Seeing It from Both Sides: Do Approaches to Involving Patients in Improving Their Safety Risk Damaging the Trust between Patients and Healthcare Professionals? An Interview Study

Objective

Encouraging patients to be more vigilant about their care challenges the traditional dynamics of patient-healthcare professional interactions. This study aimed to explore, from the perspectives of both patients and frontline healthcare staff, the potential consequences of patient-mediated intervention as a way of pushing safety improvement through the involvement of patients.

Design

Qualitative study, using purposive sampling and semi-structured interviews with patients, their relatives and healthcare professionals. Emergent themes were identified using grounded theory, with data coded using NVIVO 8.

Participants

16 patients, 4 relatives, (mean age (sd) 60 years (15); 12 female, 8 male) and 39 healthcare professionals, (9 pharmacists, 11 doctors, 12 nurses, 7 health care assistants).

Setting

Participants were sampled from general medical and surgical wards, taking acute and elective admissions, in two hospitals in north east England.

Results

Positive consequences were identified but some actions encouraged by current patient-mediated approaches elicited feelings of suspicion and mistrust. For example, patients felt speaking up might appear rude or disrespectful, were concerned about upsetting staff and worried that their care might be compromised. Staff, whilst apparently welcoming patient questions, appeared uncertain about patients’ motives for questioning and believed that patients who asked many questions and/or who wrote things down were preparing to complain. Behavioural implications were identified that could serve to exacerbate patient safety problems (e.g. staff avoiding contact with inquisitive patients or relatives; patients avoiding contact with unreceptive staff).

Conclusions

Approaches that aim to push improvement in patient safety through the involvement of patients could engender mistrust and create negative tensions in the patient-provider relationship. A more collaborative approach, that encourages patients and healthcare staff to work together, is needed. Future initiatives should aim to shift the current focus away from “checking up” on individual healthcare professionals to one that engages both parties in the common goal of enhancing safety.     

Lifetime Victimization and Physical Health Outcomes among Lesbian and Heterosexual Women

Background

Lifetime victimization experiences, including child sexual abuse (CSA), child physical abuse (CPA), adult sexual assault (ASA), and adult physical assault (APA), are associated with health problems.

Purpose

To examine relationships between cumulative victimization and physical health among heterosexual and lesbian women and determine whether these relationships differ by sexual identity.

Methods

Large samples of heterosexual (n = 482) and lesbian women (n = 394) were interviewed. Questions included lifetime victimization experiences and physical health problems.

Results

Compared to women who reported no childhood victimization, those who reported experiencing both CSA and CPA were 44% more likely to report health problems and women who experienced all four types of victimization (CSA, CPA, APA, ASA) were nearly 240% as likely to report physical health problems. Interaction analyses revealed the association between victimization and physical health did not differ by sexual identity.

Conclusions

Although lesbians were more likely to report all types of victimization, results suggest that victimization conferred increased physical health risks regardless of sexual identity.     

The Impact of Sexual Abuse in Patients Undergoing Colonoscopy

Background

Sexual abuse has been linked to strong effects on gastrointestinal health. Colonoscopy can provoke intense emotional reactions in patients with a sexual abuse history and may lead to avoidance of endoscopic procedures.

Objective

To determine whether care around colonoscopy needs adjustment for patients with sexual abuse experience, thereby exploring targets for the improvement of care around colonoscopic procedures.

Methods

Questionnaires were mailed to patients (n = 1419) from two centers within 11 months after colonoscopy. Differences in experience of the colonoscopy between patients with and without a sexual abuse history were assessed and patients'' views regarding physicians'' inquiry about sexual abuse and care around endoscopic procedures were obtained.

Results

A total of 768 questionnaires were analyzed. The prevalence of sexual abuse was 3.9% in male and 9.5% in female patients. Patients born in a non-western country reported more sexual abuse (14.9%) than those born in a western country (6.3%; p = 0.008). Discomfort during colonoscopy was indicated on a scale from 0 to 10, mean distress score of patients with sexual abuse was 4.8(±3.47) compared to 3.5(±3.11) in patients without a sexual abuse history (p = 0.007). Abdominal pain was a predictor for higher distress during colonoscopy (β = −0.019 (SE = 0.008); p = 0.02, as well as the number of complaints indicated as reason for colonoscopy (β = 0.738 (SE = 0.276); p = 0.008). Of patients with sexual abuse experience, 53.8% believed gastroenterologists should ask about it, 43.4% said deeper sedation during colonoscopy would diminish the distress.

Conclusions

Sexual abuse is prevalent in patients presenting for colonoscopy. Patients with a sexual abuse history experience more distress during the procedure and indicate that extra attention around and during colonoscopy may diminish this distress.     

Three-Year Change in the Wellbeing of Orphaned and Separated Children in Institutional and Family-Based Care Settings in Five Low- and Middle-Income Countries

Background

With more than 2 million children living in group homes, or “institutions”, worldwide, the extent to which institution-based caregiving negatively affects development and wellbeing is a central question for international policymakers.

Methods

A two-stage random sampling methodology identified community representative samples of 1,357 institution-dwelling orphaned and separated children (OSC) and 1,480 family-dwelling OSC aged 6–12 from 5 low and middle income countries. Data were collected from children and their primary caregivers. Survey-analytic techniques and linear mixed effects models describe child wellbeing collected at baseline and at 36 months, including physical and emotional health, growth, cognitive development and memory, and the variation in outcomes between children, care settings, and study sites.

Findings

At 36-month follow-up, institution-dwelling OSC had statistically significantly higher height-for-age Z-scores and better caregiver-reported physical health; family-dwelling OSC had fewer caregiver-reported emotional difficulties. There were no statistically significant differences between the two groups on other measures. At both baseline and follow-up, the magnitude of the differences between the institution- and family-dwelling groups was small. Relatively little variation in outcomes was attributable to differences between sites (11–27% of total variation) or care settings within sites (8–14%), with most variation attributable to differences between children within settings (60–75%). The percent of variation in outcomes attributable to the care setting type, institution- versus family-based care, ranged from 0–4% at baseline, 0–3% at 36-month follow-up, and 0–4% for changes between baseline and 36 months.

Interpretation

These findings contradict the hypothesis that group home placement universally adversely affects child wellbeing. Without substantial improvements in and support for family settings, the removal of institutions, broadly defined, would not significantly improve child wellbeing and could worsen outcomes of children who are moved from a setting where they are doing relatively well to a more deprived setting.     

General Practitioners Can Evaluate the Material,Social and Health Dimensions of Patient Social Status

Objective

To identify which physician and patient characteristics are associated with physicians'' estimation of their patient social status.

Design

Cross-sectional multicentric survey.

Setting

Fourty-seven primary care private offices in Western Switzerland.

Participants

Random sample of 2030 patients ≥16, who encountered a general practitioner (GP) between September 2010 and February 2011.

Main measures

Primary outcome: patient social status perceived by GPs, using the MacArthur Scale of Subjective Social Status, ranging from the bottom (0) to the top (10) of the social scale.Secondary outcome: Difference between GP''s evaluation and patient''s own evaluation of their social status. Potential patient correlates: material and social deprivation using the DiPCare-Q, health status using the EQ-5D, sources of income, and level of education. GP characteristics: opinion regarding patients'' deprivation and its influence on health and care.

Results

To evaluate patient social status, GPs considered the material, social, and health aspects of deprivation, along with education level, and amount and type of income. GPs declaring a frequent reflexive consideration of their own prejudice towards deprived patients, gave a higher estimation of patients'' social status (+1.0, p = 0.002). Choosing a less costly treatment for deprived patients was associated with a lower estimation (−0.7, p = 0.002). GP''s evaluation of patient social status was 0.5 point higher than the patient''s own estimate (p<0.0001).

Conclusions

GPs can perceive the various dimensions of patient social status, although heterogeneously, according partly to their own characteristics. Compared to patients'' own evaluation, GPs overestimate patient social status.     

Practice and Attitude of Cigarette Smoking: A Community-Based Study

Background

In Saudi Arabia many studies have addressed cigarette smoking from various perspectives. Most of these studies, however, were conducted among males and confined to Riyadh, the capital city. Such limitations have enhanced the need for community-based epidemiological studies that include both genders and various age groups and socio-demographic features, as well as different regions.

Objective

This cross-sectional study aims to assess the prevalence of cigarette smoking and to discuss the association between cigarette smoking habits and socio-demographic factors among community members of the Jazan area in southwest Saudi Arabia.

Methods

A pre-coded questionnaire was designed and tested for data consistency. A well-trained health team was assigned to gather the data from the 30 primary healthcare centers distributed across eight provinces. The response rate was 92.8% (4,326 respondents ≥13 years old). The associations among the subjects'' socio-demographic characteristics were examined by the chi-square test. A multiple logistic regression and odds ratios were calculated as well.

Results

A total of 1,017 (23.5%), 1,042 (24.1%), and 3,284 (75.9%) respondents were, respectively, current smokers (TCS), ever-smokers (TES), and non-smokers (TNS). Though current smokers seem to be more prevalent in urban populations (13.8%) than in rural populations (9.7%), the association of urbanization with a current smoking habit is insignificant.

Conclusion

Having fun, relieving stress, and the influence of parents, particularly of mothers, were the main motives that encouraged participants'' cigarette-smoking habits. This situation was worsened by the fact that accessing cigarettes was either very easy or easy for over 90% of the respondents.     

Braving Difficult Choices Alone: Children's and Adolescents' Medical Decision Making

Objective

What role should minors play in making medical decisions? The authors examined children''s and adolescents'' desire to be involved in serious medical decisions and the emotional consequences associated with them.

Methods

Sixty-three children and 76 adolescents were presented with a cover story about a difficult medical choice. Participants were tested in one of four conditions: (1) own informed choice; (2) informed parents'' choice to amputate; (3) informed parents'' choice to continue a treatment; and (4) uninformed parents'' choice to amputate. In a questionnaire, participants were asked about their choices, preference for autonomy, confidence, and emotional reactions when faced with a difficult hypothetical medical choice.

Results

Children and adolescents made different choices and participants, especially adolescents, preferred to make the difficult choice themselves, rather than having a parent make it. Children expressed fewer negative emotions than adolescents. Providing information about the alternatives did not affect participants'' responses.

Conclusions

Minors, especially adolescents, want to be responsible for their own medical decisions, even when the choice is a difficult one. For the adolescents, results suggest that the decision to be made, instead of the agent making the decision, is the main element influencing their emotional responses and decision confidence. For children, results suggest that they might be less able than adolescents to project how they would feel. The results, overall, draw attention to the need to further investigate how we can better involve minors in the medical decision-making process.     

A Stochastic Multi-Scale Model of HIV-1 Transmission for Decision-Making: Application to a MSM Population

Background

In the absence of an effective vaccine against HIV-1, the scientific community is presented with the challenge of developing alternative methods to curb its spread. Due to the complexity of the disease, however, our ability to predict the impact of various prevention and treatment strategies is limited. While ART has been widely accepted as the gold standard of modern care, its timing is debated.

Objectives

To evaluate the impact of medical interventions at the level of individuals on the spread of infection across the whole population. Specifically, we investigate the impact of ART initiation timing on HIV-1 spread in an MSM (Men who have Sex with Men) population.

Design and Methods

A stochastic multi-scale model of HIV-1 transmission that integrates within a single framework the in-host cellular dynamics and their outcomes, patient health states, and sexual contact networks. The model captures disease state and progression within individuals, and allows for simulation of therapeutic strategies.

Results

Early ART initiation may substantially affect disease spread through a population.

Conclusions

Our model provides a multi-scale, systems-based approach to evaluate the broader implications of therapeutic strategies.     

“I Can't Find Anything Wrong: It Must Be a Pulmonary Embolism”: Diagnosing Suspected Pulmonary Embolism in Primary Care,a Qualitative Study

Background

Before using any prediction rule oriented towards pulmonary embolism (PE), family physicians (FPs) should have some suspicion of this diagnosis. The diagnostic reasoning process leading to the suspicion of PE is not well described in primary care.

Objective

to explore the diagnostic reasoning of FPs when pulmonary embolism is suspected.

Method

Semi-structured qualitative interviews with 28 FPs. The regional hospital supplied data of all their cases of pulmonary embolism from June to November 2011. The patient''s FP was identified where he/she had been the physician who had sent the patient to the emergency unit. The first consecutive 14 FPs who agreed to participate made up the first group. A second group was chosen using a purposeful sampling method. The topic guide focused on the circumstances leading to the suspicion of PE. A thematic analysis was performed, by three researchers, using a grounded theory coding paradigm.

Results

In the FPs'' experience, the suspicion of pulmonary embolism arose out of four considerations: the absence of indicative clinical signs for diagnoses other than PE, a sudden change in the condition of the patient, a gut feeling that something was seriously wrong and an earlier failure to diagnose PE. The FPs interviewed did not use rules in their diagnostic process.

Conclusion

This study illustrated the diagnostic role of gut feelings in the specific context of suspected pulmonary embolism in primary care. The FPs used the sense of alarm as a tool to prevent the diagnostic error of missing a PE. The diagnostic accuracy of gut feelings has yet to be evaluated.     

Healthcare Workers' Challenges in the Implementation of Tuberculosis Infection Prevention and Control Measures in Mozambique

Objective

Healthcare Workers (HCWs) have a higher frequency of TB exposure than the general population and have therefore an occupational TB risk that infection prevention and control (IPC) measures aim to reduce. HCWs are crucial in the implementation of these measures. The objective of the study was to investigate Mozambican HCWs'' perceptions of their occupational TB risk and the measures they report using to reduce this risk. In addition, we explored the challenges HCWs encounter while using these TBIPC measures.

Methods

Focus group discussion. Analysis according content method.

Participants

Four categories of HCWs: auxiliary workers, medical (doctors and clinical officers), nurses and TB program staff.

Results

HCWs are aware of their occupational TB risk and use various measures to reduce their risk of infection. HCWs find it challenging to employ measures that minimize such risks and a lack of clear guidelines contributes to these challenges. HCWs'' and patient behavior further complicate the use of TBIPC measures.

Conclusion

HCWs in Mozambique perceive a high occupational risk of TB infection. They report several challenges using measures to reduce this risk such as shortage of material, lack of clear guidelines, insufficient motivation and inadequate training. Robust training with motivational approaches, alongside supervision and support for HCWs could improve implementation of TBIPC measures. Healthcare management should address the areas for improvement that are beyond the individual HCW''s control.     

The Association between Individual Income and Aggressive End-of-Life Treatment in Older Cancer Decedents in Taiwan

Objectives

To examine the association of individual income and end of life (EOL) care in older cancer decedents in Taiwan.

Design

Retrospective cohort study.

Setting

National Health Insurance Research Database (NHIRD) in Taiwan.

Participants

28,978 decedents >65 years were diagnosed with cancer and died during 2009-2011 in Taiwan. Of these decedents, 10941, 16535, and 1502 were categorized by individual income as having low, moderate, and high SES, respectively.

Main outcome measures

Indicators of aggressiveness of EOL care: chemotherapy use before EOL, more than one emergency department (ER) visit, more than one hospital admission, hospital length of stay >14 days, intensive care unit (ICU) admission, and dying in a hospital.

Results

Low individual income was associated with more aggressive EOL treatment (estimate -0.30 for moderate income, -0.27 for high income, both p<0.01). The major source of aggressiveness was the tendency for older decedents with low income to die in the acute care hospital. The indicators had an increasing trend from 2009 to 2011, except for hospital stay >14 days.

Conclusions

Low individual income is associated with more aggressive EOL treatment in older cancer decedents. Public health providers should make available appropriate education and hospice resources to these decedents and their families, to reduce the amount of aggressive terminal care such decedents receive.     

A Stabilization Device That Promotes the Efficiency of Cardiopulmonary Resuscitation during Ambulance Transportation to the Level as under Non-Moving Conditions

Background

The survival rate of patients with out-of-hospital cardiac arrest is low, and measures to improve the quality of cardiopulmonary resuscitation (CPR) during ambulance transportation are desirable. We designed a stabilization device, and in a randomized crossover trial we found performing CPR in a moving ambulance with the device (MD) could achieve better efficiency than that without the device (MND), but the efficiency was lower than that in a non-moving ambulance (NM).

Purpose

To evaluate whether a modified version of the stabilization device, can promote further the quality of CPR during ambulance transportation.

Methods

Participants of the previous study were recruited, and they performed CPR for 10 minutes in a moving ambulance with the modified version of the stabilization device (MVSD). The primary outcomes were effective chest compressions and no-flow fraction recorded by a skill-reporter manikin. The secondary outcomes included back pain, physiological parameters, and the participants'' rating about the device after performing CPR.

Results

The overall effective compressions in 10 minutes were 86.4±17.5% for NM, 60.9±14.6% for MND, 69.7±22.4% for MD, and 86.6%±13.2% for MVSD (p<0.001). Whereas changes in back pain severity and physiology parameters were similar under all conditions, MVSD had the lowest no-flow fraction. Differences in effective compressions and the no-flow fraction between MVSD and NM did not reach statistical significance.

Conclusions

The use of the modified device can improve quality of CPR in a moving ambulance to a level similar to that in a non-moving condition without increasing the severity of back pain.     

An Observational Study of Patient Characteristics Associated with the Mode of Admission to Acute Stroke Services in North East,England

Objective

Effective provision of urgent stroke care relies upon admission to hospital by emergency ambulance and may involve pre-hospital redirection. The proportion and characteristics of patients who do not arrive by emergency ambulance and their impact on service efficiency is unclear. To assist in the planning of regional stroke services we examined the volume, characteristics and prognosis of patients according to the mode of presentation to local services.

Study design and setting

A prospective regional database of consecutive acute stroke admissions was conducted in North East, England between 01/09/10-30/09/11. Case ascertainment and transport mode were checked against hospital coding and ambulance dispatch databases.

Results

Twelve acute stroke units contributed data for a mean of 10.7 months. 2792/3131 (89%) patients received a diagnosis of stroke within 24 hours of admission: 2002 arrivals by emergency ambulance; 538 by private transport or non-emergency ambulance; 252 unknown mode. Emergency ambulance patients were older (76 vs 69 years), more likely to be from institutional care (10% vs 1%) and experiencing total anterior circulation symptoms (27% vs 6%). Thrombolysis treatment was commoner following emergency admission (11% vs 4%). However patients attending without emergency ambulance had lower inpatient mortality (2% vs 18%), a lower rate of institutionalisation (1% vs 6%) and less need for daily carers (7% vs 16%). 149/155 (96%) of highly dependent patients were admitted by emergency ambulance, but none received thrombolysis.

Conclusion

Presentations of new stroke without emergency ambulance involvement were not unusual but were associated with a better outcome due to younger age, milder neurological impairment and lower levels of pre-stroke dependency. Most patients with a high level of pre-stroke dependency arrived by emergency ambulance but did not receive thrombolysis. It is important to be aware of easily identifiable demographic groups that differ in their potential to gain from different service configurations.     

Lack of Association between Stroke and Left Atrial Out-Pouching Structures: Results of a Case-Control Study

Background and Purpose

Clinical significance of out-pouching structures of the left atrium (LA) as potential embolic sources remains unclear. We sought to evaluate the association between stroke and LA out-pouching structures.

Methods

A case-control study was conducted to assess the prevalence of LA out-pouching structures in subjects with and without stroke. Case subjects were 270 stroke patients who had undergone cardiac CT. Control subjects were 270 age- and sex-matched patients without a history of stroke and who had undergone cardiac CT. Presence of LA out-pouching structures was determined by ECG-gated cardiac CT. The location of out-pouching structures was categorized as near Bachmann bundle, anterior, inferoseptal, inferior, and lateral. The prevalence, number and location of out-pouching structures and clinical characteristics were compared between the two groups.

Results

One hundred sixty eight out-pouching structures were identified in 139 stroke patients (51%), while a total of 169 out-pouching structures were found in 155 control patients (57%) (p=0.1949). The prevalence of LA out-pouching structures with different locations was not significantly different between the stroke group and control group. In the stroke group, the prevalence of out-pouching structures was not significantly different by subtypes of ischemic stroke and the prevalence of LA out-pouching structures was not different between patients with atrial fibrillation (AF) and without AF.

Conclusion

The left atrial out-pouching structures are commonly seen in a population with and without stroke with similar prevalence. Our study suggests that LA out-pouching structures are not significant risk factors of stroke.     

Quality along the Continuum: A Health Facility Assessment of Intrapartum and Postnatal Care in Ghana

Objective

To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate “effective coverage” of skilled attendance in Brong Ahafo, Ghana.

Methods

We conducted an assessment of all 86 health facilities in seven districts in Brong Ahafo. Using performance of key signal functions and the availability of relevant drugs, equipment and trained health professionals, we created composite quality categories in four dimensions: routine delivery care, emergency obstetric care (EmOC), emergency newborn care (EmNC) and non-medical quality. Linking the health facility assessment to surveillance data we estimated “effective coverage” of skilled attendance as the proportion of births in facilities of high quality.

Findings

Delivery care was offered in 64/86 facilities; only 3-13% fulfilled our requirements for the highest quality category in any dimension. Quality was lowest in the emergency care dimensions, with 63% and 58% of facilities categorized as “low” or “substandard” for EmOC and EmNC, respectively. This implies performing less than four EmOC or three EmNC signal functions, and/or employing less than two skilled health professionals, and/or that no health professionals were present during our visit. Routine delivery care was “low” or “substandard” in 39% of facilities, meaning 25/64 facilities performed less than six routine signal functions and/or had less than two skilled health professionals and/or less than one midwife. While 68% of births were in health facilities, only 18% were in facilities with “high” or “highest” quality in all dimensions.

Conclusion

Our comprehensive facility assessment showed that quality of routine and emergency intrapartum and postnatal care was generally low in the study region. While coverage with facility delivery was 68%, we estimated “effective coverage” of skilled attendance at 18%, thus revealing a large “quality gap.” Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.     

Fragmentation of Care Threatens Patient Safety in Peripheral Vascular Catheter Management in Acute Care– A Qualitative Study

Background

The use of peripheral vascular catheters (PVCs) is an extremely common and necessary clinical intervention, but inappropriate PVC care poses a major patient safety risk in terms of infection. Quality improvement initiatives have been proposed to reduce the likelihood of adverse events, but a lack of understanding about factors that influence behaviours of healthcare professionals limits the efficacy of such interventions. We undertook qualitative interviews with clinical staff from a large group of hospitals in order to understand influences on PVC care behaviors and subsequent patient safety.

Methods

Ten doctors, ten clinical pharmacists, 18 nurses and one midwife at a National Health Service hospital group in London (United Kingdom) were interviewed between December 2010 and July 2011 using qualitative methods. Responses were analysed using a thematic framework.

Results

Four key themes emerged: 1) Fragmentation of management and care, demonstrated with a lack of general overview and insufficient knowledge about expected standards of care or responsibility of different professionals; 2) feelings of resentment and frustration as a result of tensions in the workplace, due to the ambiguity about professional responsibilities; 3) disregard for existing hospital policy due to perceptions of flaws in the evidence used to support it; and 4) low-risk perception for the impact of PVC use on patient safety.

Conclusion

Fragmentation of practice resulted in ill-defined responsibilities and interdisciplinary resentment, which coupled with a generally low perception of risk of catheter use, appeared to result in lack of maintaining policy PVC standards which could reduced patient safety. Resolution of these issues through clearly defining handover practice, teaching interdisciplinary duties and increasing awareness of PVC risks could result in preventing thousands of BSIs and other PVC-related infections annually.     

Using Information from the Electronic Health Record to Improve Measurement of Unemployment in Service Members and Veterans with mTBI and Post-Deployment Stress

Objective

The purpose of this pilot study is 1) to develop an annotation schema and a training set of annotated notes to support the future development of a natural language processing (NLP) system to automatically extract employment information, and 2) to determine if information about employment status, goals and work-related challenges reported by service members and Veterans with mild traumatic brain injury (mTBI) and post-deployment stress can be identified in the Electronic Health Record (EHR).

Design

Retrospective cohort study using data from selected progress notes stored in the EHR.

Setting

Post-deployment Rehabilitation and Evaluation Program (PREP), an in-patient rehabilitation program for Veterans with TBI at the James A. Haley Veterans'' Hospital in Tampa, Florida.

Participants

Service members and Veterans with TBI who participated in the PREP program (N = 60).

Main Outcome Measures

Documentation of employment status, goals, and work-related challenges reported by service members and recorded in the EHR.

Results

Two hundred notes were examined and unique vocational information was found indicating a variety of self-reported employment challenges. Current employment status and future vocational goals along with information about cognitive, physical, and behavioral symptoms that may affect return-to-work were extracted from the EHR. The annotation schema developed for this study provides an excellent tool upon which NLP studies can be developed.

Conclusions

Information related to employment status and vocational history is stored in text notes in the EHR system. Information stored in text does not lend itself to easy extraction or summarization for research and rehabilitation planning purposes. Development of NLP systems to automatically extract text-based employment information provides data that may improve the understanding and measurement of employment in this important cohort.     

Hepatitis C Virus Infection and Risk of Stroke: A Systematic Review and Meta-Analysis

Background/Aims

Several studies analyzed the association between hepatitis C virus (HCV) infection and the risk of stroke or cerebrovascular death, but their findings were inconsistent. Up to date, no systematic review about the association between HCV infection and stroke was performed. We conducted a meta-analysis to examine whether HCV infection dose increase stroke risk in comparison to the population without HCV infection.

Methods

We followed standard guidelines for performance of meta-analysis. Two independent investigators identified eligible studies through structured keyword searches in several databases. Random-effects and fixed-effects models were used to synthesize the data. Heterogeneity between studies and publication bias were also accessed.

Results

Combining the data from the eligible studies, we calculated the pooled multi-factor adjusted Odds Ratio (OR) with 95% confidence interval (CI). Upon the heterogeneity found between studies, the result was 1.58 (0.86, 2.30) by random-effects model. However, after omitting the study which induced heterogeneity, the pooled OR with 95% CI was 1.97 (1.64, 2.30).

Conclusions

This meta-analysis suggested that HCV infection increased the risk of stroke. More prospective cohort studies will be needed to confirm this association with underlying biological mechanisms in the future.     

Adequate Prenatal Care Reduces the Risk of Adverse Pregnancy Outcomes in Women with History of Infertility: A Nationwide Population-Based Study

Objectives

To investigate the effects of various measures of prenatal care on adverse pregnancy outcomes in women with a history of infertility.

Study Design

A retrospective cohort study.

Methods

Data were derived by linking 2 large nationwide population-based datasets, the National Health Insurance Research Database and Taiwan Birth Certificate Registry. The study sample included 15,056 women with an infertility diagnosis and 60,224 randomly selected women without infertility matched to the study sample by maternal age. A conditional logistic regression analysis was performed for the analysis.

Results

Women diagnosed with infertility respectively had 1.39 (95% CI, 1.06~1.83), 1.15 (95% CI, 1.08~1.24), 1.13 (95% CI, 1.08~1.18), and 1.08 (95% CI, 1.05~1.12) higher odds of having very low birth weight (VLBW) babies, preterm births, labor complications, and cesarean sections (CSs) compared to women without infertility. Inadequate numbers of total and major prenatal visits and late initiation of prenatal care increased the risks of adverse pregnancy outcomes in women with infertility, especially the risk of a VLBW baby. However, no significant associations were found for the risks of adverse birth outcomes in infertile women with adequate prenatal care compared to fertile women with adequate care.

Conclusions

Study findings suggest that adequate prenatal care can reduce the risk of adverse pregnancy outcomes in women with infertility.