotactic breast biopsy of nonpalpable lesions: determinants of ductal carcinoma in situ underestimation rates.

PURPOSE: To measure the effect of biopsy device, probe size, mammographic lesion type, lesion size, and number of samples obtained per lesion on the ductal carcinoma in situ (DCIS) underestimation rate. MATERIALS AND METHODS: Nonpalpable breast lesions at 16 institutions received a histologic diagnosis of DCIS after 14-gauge automated large-core biopsy in 373 lesions and after 14- or 11-gauge directional vacuum-assisted biopsy in 953 lesions. The presence of histopathologic invasive carcinoma was noted at subsequent surgical biopsy. RESULTS: By performing the chi(2) test, independent significant DCIS underestimation rates by biopsy device were 20.4% (76 of 373) of lesions diagnosed at large-core biopsy and 11.2% (107 of 953) of lesions diagnosed at vacuum-assisted biopsy (P <.001); by lesion type, 24.3% (35 of 144) of masses and 12.5% (148 of 1,182) of microcalcifications (P <.001); and by number of specimens per lesion, 17.5% (88 of 502) with 10 or fewer specimens and 11.5% (92 of 799) with greater than 10 (P <.02). DCIS underestimations increased with lesion size. CONCLUSION: DCIS underestimations were 1.9 times more frequent with masses than with calcifications, 1.8 times more frequent with large-core biopsy than with vacuum-assisted biopsy, and 1.5 times more frequent with 10 or fewer specimens per lesion than with more than 10 specimens per lesion.

Bedside cardiac examination: constancy in a sea of change.

The general trend in the recent literature has been to highlight the difficulties and shortcomings of the physical examination and to attribute these difficulties to deficiencies in training rather than to intrinsic weaknesses in auscultation itself. The call is for better training. Given the advice of the authors mentioned above, individual training may be warranted at the postgraduate level and in the large community of practicing internists and cardiologists. Although not proven, it is likely that individual training with computer technology, audiotape instruction, or simulator technology such as described in the following paragraphs would be effective at improving bedside clinical diagnosis and cost-effective patient care in the postgraduate, continuing medical education setting. The advances in auscultation during the last few years have been more incremental than fundamental. There is ongoing research into the mechanism of production of S3 and S4, and mathematical modeling techniques have recently been used with some success in evaluating the vibrations of S3 and S4 as forced, damped oscillations of a viscoelastic system. Analysis of sound energy with the technique of spectral waveform analysis, which investigates the frequency content of sound signals, has been used for many years in the study of cardiovascular sound. By the use of various methods of mathematical analysis, investigators have found potentially useful information in spectral sound patterns of prosthetic valves, murmur characteristics, and even potentially hemodynamic information from heart sounds. Despite the mathematical advances, there are still disturbing drawbacks to some of the analytic techniques, such as the production of mathematical terms containing "negative energy." Although the potential of obtaining significant clinical information from spectral analysis of heart sound recordings is attractive, the clinical usefulness of such techniques remains virtually nonexistent. Similar to the recent advances in auscultation, the technical advances in the design of the stethoscope have also been more incremental than fundamental. There are at least 3 recently introduced electronic stethoscopes that have the capability of amplification and filtration and that claim noise reduction. Because their introduction is recent, no information is available in the peer-review literature regarding their clinical performance; therefore their place in the clinical arena remains to be elucidated--perhaps a boon for patient care providers with specific hearing defects and perhaps useful in noisy clinical environments. Peer-review literature has not shown clear superiority of one type of acoustic stethoscope over another. The teaching of auscultation has been an area of recognized importance in patient care since the inception of auscultation as a medical art. Attempts to facilitate practitioner learning in the performance and interpretation of auscultation have advanced through the decades limited only by the technical infrastructure of the day. The availability of recorded heart sounds and murmurs appeared shortly after the availability of recording and playback devices, with first vinyl and later tape recordings. In 1974, technology was employed to create a virtual patient named "Harvey," an engineered cardiology patient simulator that reproduces many of the physical findings of the cardiology examination. Later, with the advent of commercially available CD-ROM devices, newer, better-integrated teaching devices have been developed, some of them outstanding in their clarity and quality. Despite the obvious value of such instructional aids that are best used in the individual setting, there is evidence that the classroom is still of significant value in teaching auscultation. However, nowhere else in the practice of medicine is a mentor approach more valuable than in learning auscultation. (ABSTRACT TRUNCATED)

Distinct effects of surfactant protein A or D deficiency during bacterial infection on the lung.

Mice lacking surfactant protein (SP)-A (SP-A-/-) or SP-D (SP-D-/-) and wild-type mice were infected with group B streptococcus or Haemophilus influenzae by intratracheal instillation. Although decreased killing of group B streptococcus and H. influenzae was observed in SP-A-/- mice but not in SP-D-/- mice, deficiency of either SP-A or SP-D was associated with increased inflammation and inflammatory cell recruitment in the lung after infection. Deficient uptake of bacteria by alveolar macrophages was observed in both SP-A- and SP-D-deficient mice. Isolated alveolar macrophages from SP-A-/- mice generated significantly less, whereas those from SP-D-/- mice generated significantly greater superoxide and hydrogen peroxide compared with wild-type alveolar macrophages. In SP-D-/- mice, bacterial killing was associated with increased lung inflammation, increased oxidant production, and decreased macrophage phagocytosis. In contrast, in the absence of SP-A, bacterial killing was decreased and associated with increased lung inflammation, decreased oxidant production, and decreased macrophage phagocytosis. Increased oxidant production likely contributes to effective bacterial killing in the lungs of SP-D-/- mice. The collectins, SP-A and SP-D, play distinct roles during bacterial infection of the lung.

Atypical ductal hyperplasia diagnosed at stereotactic breast biopsy: improved reliability with 14-gauge, directional, vacuum-assisted biopsy.

PURPOSE: To compare histologic findings of atypical ductal hyperplasia (ADH) at 14-gauge, directional, vacuum-assisted breast biopsy (hereafter, vacuum-assisted biopsy) and at 14-gauge, automated, large-core breast biopsy (hereafter, large-core biopsy) with findings at histologic examination after surgical biopsy. MATERIALS AND METHODS: Nonpalpable breast lesions were diagnosed as ADH at histologic examination after vacuum-assisted biopsy in 88 lesions in seven institutions and after large-core biopsy in 55 previously reported lesions. Histologic findings at subsequent surgical biopsy were compared for the presence of carcinoma. RESULTS: On the basis of histologic findings of carcinoma at surgical biopsy, the diagnosis of ADH was not correct in 26 (48%) of 54 lesions sampled at large-core biopsy and in 13 (18%) of 74 lesions sampled at vacuum-assisted biopsy (Fisher exact test, P < .0004). More tissue specimens were obtained at vacuum-assisted biopsy (mean, 15.8 specimens) than at large-core biopsy (mean, 9.7 specimens). Individual specimens were twice as large at vacuum-assisted biopsy (mean, 34 mg) as at large-core biopsy (mean, 17 mg) (previously reported). CONCLUSION: ADH was diagnosed 2.7 times more reliably at vacuum-assisted biopsy than at large-core biopsy (with no increase in complications) with most of the improvement as a result of acquisition of more than 10 specimens per lesion, but carcinoma was sufficiently underestimated with both methods to necessitate surgical biopsy.