Una propuesta de política pública: programa de cultura de donación de órganos en Morelia, Michoacán, México / A public policy proposal: organ donation culture program in Morelia, Michoacán, México

Resumen El trasplante de órganos en nuestros tiempos es un procedimiento médico de rutina y, en muchos casos, representa la única alternativa para que los pacientes en listas de espera puedan continuar su vida. Pese a eso, la problemática en la ciudad de Morelia, Michoacán, es similar a la presentada alrededor del mundo, pues la escasa cultura de donación de órganos impide a quienes la apoyan llevar a la práctica su deseo, porque, al momento de solicitar el consentimiento de donación post mortem prevalece un alto porcentaje de negativas familiares. Este trabajo tuvo por objetivo diseñar una política pública desde un enfoque racional, utilizando la metodología del marco lógico, del cual resultó una propuesta de programa de cultura de donación de órganos post mortem en la ciudad de Morelia, Michoacán, a fin de contrarrestar dichas negativas y potencializar las donaciones y los trasplantes de órganos.

Hearing healthcare gaps in LMICS: snapshot from a semi-urban community in Nigeria.

BACKGROUND: Low and middle-income countries (LMICs) have high prevalence of hearing loss which are mainly due to preventable causes. While urban communities in LMICs are likely to have functional hearing healthcare delivery infrastructure, rural and semi-urban communities may have different reality. OBJECTIVES: This study aimed to provide: (i) a snapshot of the burden of ear diseases and (ii) a description of available hearing healthcare resources in a semi-urban Nigerian community. METHODS: A cross-sectional study of households selected by multistage random sampling technique. Seventy-four participants: 39 males and 35 females with mean age of 34 years ± 5.24 were recruited and answered a structured questionnaire. In addition, the availability of hearing healthcare services in 15 health centers within the community were determined. RESULTS: All participants reported recent occurrence of ear complaints or gave similar history in a household member. Common complaints were ear discharge, ear pain and hearing loss. Medical intervention was sought from patent medicine stores, hospitals and traditional healers. None of the assessed hospitals within the study site was manned by an ENT surgeon or ENT trained nurse. CONCLUSION: Despite the heavy burden of ear complaints there is inadequate hearing healthcare delivery in a typical LMIC community. This highlights the need for urgent improvement of hearing healthcare.

The feasibility of medical unmanned aerial systems in suburban areas.

Out-of-Hospital Cardiac Arrests (OHCA) are one of the biggest challenges facing medical systems world-wide. Each year, more than 420,000 Americans experience cardiac arrests with a survival rate of approximately 10%.1 A large challenge to treating OHCA continues to be rapid access to AEDs which can increase survival rates up to 40%.1 While pivotal to an OHCA patient's survival, AEDs are not always readily available. Advances in unmanned aerial systems (UAS) - commonly referred to as drones - can provide a solution since UAS have the ability to rapidly carry an AED payload to an emergency site. This study examined the potential use of UAS delivered AEDs in suburban areas by using the Charlottesville-Albemarle area as an example. This study was carried out by using Geographical Information Systems mapping. Specifications of the Eagle drone model by Flirtey were used to develop a beneficial drone placement plan. Models were created with drones at first responder stations. Coverage area of the drones at first responder stations was compared to coverage area of drone units placed at "ideal" locations in the Charlottesville-Albemarle County area. Population statistics were gathered from the GIS program Social Explorer, using data from the U.S. Census Bureau. The "ideal" location placement plan was then evaluated for an estimate of total population covered by the system. Finally, ideal drone placements were evaluated and compared to response time and distances versus a local EMS ground unit. With the derived ideal placements, 70.08% of the area would have drone coverage that could deliver an AED in less than five minutes and 97.97% of the area would have coverage in less than 10 min. At minimum, 94.72% of the population would be covered by the ideal placements of drones within the area. Drone response time was significantly faster than ground EMS response by a factor of 5× (P value < .05). Drones were able to get to the incident scene of a theoretical OHCA faster without and with vertical response challenges. The results show that UAS delivery of AEDs is not only possible in the Charlottesville-Albemarle County area, but an effective way to decrease response time to improve chances of survival for a person experiencing an OHCA in similar suburban areas.

Mortality Variations of COVID-19 from Different Hospital Settings During Different Pandemic Phases: A Multicenter Retrospective Study.

INTRODUCTION: Diverse coronavirus disease 2019 (COVID-19) mortalities have been reported but focused on identifying susceptible patients at risk of more severe disease or death. This study aims to investigate the mortality variations of COVID-19 from different hospital settings during different pandemic phases. METHODS: We retrospectively included adult (≥18 years) patients who visited emergency departments (ED) of five hospitals in the state of Texas and who were diagnosed with COVID-19 between March-November 2020. The included hospitals were dichotomized into urban and suburban based on their geographic location. The primary outcome was mortality that occurred either during hospital admission or within 30 days after the index ED visit. We used multivariable logistic regression to investigate the associations between independent variables and outcome. Generalized additive models were employed to explore the mortality variation during different pandemic phases. RESULTS: A total of 1,788 adult patients who tested positive for COVID-19 were included in the study. The median patient age was 54.6 years, and 897 (50%) patients were male. Urban hospitals saw approximately 59.5% of the total patients. A total of 197 patients died after the index ED visit. The analysis indicated visits to the urban hospitals (odds ratio [OR] 2.14, 95% confidence interval [CI], 1.41, 3.23), from March to April (OR 2.04, 95% CI, 1.08, 3.86), and from August to November (OR 2.15, 95% CI, 1.37, 3.38) were positively associated with mortality. CONCLUSION: Visits to the urban hospitals were associated with a higher risk of mortality in patients with COVID-19 when compared to visits to the suburban hospitals. The mortality risk rebounded and showed significant difference between urban and suburban hospitals since August 2020. Optimal allocation of medical resources may be necessary to bridge this gap in the foreseeable future.

Percepción de médicos que realizan el Servicio Rural y Urbano-Marginal de salud en Perú sobre el primer nivel de atención / Effect of Rural and Marginal Urban Health Service on the physicians' perception of primary health care in Peru

RESUMEN Objetivo: Determinar la percepción de los médicos que realizan el Servicio Rural y Urbano Marginal de Salud (SERUMS) en Perú sobre el trabajo en el primer nivel de atención (PNA) y sus factores asociados. Materiales y métodos: Se realizó un análisis secundario de datos de una muestra de médicos que realizaron el SERUMS el 2016. Para evaluar la variable de interés se utilizó la escala de «Percepción sobre el trabajo en el PNA¼, cuyos puntajes más altos indican una peor percepción del trabajo en el PNA. Se aplicó una encuesta basal (antes del SERUMS) y una encuesta de seguimiento (8-12 meses de iniciado el SERUMS) y se evaluaron las diferencias en los puntajes. Resultados: De los 780 encuestados, 215 (27,6%) completaron la encuesta basal y de seguimiento. La media del puntaje incrementó considerablemente (de 3,4 a 6,7; p < 0,001), lo que indica una peor percepción del trabajo en el PNA tras iniciar el SERUMS. De los tres dominios de la encuesta, el de las percepciones sobre el médico que trabaja en el PNA y el de las percepciones sobre el trabajo asistencial en el PNA incrementaron los puntajes de percepción sobre el trabajo en el PNA. No se encontraron variables sociodemográficas asociadas al cambio en los puntajes. Conclusiones: La percepción de los médicos sobre el trabajo en el PNA se deteriora luego de iniciar el SERUMS. Se deben promover estrategias que incentiven el interés de los médicos en este nivel de atención.

ABSTRACT Objective: To determine the effect of the Rural and Marginal Urban Health Service (SERUMS) on the physicians' perception of work in the primary health care (PHC) setting and its associated factors. Materials and methods: A secondary data analysis of a sample of physicians who performed the SERUMS in 2016 was carried out. To evaluate the variable of interest, the scale "Perception of work in the PHC setting" was used, higher scores indicated a negative perception of work in the PHC setting. A baseline survey (before the SERUMS) and a follow-up survey (8-12 months after starting the SERUMS) were applied and differences in both scores were evaluated. Results: Of the 780 respondents, 215 (27.6%) completed the baseline and follow-up survey. The average score increased considerably (from 3.4 to 6.7; p < 0.001), which shows a negative perception of work in the PHC setting after participating in the SERUMS. Of the three parts of the survey, the one regarding perceptions by the physicians working in the PHC and the one about perceptions of medical work in the PHC setting increased the perception scores. No sociodemographic variables were found to be associated with the change in scores. Conclusions: Physicians' perception about work in the PHC setting deteriorated after participating in the SERUMS. Therefore, strategies to encourage physicians' interest in working at this level of healthcare should be promoted.

Factors Affecting the Interest in a Surgical Career among Medical Students at a Nonurban, Tertiary Care Academic Institution.

BACKGROUND: Present day medical students are inherently different from those in the past by growing up in a uniquely different environment that shapes their personal and professional values which affects their career decisions. Vascular surgery (VS) task force is facing a shortage in the near future. The purpose of this analysis is to gain a better understanding of the medical students' perceptions about surgery in general and VS in particular. Our institution is a large, tertiary care medical center, which is in a nonurban location. Our goal was to identify any barriers in the recruitment of prospective students to VS and to implement directives to address such barriers. METHODS: An online questionnaire was distributed to Penn State Hershey College of Medicine medical students. Our institution has an established 0 + 5 VS residency program and a VS interest group. It was designed to understand potential barriers in the recruitment of medical students choosing VS as a career. Survey consisted of 23 questions, which were carefully designed to collect information about student demographics, interest in medical profession in general, opinions about the field of surgery, and reasons for having an interest or no interest in VS. RESULTS: Five hundred sixty medical students at Penn State Hershey College of Medicine were surveyed, of whom 143 (26%) completed the survey. About 58.7% were females and two-thirds of the respondents were in the age range of 21-25 years. The following factors were significantly associated with pursing surgical career: Medical Student Year III (odds ratio [OR] 0.36, confidence interval [CI] 0.19-0.69), surgical mentorship (OR 6.01, CI 1.30-28), wanting more exposure to VS (OR 6.15, CI 2.07-18.23), and opportunity to complete training within 5 years (OR 1.14, CI 1.03-1.25) (all P < 0.05). Specifically, for VS, following factors were found to be associated with increased likelihood of choosing a VS career: variety of operative cases, ability to operate on multiple anatomic areas of the body, and opportunity to complete training within 5 years (all P < 0.05). Following factors were associated with not choosing a VS career: surgical career not for me, long duration of surgical training, financial aid burden, marital status, and complexity of operations (all P < 0.05). Students cited following concerns for choosing a surgical career: burnout (61%), stress (12.8%), work hours (12.1%), and stressful life style (5.7%). CONCLUSIONS: Potential barriers of students in choosing a surgical career are fundamentally grounded in their overall perception of surgery but are independently associated with their level of education (medical student-III versus others), strong surgical mentorship, the desire to be exposed to VS, and the opportunity to complete subspecialty surgical training within 5 years. For VS, attractive factors were variety of operative cases, ability to operate on multiple anatomic areas of the body, and opportunity to complete training within 5 years. Overall, burnout associated with surgical career is the most common concern for medical students.

Resource Reallocation during the COVID-19 Pandemic in a Suburban Hospital System: Implications for Outpatient Hip and Knee Arthroplasty.

The COVID pandemic of 2020 has emerged as a global threat to patients, health care providers, and to the global economy. Owing to this particular novel and highly infectious strain of coronavirus, the rapid community spread and clinical severity of the subsequent respiratory syndrome created a substantial strain on hospitals and health care systems around the world. The rapid surge of patients presenting over a small period for emergent clinical care, admission to the hospital, and intensive care units with many requiring mechanically assisted ventilators for respiratory support demonstrated the potential to overwhelm health care workers, hospitals, and health care systems. The purpose of this article is to describe an effective system for redeployment of health care supplies, resources, and personnel to hospitals within a suburban academic hospital system to optimize the care of COVID patients, while treating orthopedic patients in an equally ideal setting to maximize their surgical and clinical care. This article will provide a particular focus on the current and future role of a specialty hip and knee hospital and its partnering ambulatory surgery center in the context of an outpatient arthroplasty program.

Mistriaged Advanced Life Support Patients in a Two-Tiered, Suburban Emergency Medical Services System.

INTRODUCTION: Emergency medical services (EMS) systems exist to provide prehospital care in diverse environments throughout the world. Advanced Life Support (ALS) services can provide advanced care including 12-lead electrocardiogram (ECG), endotracheal intubation and parenteral medication administration. Basic Life Support (BLS) can provide basic care such as splinting, wound care and cardiopulmonary resuscitation. ALS can release patients to BLS for transport to the hospital, and this is an area of high risk. Our study examines patients who were triaged and admitted to a critical care location, including an intensive care unit (ICU), cardiac catheterization laboratory, or operating room (OR). METHODS: The analysis included data from 2007-2015 of all patients who were triaged. We evaluated demographics, admission diagnoses, and dispositions using descriptive statistics. Diagnoses were grouped into categories based on the system. RESULTS: We found that 372/17,639 (2%) of patients were mistriaged to BLS and admitted to a critical care location. The average age was 64. The most common diagnosis categories were neurological (24%), gastrointestinal (GI)/abdominal pain (15%), respiratory (12%), and cardiac (12%). CONCLUSION: It is uncommon for patients triaged from ALS to BLS to be admitted to an ICU, catheterization lab or OR, with a rate of 2%. Neurological, GI, respiratory, and cardiac diagnoses were the most frequent categories of patient complaints that were mistriaged. This study should lead to further studies to examine this patient population.

Outcomes After Prehospital Endotracheal Intubation in Suburban/Rural Pediatric Trauma.

BACKGROUND: Trauma is the leading cause of death in pediatric patients over 1 y of age. Controversy exists regarding prehospital airway management for these patients, with some studies suggesting that endotracheal intubation in the field or at a referring hospital is associated with increased mortality and complication rate. These studies were largely performed at urban centers, and it is unclear whether the results apply to suburban/rural networks with longer transport times and more stops at referring hospitals. The purpose of this study is to evaluate differential outcomes in pediatric trauma patients who underwent endotracheal intubation at the scene of injury, referring hospital, or pediatric trauma center in a predominantly rural/suburban setting. MATERIALS AND METHODS: A retrospective review was performed evaluating trauma patients age 18 y or younger at a single institution over 10 y (2004-2014). Patients were selected who underwent endotracheal intubation and were classified based on location of intubation (scene, referring hospital, or trauma center). Fischer's exact test and t-tests were performed for comparison. Univariate and multivariate regression analyses were performed. RESULTS: 288 patients were identified. 155 (53.8%) were intubated at the scene of injury, 55 (19.1%) at a referring hospital, and 72 (25%) at the trauma center. Overall mortality was 21.9%, which was highest in the scene intubation group (29.7%) compared with the referring hospital (20%) and trauma center (5.6%) groups (P < 0.01). Patients intubated at the scene had higher Injury Severity Scores and lower Glasgow Coma Scale scores (P < 0.01). Duration of intubation was lowest in the trauma center group (P < 0.01). Complication rate was highest in the referring hospital group (P < 0.05). Multivariate analysis revealed that age, injury severity, and neurologic status were the key drivers of mortality rather than location of intubation. CONCLUSIONS: Mortality and duration of intubation were lowest in trauma patients intubated at a pediatric trauma center. However, location of intubation was not a significant independent predictor of mortality or complications on multivariate analysis, suggesting that age, injury severity, and neurologic status are the main indicators of prognosis in severe pediatric trauma.

Use of Mechanical Cardiopulmonary Resuscitation Devices for Out-of-Hospital Cardiac Arrest, 2010-2016.

Importance: Out-of-hospital cardiac arrest is a common scenario facing prehospital emergency medical services (EMS) professionals and nearly always involves either manual or mechanical cardiopulmonary resuscitation (CPR). Mechanical CPR devices are expensive and prior clinical trials have not provided evidence of benefit for patients when compared with manual CPR. Objectives: To investigate the use of mechanical CPR in the prehospital setting and determine whether patient demographic characteristics or geographical location is associated with its use. Design, Setting, and Participants: A retrospective cross-sectional study was performed using the 2010 through 2016 National Emergency Medical Services Information System data. Participants included all patients identified by EMS professionals as having out-of-hospital cardiac arrest. Main Outcomes and Measures: Use of CPR, categorized as manual or mechanical. Results: From 2010 to 2016, 892 022 patients (38.6% female, 60.4% male, missing for 1%; mean [SD] age, 61.1 [20.5] years) with out-of-hospital cardiac arrest were identified by EMS professionals. Overall, manual CPR was used for 618 171 patients (69.3%) and mechanical CPR was used for 45 493 patients (5.1%). The risk-standardized rate of mechanical CPR use, accounting for patient demographic and geographical characteristics, rose from 1.9% in 2010 to 8.0% in 2016 (P < .001). In multivariable analyses, use of mechanical CPR devices was increasingly likely over time among patients identified with out-of-hospital cardiac arrest treated by EMS professionals, increasing from an adjusted odds ratio of 1.58 (95% CI, 1.42-1.77; P < .001) when comparing 2011 with 2010, to an adjusted odds ratio of 11.32 (95% CI, 10.22-12.54; P < .001) when comparing 2016 with 2010. In addition, several other patient demographic and geographical characteristics were associated with a higher likelihood of receiving mechanical CPR, including being 65 years or older, being male, being Hispanic, as well as receiving treatment in the Northeast Census Region, in a suburban location, or in a zip code with a median annual income greater than $20 000. Conclusions and Relevance: Mechanical CPR device use increased more than 4-fold among patients with out-of-hospital cardiac arrest treated by EMS professionals. Given the high costs of mechanical CPR devices, better evidence is needed to determine whether these devices improve clinically meaningful outcomes for patients treated for out-of-hospital cardiac arrest by prehospital EMS professionals to justify the significant increase in their use.

Prevalence of Staphylococcus aureus and methicillin-resistant S aureus on environmental surfaces in Ohio nursing homes.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is common in medical institutions. We sought to examine the prevalence of S aureus on environmental surfaces in nursing homes and to obtain molecular information on contaminating strains. METHODS: A total of 259 environmental samples were collected from 7 different nursing homes in Northeast Ohio (NEO), from suburban, urban, and rural settings. The presence of the mecA and PVL genes was determined, and spa typing was performed in order to identify molecular types. RESULTS: The prevalence of S aureus was 28.6% (74/259). The prevalence of MRSA and methicillin-susceptible S aureus was 20.1% (52/259) and 8.5% (22/259), respectively. S aureus contamination in suburban, urban, and rural sites was 25.7% (38/148), 45.9% (34/74), and 5.4% (2/37), respectively. MRSA was detected in 16.9% (25/148) of suburban samples and 36.5% (27/74) of urban samples. No MRSA was found in rural samples. Nursing homes from urban areas had a significantly higher (P < .001) prevalence of S aureus compared to nursing homes from suburban and rural sites. Areas with high nurse touch rates were the most commonly contaminated. CONCLUSIONS: We found differences in the prevalence of S aureus and MRSA in nursing homes in different regions of NEO. Part of these differences may result from transfers from hospitals; the urban nursing homes had 4 to 15 hospitals nearby, whereas suburban and rural locations had 1 to 3 hospitals within the area.

Poor Access to Breast Reconstruction: A Geographical Shortage of Plastic Surgeons Relative to Breast Surgeons in the United States.

BACKGROUND: Breast cancer surgery involves removal of cancer performed by a breast surgeon and reconstruction performed by a plastic surgeon. Historically, many women have not undergone breast reconstruction surgery (BRS), with current literature suggesting that geographic barriers may play a role. Our objective was to determine if there is a geographic shortage of plastic surgeons in the United States and to assess for trends in access to BRS for rural, suburban, and urban populations. METHODS: A database investigation of the 2018 membership for the American Society of Breast Surgeons and the American Society of Plastic Surgeons was performed. We searched for a breast surgeon's geographic presence by zip code and looked for the presence of a plastic surgeon within 10 and 20 miles. Zip codes were then categorized as urban, suburban, or rural. Within each population category, the average numbers of breast surgeons and plastic surgeons were quantified. RESULTS: Twenty-five percent of breast surgeon zip codes had no plastic surgeons located within 10 miles; 10% of breast surgeon zip codes had no plastic surgeon within 20 miles. There were on average 7.03 breast surgeons in each urbanized area. Suburban and rural areas had an average of 1.14 and 1.00 breast surgeons, respectively. There were on average 10.97 plastic surgeons per urbanized area. Suburban and rural areas had, on average, 0.23 and 0.06 plastic surgeons, respectively. CONCLUSIONS: A national comparison of the geographical distribution between breast surgeons and plastic surgeons indicates a shortage of plastic surgeons, especially in rural and suburban areas.

A qualitative study: The promotion of exclusive breastfeeding (EBF) by integrated service post (ISP) cadres in suburban city

Objective: This study aims to explore EBF promotion activities that have been carried out by ISP cadres during this time in the work area of the CHC in Rumbai Pesisir Pekanbaru Riau. Method: The design of this study is a qualitative method with a phenomenological approach. Respondents in this study were ISP cadres with the determination of respondents using a purposive sampling approach, in order to obtain 11 respondents who appropriate the inclusion criteria as follows: cadres who are active in promoting exclusive EBF, cooperatives, aged ≤ 55 years, become a cadre for at least 2 years. Data collection methods in this study are through focus group discussion (FGD). Data processing from the FGD were analyzed according to the Colaizzi method. Results: The results of the data analysis found five themes, namely: (1) Types of EBF promotion activities carried out by cadres, (2) cadre behavior in EBF promotions, (3) cadres' ability to promote EBF, (4) constraints in carrying out EBF promotions, (5) the need for cadres to improve the ability of EBF promotions. Conclusion: Needs for EBF promotion training and cadre guidebooks, guidance and supervision by community health centers (CHC) in the implementation of this EBF promotion

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Diferencias en la nota del ENAM y el promedio ponderado universitario en postulantes al servicio rural peruano, 2008-2015 / Differences in the ENAM grade and the university weighted average in applicants to the Peruvian Rural Health Service, 2008-2015

INTRODUCCIÓN: El Servicio Rural y Urbano Marginal de Salud (SERUMS) es un programa obligatorio al finalizar la carrera médica en el Perú, para la adjudicación de una plaza se toma en cuenta la nota del promedio ponderado promocional (PPP) y del Examen Nacional de Medicina (ENAM). MATERIALES Y MÉTODOS: Estudio analítico, retrospectivo, se empleó el registro de inscritos al SERUMS en el período 2008-2015. Se evaluó la diferencial entre la nota de calificación del ENAM y el PPP, por proceso de adjudicación y según procedencia de la universidad. Se obtuvo estadísticos de asociación. RESULTADOS: De los 21.296 evaluados, el rango de notas del promedio final en las universidades peruanas fue de 10,3-12,7 (PPP: 12,7-14,0 y ENAM: 9,3-12,3), en las de Cuba fue 5,5-12,9 (PPP: 16,9-18,3 y ENAM: 0,0-10,1), en las de Bolivia fue 3,6-11,2 (PPP: 12,0-13,2 y ENAM: 0,0-10,3) y en otras universidades del extranjero fue 4,2-11,7 (PPP: 13,6-17,1 y ENAM: 0,0-10,6). Al realizar el cálculo de la diferencial del ENAM-PPP se halló discrepancia estadísticamente significativa (p < 0,001) en todos los casos, según el tipo de universidad. CONCLUSIONES: Existen diferencias estadísticamente significativas entre las notas finales, los PPP y el ENAM según la procedencia de la universidad. Esto podría generar inequidad al elegir una plaza en el SERUMS y podría indicar que los modelos de adquisición de conocimientos fueron distintos, lo que debe evaluarse para estudiar su repercusión durante el SERUMS

INTRODUCTION: The Rural and Urban Marginal Health Service (SERUMS) is a mandatory program at the end of the medical career in Peru. The promotional grade point average (PPP) and the national medical examination (ENAM) grades are used when awarding places. MATERIALS AND METHODS: An analytical, retrospective study was conducted using the registration of SERUMS in the processes between 2008 and 2015. The differential between the ENAM and PPP grades was evaluated, by an adjudication process and according to the origin of the university. Association statistics were obtained. RESULTS: From the 21,296 evaluated, the range of grades of the final average in the Peruvian universities was 10.3-12.7 (PPP: 12.7-14.0 and ENAM: 9.3-12.3). In Cubans it was 5.5-12.9 (PPP: 16.9-18.3 and ENAM: 0.0-10.1), in Bolivians it was 3.6-11.2 (PPP: 12.0-13.2 and ENAM: 0.0-10.3), and in other foreign universities it was 4.2-11.7 (PPP: 13.6-17.1 and ENAM: 0.0-10, 6). When calculating the ENAM-PPP differential, a statistically significant discrepancy (P < .001) was found in all cases, and depending on the type of university. CONCLUSIONS: There are statistically significant differences between the final grades of the PPPs and the ENAM according to the origin of the university. This could create inequity in choosing a place in the SERUMS, and could suggest that the acquisition of knowledge models are different, which should be evaluated in order to study their impact during the SERUMS

Induced Abortion Provision Among a National Sample of Obstetrician-Gynecologists.

OBJECTIVE: To estimate the proportion of obstetrician-gynecologists (ob-gyns) who provided induced abortion in the prior year, disaggregated by surgical and medication methods, and document barriers to provision of medication abortion. METHODS: In 2016-2017, we conducted a cross-sectional survey of a national sample of American College of Obstetricians and Gynecologists Fellows and Junior Fellows who were part of the Collaborative Ambulatory Research Network. We sent the survey by email, and mailed nonresponders paper surveys. We performed descriptive statistics, χ tests, and logistic regression analyses. RESULTS: Sixty-seven percent (655/980) of Collaborative Ambulatory Research Network members responded. Ninety-nine percent reported seeing patients of reproductive age, and 72% reported having a patient in the prior year who needed or wanted an abortion. Among those seeing patients of reproductive age, 23.8% (95% CI 20.5%-27.4%) reported performing an induced abortion in the prior year; 10.4% provided surgical and medication abortion, 9.4% surgical only, and 4.0% medication only. In multivariable analysis, physicians practicing in the Midwest (adjusted odds ratio [AOR] 0.31, 95% CI 0.16-0.60) or South (AOR 0.22, 95% CI 0.11-0.42) had lower odds of provision compared with those practicing in the Northeast, whereas those practicing in an urban inner city (AOR 2.71, 95% CI 1.31-5.60) or urban non-inner-city area (AOR 2.89, 95% CI 1.48-5.64 vs midsize towns, rural areas, or military settings) had higher odds of provision. The most common reasons for not providing medication abortion were personal beliefs (34%) and practice restrictions (19%). Among those not providing medication abortion, 28% said they would if they could write a prescription for mifepristone. CONCLUSION: Compared with the previous national survey in 2008-2009, abortion provision may be increasing among practicing ob-gyns, although important geographic disparities persist. Few provide medication abortion, but uptake might increase if mifepristone could be prescribed.

CEO Turnover Among U.S. Acute Care Hospitals, 2006-2015: Variations by Type of Geographic Area.

EXECUTIVE SUMMARY: Recent reports have documented rising rates of CEO turnover. This phenomenon can have negative implications for hospitals and their surrounding communities, particularly in under-resourced rural communities. Ostensibly, components of the Affordable Care Act have addressed some of these resource challenges and may have helped to slow the CEO turnover trend in rural areas. We examined this possibility with a longitudinal analysis of U.S. acute care hospitals over an extended period (2006-2015) to examine whether patterns of CEO change differed for hospitals in different types of geographic areas (e.g., rural vs. urban). The rates revealed by our analysis seem to be problematic, with nearly one-quarter of all U.S. hospitals experiencing a change in CEO every 3 to 4 years, on average. Moreover, while the likelihood of a CEO change increased significantly over time for hospitals in nearly all types of geographic areas, it was nearly twice as large for frontier hospitals in areas with fewer than 2,500 residents compared to urban and rural hospitals. Our study suggests that the stability of hospital CEO leadership has declined over the past decade, particularly for vulnerable frontier hospitals, and highlights the need for recruitment and retention strategies to address this challenge.

Life With HIV in a Canadian Suburban Community: A Qualitative Inquiry of Health Care and Social Services Access.

HIV has been examined in urban and rural contexts, but the suburban gradient has not been sufficiently described, despite the fact that many Canadians live in suburbia. Using qualitative description, we investigated how people living with HIV in a suburban community in Ontario, Canada, accessed health care and social services. Posters at the regional AIDS Service Organization and snowball sampling were used to recruit and interview 13 adult participants with various experiences and perspectives. A content analysis identified three meta-themes in the interviews: (a) transportation cost and time: barriers to access, (b) isolation, and (c) defective primary care: unmet and deflected needs. The findings have implications for the (a) development of community-based groups, (b) the role of transportation in health care and social services utilization, (c) community-based, interprofessional health and social care services, and (d) aging with HIV.

Regionwide Retrospective Survey of Acute Mechanical Thrombectomy in Tama, Suburban Tokyo: A Preliminary Report.

BACKGROUND AND PURPOSE: To improve results of acute thrombectomy, the time from stroke onset to efficient recanalization must be minimized. Studies have confirmed the importance of rapid treatment, workflow, and efficient team-based care for acute thrombectomy in large vessel occlusion. This study examined the challenges facing mechanical thrombectomy in the Tama area (population, 4.3 million), a densely populated urban area of Tokyo, Japan, and analyzed retrospective data from the Tama-REgistry of Acute endovascular Thrombectomy. METHODS: This study was a retrospective observational study using data from Tama-REgistry of Acute endovascular Thrombectomy, a multicenter registry of mechanical thrombectomy for acute ischemic stroke in the Tama area of Tokyo. The survey covered 396 patients with large vessel occlusion who underwent acute thrombectomy between January 2015 and March 2017. Participating facilities are 12 of the 13 recanalization therapy-capable stroke centers. RESULTS: We analyzed 326 cases for which modified Rankin Scale score at 90days was available, of which 264 cases were directly admitted, and 62 cases were transferred from other stroke centers. Median time from stroke onset to hospital arrival was 111 minutes, and from arrival to efficient recanalization was 135 minutes. Efficient recanalization was achieved in 257 cases (78.8%), symptomatic hemorrhage developed in 19 cases (5.8%), and modified Rankin Scale 0-2 at 90days was seen in 129 cases (39.6%). The vast majority of patients (n = 299, 94.3%) were transferred within 10km to the enrolling hospital. CONCLUSIONS: These results provide useful information about the emergent transfer system for patients with large vessel occlusion in a densely populated urban area.

Comparing private and public transport access to diabetic health services across inner, middle, and outer suburbs of Melbourne, Australia.

BACKGROUND: Melbourne, Australia is experiencing rapid population growth, with much of this occurring in metropolitan outer suburban areas, also known as urban growth areas. Currently little is known about differences in travel times when using private and public transport to access primary and secondary services across Melbourne's urban growth areas. Plan Melbourne Refresh, a recent strategic land use document has called for a 20 min city, which is where essential services including primary health care, can be accessed within a 20 min journey. Type 2 diabetes mellitus (T2DM) is a major chronic condition in Australia, with some of Melbourne's growth areas having some of the highest prevalence across Australia. This study explores travel times to diabetic health care services for populations residing in inner, middle and outer suburbs of metropolitan Melbourne. METHOD: Geographic information systems (GIS) software were used to map the location of selected diabetic primary and secondary health care service providers across metropolitan inner, middle, outer established, outer urban growth and outer fringe areas of Melbourne. An origin-destination matrix was used to estimate travel distances from point of origin (using a total of approximately 50,000 synthetic residential addresses) to the closest type of each diabetic health care service provider (destinations) across Melbourne. ArcGIS was used to estimate travel times for private transport and public transport; comparisons were made by area. RESULTS: Our study indicated increased travel times to diabetic health services for people living in Melbourne's outer growth and outer fringe areas compared with the rest of Melbourne (inner, middle and outer established). Compared with those living in inner city areas, the median time spent travelling to diabetic services was between 2.46 and 23.24 min (private motor vehicle) and 12.01 and 43.15 min (public transport) longer for those living in outer suburban areas. Irrespective of travel mode used, results indicate that those living in inner and middle suburbs of Melbourne have shorter travel times to access diabetic health services, compared with those living in outer areas of Melbourne. Private motor vehicle travel times were approximately 4 to 5 times faster than public transport modes to access diabetic health services in all areas. CONCLUSION: Those living in new urban growth communities spend considerably more time travelling to access diabetic health services - particularly specialists - than those living in established areas across Melbourne.