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Wesevich A, De Fer TM, Awad MM, Woodhouse J, Andriole DA, Brunt LM. A Capstone Course for Senior Medical Students: from Innovative Elective to Required Core Curriculum. Med Sci Educ 2024; 34:171-180. [PMID: 38510417 PMCID: PMC10948630 DOI: 10.1007/s40670-023-01880-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 03/22/2024]
Abstract
We describe our institution's development and implementation of our Capstone course from a small elective course to the only required fourth-year course. The course's structure evolved from mostly didactic to one including various workshops and simulation sessions. Course content has become increasingly specialty-specific. Implementation requires high faculty and resident involvement. Evaluations indicate a positive impact of the course on participants' self-reported confidence and residency preparedness. Assessment remains pass/fail with more specialty-specific questions. As steadily increasing numbers of medical schools are developing transition to residency courses, we share our Capstone course's evolution and lessons learned over the past nine years. Supplementary Information The online version contains supplementary material available at 10.1007/s40670-023-01880-2.
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Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL USA
| | - Thomas M. De Fer
- Department of Medicine, Washington University School of Medicine, St. Louis, MO USA
| | - Michael M. Awad
- Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Julie Woodhouse
- Office of Education, Washington University School of Medicine, St. Louis, MO USA
| | - Dorothy A. Andriole
- Medical Education Research, Association of American Medical Colleges, Washington, D.C. USA
| | - L. Michael Brunt
- Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
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Wesevich A, Peek ME, Ratain MJ. An Ethical and Financial Obligation for Sickle Cell Disease Gene Therapy in the United States. Ann Intern Med 2024; 177:85-86. [PMID: 38048579 DOI: 10.7326/m23-2428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois (A.W., M.J.R.)
| | - Monica E Peek
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (M.E.P.)
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois (A.W., M.J.R.)
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Wesevich A, Mocha G, Kiwara F, Chao C, Shabani I, Igenge JZ, Schroeder K. Wilms tumor treatment protocol compliance and the influence on outcomes for children in Tanzania. Pediatr Blood Cancer 2023; 70:e30704. [PMID: 37789508 DOI: 10.1002/pbc.30704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/25/2023] [Accepted: 09/18/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Standardized Wilms tumor treatment protocols exist for low- and middle-income countries, but outcomes equivalent to high-income countries are not achieved outside of clinical trials. As Wilms tumor treatment protocols in Africa shift with increasing resource capacity, it is not known how treatment compliance to each stage of therapy affects outcomes and where the critical breakpoints are for protocol adherence in clinical practice. PROCEDURE We describe both treatment outcomes and treatment protocol adherence in a retrospective single-center cohort study of pediatric Wilms tumor patients at a zonal cancer referral hospital in Tanzania from 2016 to 2019, treated per the International Society of Paediatric Oncology standard (2016-2017) or Tanzania adapted (2018-2019) therapy protocols. RESULTS A total of 69 patients were evaluated. The two-year overall survival and event-free survival rates were 40% and 29%, respectively. Only 29% of patients completed recommended chemotherapy per protocol, and completion of preoperative and postoperative chemotherapy was predictive of two-year overall survival (odds ratio [OR] 14.4, p < .001). There were delays at almost every stage of treatment, especially time from preoperative chemotherapy to surgery (56 days), from surgery to pathology report (30 days), and from surgery to initiation of postoperative chemotherapy (38 days). CONCLUSIONS Nonadherence with recommended Wilms tumor treatment guidelines due to key health system delays correlated to reduced overall survival rates, with chemotherapy nonadherence due to abandonment, lack of surgery, and deaths on therapy as the strongest contributors. Future interventions targeting health system delays and reducing deaths during therapy are critical to improving protocol compliance and increasing overall survival for pediatric Wilms tumor patients in low-resource settings.
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Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
| | - George Mocha
- Department of Urology, Rabininsia Memorial Hospital, Dar Es Salaam, Tanzania
| | - Frank Kiwara
- Department of Urology, Mbeya Zonal Referral Hospital, Mbeya, Tanzania
| | - Colin Chao
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Idd Shabani
- Department of Pathology, Bugando Medical Centre, Mwanza, Tanzania
| | - John Z Igenge
- Department of Urology, Bugando Medical Centre, Mwanza, Tanzania
| | - Kristin Schroeder
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Global Health, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Oncology, Bugando Medical Centre, Mwanza, Tanzania
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DuVall AS, Wesevich A, Larson RA. Developing Targeted Therapies for T Cell Acute Lymphoblastic Leukemia/Lymphoma. Curr Hematol Malig Rep 2023; 18:217-225. [PMID: 37490229 DOI: 10.1007/s11899-023-00706-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 07/26/2023]
Abstract
PURPOSE OF REVIEW Largely, treatment advances in relapsed and/or refractory acute lymphoblastic leukemia (ALL) have been made in B cell disease leaving T cell ALL reliant upon high-intensity chemotherapy. Recent advances in the understanding of the biology of T-ALL and the improvement in immunotherapies have led to new therapeutic pathways to target and exploit. Here, we review the more promising pathways that are able to be targeted and other therapeutic possibilities for T-ALL. RECENT FINDINGS Preclinical models and early-phase clinical trials have shown promising results in some case in the treatment of T-ALL. Targeting many different pathways could lead to the next advancement in the treatment of relapsed and/or refractory disease. Recent advances in cellular therapies have also shown promise in this space. When reviewing the literature as a whole, targeting important pathways and antigens likely will lead to the next advancement in T-ALL survival since intensifying chemotherapy.
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Affiliation(s)
- Adam S DuVall
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, USA.
| | - Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, USA
| | - Richard A Larson
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, USA
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Wesevich A, Ratain MJ. Project Optimus: Is the US Food and Drug Administration Waiving Dose Optimization for Orphan Drugs? JAMA Oncol 2023; 9:1489-1490. [PMID: 37651126 DOI: 10.1001/jamaoncol.2023.3292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
This Viewpoint discusses the US Food and Drug Administration’s Project Optimus, which focuses on new oncology drug dose optimization and examines concerns about the accelerated postmarketing approval of adjusted dosing of oncologic drugs.
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Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
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Wesevich A, Ratain MJ. Do patent applications and Cooperative Research and Development Agreements between the National Cancer Institute and industry serve the public interest? Nat Biotechnol 2023; 41:1517-1519. [PMID: 37950004 DOI: 10.1038/s41587-023-02004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA.
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Wesevich A, He G, Tomczyk G, Reid P. Role-Specific Curricular Needs for Identification and Management of Immune-Related Adverse Events. J Cancer Educ 2023; 38:1486-1492. [PMID: 37022615 PMCID: PMC10078044 DOI: 10.1007/s13187-023-02289-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 06/19/2023]
Abstract
Immune checkpoint inhibitors (ICIs) activate the immune system against cancer and have become standard of care for many cancers. With increased ICI use, their toxicities known as immune-related adverse events (irAEs) are becoming more common, but it is unclear how prepared relevant clinicians feel to diagnose and treat irAEs. The objective of this study was to assess irAE knowledge, confidence, and experience among generalists and oncology clinicians to guide future curricular interventions related to irAEs. A 25-item survey with questions assessing knowledge, experience level, confidence, and resource utilization regarding irAE diagnosis and management was sent to University of Chicago-affiliated (UChicago) internal medicine residents and hospitalists (inpatient irAE management) along with UChicago oncology fellows, attendings, nurse practitioners (NPs), and physician assistants (PAs) (inpatient and outpatient) as well as Chicago community oncologists (outpatient) in June 2022. Overall response rate was 37% (171/467). Knowledge scores averaged below 70% for all clinicians. "No idea" responses were most common with knowledge questions on steroid-sparing agent use and ICI use for patients with preexisting autoimmune disease. IrAE experience correlated with higher knowledge for oncology attendings (p = 0.015) and hematology/oncology NPs/PAs (p = 0.031). IrAE experience correlated with higher confidence for residents (p = 0.026), oncology fellows (p = 0.047), and hematology/oncology NPs/PAs (p = 0.042). Most commonly utilized resources were colleagues and UpToDate, and most clinicians were very likely to use online resources in the future. Knowledge and confidence gaps exist, and they were somewhat mitigated by experience. Future irAE curricula can fill these needs through online role-specific resources: irAE identification for generalists versus irAE identification and management for oncologists.
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Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Gong He
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Greg Tomczyk
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Pankti Reid
- Section of Rheumatology, Department of Medicine, University of Chicago, Chicago, IL, USA.
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Wesevich A, Goldstein DA, Paydary K, Peer CJ, Figg WD, Ratain MJ. Interventional pharmacoeconomics for immune checkpoint inhibitors through alternative dosing strategies. Br J Cancer 2023; 129:1389-1396. [PMID: 37542109 PMCID: PMC10628132 DOI: 10.1038/s41416-023-02367-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/05/2023] [Accepted: 07/12/2023] [Indexed: 08/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are approved for the treatment of a variety of cancer types. The doses of these drugs, though approved by the Food and Drug Administration (FDA), have never been optimised, likely leading to significantly higher doses than required for optimal efficacy. Dose optimisation would hypothetically decrease the risk, severity, and duration of immune-related adverse events, as well as provide an opportunity to reduce costs through interventional pharmacoeconomic strategies such as off-label dose reductions or less frequent dosing. We summarise existing evidence for ICI dose optimisation to advocate for the role of interventional pharmacoeconomics.
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Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Daniel A Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Clalit Health Service, Tel Aviv, Israel
- Optimal Cancer Care Alliance, Chicago, IL, USA
| | - Koosha Paydary
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Cody J Peer
- Clinical Pharmacology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - William D Figg
- Clinical Pharmacology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA.
- Optimal Cancer Care Alliance, Chicago, IL, USA.
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Wesevich A, Patel-Nguyen S, Fridman I, Langan E, Parente V. Patient Factors Associated With Biased Language in Nightly Resident Verbal Handoff. JAMA Pediatr 2023; 177:1098-1100. [PMID: 37578802 PMCID: PMC10425858 DOI: 10.1001/jamapediatrics.2023.2581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/27/2023] [Indexed: 08/15/2023]
Abstract
This cross-sectional study uses audio recordings of resident handoff of inpatient general medicine and general pediatrics teams to measure the extent of stigmatizing language and describes associations between patient factors and biased language in handoffs.
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Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Illinois
| | - Sonya Patel-Nguyen
- Division of Hospital Medicine, Departments of Medicine & Pediatrics, Duke University, Durham, North Carolina
| | - Ilona Fridman
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | | | - Victoria Parente
- Division of Hospital Medicine, Department of Pediatrics, Duke University, Durham, North Carolina
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10
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Chagomerana MB, Harrington BJ, DiPrete BL, Wallie S, Maliwichi M, Wesevich A, Phulusa JN, Kumwenda W, Jumbe A, Hosseinipour MC. Three-year outcomes for women newly initiated on lifelong antiretroviral therapy during pregnancy - Malawi option B. AIDS Res Ther 2023; 20:37. [PMID: 37308909 PMCID: PMC10258937 DOI: 10.1186/s12981-023-00523-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 05/02/2023] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Antiretroviral therapy (ART) is very effective in preventing vertical transmission of HIV but some women on ART experience different virologic, immunologic, and safety profiles. While most pregnant women are closely monitored for short-term effects of ART during pregnancy, few women receive similar attention beyond pregnancy. We aimed to assess retention in care and clinical and laboratory-confirmed outcomes over 3 years after starting ART under Malawi's Option B + program. METHODS We conducted a prospective cohort study of pregnant women newly diagnosed with HIV who started tenofovir disoproxil fumarate/emtricitabine/efavirenz (TDF/3TC/EFV) for the first time at Bwaila Hospital in Lilongwe, Malawi between May 2015 and June 2016. Participants were followed for 3 years. We summarized demographic characteristics, pregnancy outcomes, and clinical and laboratory adverse events findings using proportions. Log-binomial regression models were used to estimate the overall risk ratios (RR) and the corresponding 95% confidence interval (CI) for the association between index pregnancy (i.e. index pregnancy vs. subsequent pregnancy) and preterm birth, and index pregnancy and low birthweight. RESULTS Of the 299 pregnant women who were enrolled in the study, 255 (85.3%) were retained in care. There were 340 total pregnancies with known outcomes during the 36-month study period, 280 index pregnancies, and 60 subsequent pregnancies. The risks of delivering preterm (9.5% for index pregnancy and13.5% for subsequent pregnancy: RR = 0.70; 95% CI: 0.32-1.54), or low birth weight infant (9.8% for index pregnancy and 4.2% for subsequent pregnancy: RR = 2.36; 95% CI: 0.58-9.66) were similar between index and subsequent pregnancies. Perinatally acquired HIV was diagnosed in 6 (2.3%) infants from index pregnancies and none from subsequent pregnancies. A total of 50 (16.7%) women had at least one new clinical adverse event and 109 (36.5%) women had at least one incident abnormal laboratory finding. Twenty-two (7.3%) women switched to second line ART: of these 64.7% (8/17) had suppressed viral load and 54.9% (6/17) had undetectable viral load at 36 months. CONCLUSION Most of the women who started TDF/3TC/EFV were retained in care and few infants were diagnosed with perinatally acquired HIV. Despite switching, women who switched to second line therapy continued to have higher viral loads suggesting that additional factors beyond TDF/3TC/EFV failure may have contributed to the switch. Ongoing support during the postpartum period is necessary to ensure retention in care and prevention of vertical transmission.
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Affiliation(s)
- Maganizo B Chagomerana
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Bryna J Harrington
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Johns Hopkins Dept. of Gynecology & Obstetrics, Baltimore, MD, USA
| | - Bethany L DiPrete
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Austin Wesevich
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA
| | | | - Wiza Kumwenda
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Allan Jumbe
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Mina C Hosseinipour
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Wesevich A, De Fer TM, Awad MM, Woodhouse J, Andriole DA, Brunt LM. A Capstone Course for Senior Medical Students: From Innovative Elective to Required Core Curriculum. Academic Medicine 2022; 97:S148. [PMID: 37838880 DOI: 10.1097/acm.0000000000004864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Austin Wesevich
- Author affiliations: A. Wesevich, University of Chicago; T.M. De Fer, M.M. Awad, J. Woodhouse, L.M. Brunt, Washington University School of Medicine; D.A. Andriole, Association of American Medical Colleges
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Wesevich A, Jiao MG, Santanam TS, Chung RJ, Uchitel J, Zhang Q, Brindis CD, Ford CA, Counts NZ, Wong CA. Adolescent and Young Adult Perspectives on Quality and Value in Health Care. Acad Pediatr 2022; 23:782-789. [PMID: 36288750 DOI: 10.1016/j.acap.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/12/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe adolescent and young adult (AYA) perspectives on defining quality and value in health care and to gain understanding of their knowledge of value-based payment. METHODS A text message-based survey was sent to a convenience sample of AYAs aged 14 to 24 in 2019. Participants were asked 4 open-ended questions: 1) how they would define "good health care," 2) what factors to consider in rating doctors, 3) whose opinions should matter most when rating doctors, and 4) the best ways to collect AYA opinions on doctors, and one yes/no question on their awareness of value-based payment. Analyses included descriptive demographic statistics and an inductive thematic approach with multivariable models comparing adolescent (14-18) and young adult (19-24) responses. RESULTS Response rate was 61.0% (782/1283). Most participants were White (63.3%), female (53.3%), and adolescents (55.6%). Common themes from the first 2 questions included accessibility (specifically affordability), coverage benefits, and care experience (including compassion, respect, and clinical competence). Young adults more commonly mentioned affordability than adolescents (54.4% vs 43.3%, P = .001) and more commonly felt their opinion should matter more than their parents when rating doctors (80.6% vs 62.0%, P < .001). Only 21.0% of AYAs were familiar with the potential value-based link between physician payment and care quality. CONCLUSIONS When considering quality and value in health care, AYAs expressed their desired agency in rating the quality of their care and clinicians. AYAs' perspectives on health care quality, including the importance of care accessibility and affordability, should be considered when designing youth-centered care delivery and value-based payment models.
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Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago (A Wesevich), Chicago, Ill; Department of Medicine, Department of Pediatrics, Duke University School of Medicine (A Wesevich and RJ Chung), Durham, NC
| | - Megan G Jiao
- Duke-Margolis Center for Health Policy, Duke University (MG Jiao, TS Santanam, J Uchitel, Q Zhang, and CA Wong), Durham, NC
| | - Taruni S Santanam
- Duke-Margolis Center for Health Policy, Duke University (MG Jiao, TS Santanam, J Uchitel, Q Zhang, and CA Wong), Durham, NC
| | - Richard J Chung
- Department of Medicine, Department of Pediatrics, Duke University School of Medicine (A Wesevich and RJ Chung), Durham, NC
| | - Julie Uchitel
- Duke-Margolis Center for Health Policy, Duke University (MG Jiao, TS Santanam, J Uchitel, Q Zhang, and CA Wong), Durham, NC
| | - Qintian Zhang
- Duke-Margolis Center for Health Policy, Duke University (MG Jiao, TS Santanam, J Uchitel, Q Zhang, and CA Wong), Durham, NC
| | - Claire D Brindis
- Adolescent and Young Adult National Health Information Center and Philip R. Lee Institute for Health Policy Studies, University of California (CD Brindis), San Francisco, Calif
| | - Carol A Ford
- Division of Adolescent Medicine, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and the Children's Hospital of Philadelphia (CA Ford), Philadelphia, Pa
| | | | - Charlene A Wong
- Duke-Margolis Center for Health Policy, Duke University (MG Jiao, TS Santanam, J Uchitel, Q Zhang, and CA Wong), Durham, NC.
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Wesevich A, Key-Solle M, Kandakatla A, Feeney C, Pollak KI, LeBlanc TW. Utilization of Text Messages to Supplement Rounding Communication: a Randomized Feasibility Study. J Gen Intern Med 2022; 37:2991-2997. [PMID: 35212877 PMCID: PMC9485328 DOI: 10.1007/s11606-021-07285-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Fragmented communication with patients and families during hospitalizations often leaves patients confused about the daily plan. OBJECTIVE To pilot a supplemental text message-based platform for improving bidirectional communication about the clinical plan and patients' goals. DESIGN Randomized controlled trial PARTICIPANTS: Thirty adult patients, thirty caregivers of pediatric patients, and the interns caring for them on inpatient general medicine and pediatric services. INTERVENTIONS Patients and caregivers were texted or emailed daily to report their personal goal and assess their understanding of the team's clinical plan. Interns were texted daily to report the team's clinical plan and to assess their understanding of the patient's personal goal. MAIN MEASURES Primary outcomes were feasibility, defined as survey response rates, and acceptability. Secondary outcomes were patient comprehension of the clinical plan, trainee comprehension of the patient's goal, patient-centered communication scores, and educational satisfaction scores. KEY RESULTS Thirty adult patients, thirty caregivers of pediatric patients, fourteen general medicine interns, and six general pediatric interns enrolled. Intervention feasibility was met, with survey response rates of 80% for general medicine trainees, 67% for general pediatric trainees, 58% for adult patients, and 70% for caregivers. Patients and caregivers in the intervention arm had higher understanding of medication changes (76% vs 50%, p = 0.02) and new consultations (90% vs 61%, p = 0.002). Interns had higher understanding of patients' goals in the intervention arm (93% vs 40%, p < 0.001), particularly for adult patients (97% vs 17%, p < 0.001). Caregivers rated communication higher regarding information to help make decisions (p = 0.04). Interviews demonstrated high acceptability. CONCLUSIONS Our text message-based communication intervention was feasible and acceptable to all involved participants, with preliminary signals of efficacy. The intervention may contribute to improved understanding of medication changes and new consultations, as well as help in making decisions. A large, randomized efficacy trial of this intervention is warranted. Graphical abstract.
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Affiliation(s)
- Austin Wesevich
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
- Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA.
| | - Mikelle Key-Solle
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | | | - Colby Feeney
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Kathryn I Pollak
- Cancer Prevention and Control, Duke Cancer Institute, Durham, NC, USA
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Wesevich A, George M, Kiwara F, Chao C, Shabani I, Igenge J, Schroeder K. Abstract 102: Breakpoints in Protocol Compliance and Their Influence on Outcomes for Children with Wilms Tumor in Northern Tanzania. Cancer Epidemiol Biomarkers Prev 2021. [DOI: 10.1158/1538-7755.asgcr21-102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Purpose: Standardized treatment protocols for Wilms tumor have been developed for use in low- and middle-income countries (LMICs), but equivalent outcomes as high-income countries are not achieved outside of clinical trials. To identify critical breakpoints in protocol adherence contributing to reduced outcomes, we evaluated treatment compliance and impact of the completion of each stage of therapy on outcomes for Wilms tumor patients at a regional cancer referral hospital in northern Tanzania.
Methods: This is a retrospective single-center cohort study for children diagnosed with Wilms tumor from 2016-2019 in Tanzania, treated per the International Society of Pediatric Oncology (SIOP) Africa adapted (2016-17) or standard (2018-19) therapy protocols. Treatment compliance was evaluated for both timing of chemotherapy initiation, and completion of risk-adapted therapy duration per protocol.
Results: A total of 72 patients were evaluated. The two-year overall survival and event-free survival rates were 44% and 27%, respectively. Only 22% of patients completed recommended chemotherapy per protocol. There were delays at each stage of treatment, especially time to surgery (74 days), pathology report (32 days), and initiation of postoperative chemotherapy (39 days). A total of 38% of patients abandoned care, with 44% of abandonment occurring prior to surgery, 30% immediately after surgery, and 26% during post-operative chemotherapy. Compliance with surgical resection (p=0.05) and postoperative chemotherapy (p=0.04) were predictive of two-year overall survival.
Conclusion: Standardized Wilms tumor treatment protocol compliance outside of clinical trials is low in many LMICs. In the current study, noncompliance with recommended chemotherapy correlated to reduced overall survival rates, with several identified key health system delays contributing to poor compliance. Future interventions targeting health system delays are critical to improve protocol compliance, increasing overall survival for pediatric Wilms tumor patients in LMICs.
Citation Format: Austin Wesevich, Mocha George, Frank Kiwara, Colin Chao, Idd Shabani, John Igenge, Kristin Schroeder. Breakpoints in Protocol Compliance and Their Influence on Outcomes for Children with Wilms Tumor in Northern Tanzania [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 102.
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Igenge J, Stocks J, Zhang G, George M, Kiwara F, Mafwimbo J, Maxmilian M, Wesevich A, Schroeder K. Abstract 112: Use of WhatsApp to Improve Medical Provider Communication for Children with Wilms Tumor in Tanzania. Cancer Epidemiol Biomarkers Prev 2021. [DOI: 10.1158/1538-7755.asgcr21-112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Purpose: Due to the rapid expansion of mobile phone usage throughout the world, mobile health (mHealth) technologies offer an innovative strategy to overcome challenges of care coordination and limited communication between pediatric cancer providers in LMICs. Our objective was to evaluate the use of the social media application WhatsApp to improve provider communication and outcomes for children diagnosed with Wilms tumor at a regional cancer treatment facility in Tanzania.
Methods: A WhatsApp provider group was established in 2016 to facilitate communication between surgical, medical and psychosocial support providers at the regional cancer referral hospital in northern Tanzania. All messages exchanged from 2016-2019 were extracted and coded for thematic content. Treatment compliance and process outcomes were compared for patients discussed versus those that were not over the 4-year period.
Results: A total of 669 messages for 55 patients were reviewed. Most messages were sent by the pediatric oncologist (44.8%, n=273) and urology resident (43.2%, n=263). Using the application to coordinate patient care reduced time to surgery from 90 days [IQR 65-109] to 60 days [IQR 47-80], and time to post-operative chemotherapy initiation from 46 days [IQR 39-55] to 19 days [IQR 16-30]. Rate of treatment abandonment was decreased for patients discussed in the chat group (26.7%) compared to those not discussed (38.2%).
Conclusion: To our knowledge this is the first study to assess the use of WhatsApp to improve provider communication for children with cancer in LMICs. As access to smartphone technology and internet access improves, applications like WhatsApp can be used as a low-cost strategy to target health system inefficiencies and improve outcomes for children with cancer globally.
Citation Format: John Igenge, Jacob Stocks, Gloria Zhang, Mocha George, Frank Kiwara, Judy Mafwimbo, Mastidia Maxmilian, Austin Wesevich, Kristin Schroeder. Use of WhatsApp to Improve Medical Provider Communication for Children with Wilms Tumor in Tanzania [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 112.
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Kapito-Tembo AP, Bauleni A, Wesevich A, Ongubo D, Hosseinipour MC, Dube Q, Mwale P, Corbett A, Mwapasa V, Phiri S. Growth and Neurodevelopment Outcomes in HIV-, Tenofovir-, and Efavirenz-Exposed Breastfed Infants in the PMTCT Option B+ Program in Malawi. J Acquir Immune Defic Syndr 2021; 86:81-90. [PMID: 33027153 DOI: 10.1097/qai.0000000000002515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pregnant and breastfeeding women in Option B+ in Malawi received antiretroviral drugs (ARVs) containing efavirenz (EFV) and tenofovir disoproxil fumarate (TDF). However, effects on growth, renal, bone metabolism, and neurodevelopment of long-term exposure to low doses of these drugs through breast milk in HIV-exposed infants are unclear. METHODS Prospective cohorts of TDF-and-EFV-exposed and TDF-and-EFV-unexposed breastfed infants of HIV-infected and HIV-uninfected mothers in Option B+ were recruited in 2:1 ratio, respectively, followed from birth to 18 months. Infants with low birth weight, premature birth, and congenital abnormalities were excluded. Anthropometrics were assessed at birth, 6 weeks, 3, 6, 12, and 18 months. Neurodevelopment assessments used the Bayley Scales of Infant and Toddler Development III from 6 weeks. Creatinine, alkaline phosphatase, and phosphorus were assessed at 3, 6, and 12 months. RESULTS Of 260 HIV-and-ARV-exposed and 125 HIV-and-ARV-unexposed infants enrolled at birth, 87% and 57%, 78% and 59%, 77% and 54%, 73% and 51%, and 65% and 43% completed 6-weeks, 3, 6, 12, and 18 months visits, respectively. There were no significant differences in the mean Z-scores for length-for-age, weight-for-age, weight-for-length, mid-upper arm circumference-for-age, and head circumference-for-age between groups except at 6-weeks for length-for-age. No bone fractures occurred. Neurodevelopment outcomes were similar between groups. Of creatinine, alkaline phosphatase, and serum phosphate measurements, 1.7%, 2.6%, and 3.3% reached any toxicity levels grades 1-4, respectively, with no differences between groups. CONCLUSION Long-term exposure to EFV and TDF through breastfeeding in infants of HIV-infected mothers does not seem to result in significant growth, neurodevelopment, renal, or bone adverse outcomes. Data support safety of breastfeeding through 18 months within the Option B+ program.
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Affiliation(s)
- Atupele P Kapito-Tembo
- MAC Communicable Diseases Action Centre, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Malawi
| | - Andy Bauleni
- MAC Communicable Diseases Action Centre, University of Malawi College of Medicine, Blantyre, Malawi
| | | | | | - Mina C Hosseinipour
- UNC Project-Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Queen Dube
- Ministry of Health Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Patrick Mwale
- MAC Communicable Diseases Action Centre, University of Malawi College of Medicine, Blantyre, Malawi
| | - Amanda Corbett
- UNC Eshleman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Victor Mwapasa
- Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Malawi
| | - Sam Phiri
- Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Lighthouse Trust, Kamuzu Central Hospital, Lilongwe, Malawi ; and
- Department of Global Health, University of Washington, Seattle, WA
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Affiliation(s)
- Francis Deng
- Radiology resident, Massachusetts General Hospital, Boston, Massachusetts; ; ORCID: https://orcid.org/0000-0003-3117-5076. Internal medicine and pediatrics resident, Duke University Medical Center, Durham, North Carolina; ORCID: https://orcid.org/0000-0001-5202-1231
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Wesevich A, Hosseinipour MC, Golin CE, McGrath N, Tsidya M, Chimndozi L, Bhushan N, Hoffman I, Miller WC, Rosenberg NE. Female adherence self-efficacy before and after couple HIV testing and counseling within Malawi's Option B+ program. AIDS Care 2019; 32:170-174. [PMID: 31238717 DOI: 10.1080/09540121.2019.1634789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Adherence self-efficacy, belief in one's ability to adhere to daily medication, is strongly associated with antiretroviral therapy (ART) adherence and preventing mother-to-child HIV transmission. Couple-based interventions could enhance self-efficacy and adherence. We assessed the relationship between couple HIV testing and counseling (cHTC) and adherence self-efficacy using a 100-point culturally-adapted adherence self-efficacy scale (ASES). Secondarily, we explored the relationship between ASES and ART adherence. Ninety HIV-positive pregnant women at an antenatal clinic in Lilongwe, Malawi were enrolled in an observational cohort study. They were assessed with ASES immediately before and one month after receiving cHTC. Median ASES scores were 100 (IQR 95, 100) before and 100 (IQR 99, 100) after cHTC; there was a significant median difference (p = 0.02) for participants before and after cHTC. This change in ASES scores was associated with the odds of self-reported ART adherence in the full population (OR 1.1, p = 0.01), and there was a trend in the same direction for participants with imperfect baseline ASES scores (OR 1.1, p = 0.2). In our population, adherence self-efficacy and ART adherence were both quite high, and those who had room to improve in self-efficacy may have benefited from cHTC, which in turn could impact ART adherence and ultimately mother-to-child transmission.
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Affiliation(s)
- Austin Wesevich
- University of North Carolina Project, Lilongwe, Malawi.,Tidziwe Centre, Lilongwe, Malawi
| | - Mina C Hosseinipour
- University of North Carolina Project, Lilongwe, Malawi.,Tidziwe Centre, Lilongwe, Malawi.,Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Carol E Golin
- Departments of Medicine and of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Nuala McGrath
- Departments of Primary Care and Population Sciences and of Social Statistics and Demography, University of Southampton, Southampton, UK
| | - Mercy Tsidya
- University of North Carolina Project, Lilongwe, Malawi.,Tidziwe Centre, Lilongwe, Malawi
| | - Limbikani Chimndozi
- University of North Carolina Project, Lilongwe, Malawi.,Tidziwe Centre, Lilongwe, Malawi
| | - Nivedita Bhushan
- University of North Carolina Project, Lilongwe, Malawi.,Department of Health Behavior, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Irving Hoffman
- University of North Carolina Project, Lilongwe, Malawi.,Tidziwe Centre, Lilongwe, Malawi.,Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - William C Miller
- Division of Epidemiology, The Ohio State University, Columbus, USA
| | - Nora E Rosenberg
- University of North Carolina Project, Lilongwe, Malawi.,Tidziwe Centre, Lilongwe, Malawi.,Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, USA
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Bhushan NL, Golin CE, McGrath N, Maman S, Tsidya M, Chimndozi L, Wesevich A, Hoffman IF, Hosseinipour MC, Miller WC, Rosenberg NE. The impact of HIV couple testing and counseling on social support among pregnant women and their partners in Lilongwe, Malawi: an observational study. AIDS Care 2019; 31:199-206. [PMID: 30182730 PMCID: PMC6322660 DOI: 10.1080/09540121.2018.1510102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 08/01/2018] [Indexed: 12/20/2022]
Abstract
Couples HIV testing and counseling (couple counseling) promotes safer sexual behaviors, increases communication between couples, and decreases HIV transmission. However, the impact of couple counseling on social support, critical for persons living with HIV, has not been examined. Ninety couples with a recently tested HIV-positive pregnant woman (female-positive couples) and 47 couples with a recently tested HIV-negative pregnant woman (female-negative couples) were enrolled in an observational study at an antenatal clinic in Malawi. Each couple member was assessed immediately before and one month after couple counseling for partner, family, and peer social support using the Multidimensional Scale of Perceived Social Support. Before couple counseling, social support was lower among women than men in both female-positive couples (β = -10.00, p < .01) and female-negative couples (β = -8.43, p < .01). After couple counseling, social support increased for women in female-positive couples (β = 4.01, p < .01) and female-negative couples (β = 4.69, p < .01) but not for men in either type of couple. Couple counseling could be an effective strategy to increase social support for women, including those with recent HIV diagnoses.
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Affiliation(s)
- Nivedita L Bhushan
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
- b School of Public Health , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Carol E Golin
- b School of Public Health , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
- c School of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Nuala McGrath
- d Faculty of Medicine and Faculty of Social, Human, and Mathematical Sciences , University of Southampton , Southampton , UK
| | - Suzanne Maman
- b School of Public Health , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Mercy Tsidya
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
| | - Limbikani Chimndozi
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
| | - Austin Wesevich
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
| | - Irving F Hoffman
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
- c School of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Mina C Hosseinipour
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
- c School of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - William C Miller
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
- b School of Public Health , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
- c School of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
- e Division of Epidemiology , The Ohio State University , Columbus , OH , USA
| | - Nora E Rosenberg
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
- b School of Public Health , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
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Rosenberg NE, Graybill LA, Wesevich A, McGrath N, Golin CE, Maman S, Tsidya M, Chimndozi L, Hoffman IF, Hosseinipour MC, Miller WC. Individual, Partner, and Couple Predictors of HIV Infection among Pregnant Women in Malawi: A Case-Control Study. AIDS Behav 2018; 22:1775-1786. [PMID: 29086117 DOI: 10.1007/s10461-017-1947-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We aimed to understand drivers of HIV-infection in pregnant women in Malawi. The study was conducted in antenatal and labor and delivery wards. HIV-infected women and their partners (cases) were frequency matched in a 1:2 ratio based on age and screening location to HIV-uninfected women and their partners (controls) in a prevalent case-control study. Characteristics associated with female HIV infection were assessed using logistic regression modeling. At screening, HIV-infected women were more likely to have partners outside Lilongwe than HIV-uninfected women (24% vs. 0%, p < 0.0001). Case females were more likely to have HIV-infected study partners than control females (75% vs. 4%, p < 0.0001). The odds of female HIV-infection were higher if either couple member reported ≥ 2 lifetime marriages (OR 9.0, CI 2.6-30.9) or ≥ 3 lifetime partners (OR 18.0, CI 3.1-103.6) and lower if either reported past couple HIV testing and counseling (OR 0.1, CI 0.04-0.3). Targeting women with migrating partners, promoting couple HIV testing and counseling, and limiting partners could slow HIV transmission.
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Affiliation(s)
- Nora E Rosenberg
- UNC Project, University of North Carolina at Chapel Hill, Lilongwe, Malawi.
- School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- UNC Project, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi.
| | - Lauren A Graybill
- UNC Project, University of North Carolina at Chapel Hill, Lilongwe, Malawi
- School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Austin Wesevich
- UNC Project, University of North Carolina at Chapel Hill, Lilongwe, Malawi
| | - Nuala McGrath
- Faculty of Medicine and Faculty of Social, Human, and Mathematical Sciences, University of Southampton, Southampton, England, UK
| | - Carol E Golin
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Suzanne Maman
- School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mercy Tsidya
- UNC Project, University of North Carolina at Chapel Hill, Lilongwe, Malawi
| | | | - Irving F Hoffman
- UNC Project, University of North Carolina at Chapel Hill, Lilongwe, Malawi
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- UNC Project, University of North Carolina at Chapel Hill, Lilongwe, Malawi
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William C Miller
- Department of Epidemiology, Ohio State University, Columbus, OH, USA
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Affiliation(s)
- Francis Deng
- Resident in diagnostic radiology, Massachusetts General Hospital, and clinical fellow, Harvard Medical School, Boston, Massachusetts; ; ORCID: http://orcid.org/0000-0003-3117-5076. Resident in otolaryngology, Massachusetts Eye and Ear, and clinical fellow, Harvard Medical School, Boston, Massachusetts; ORCID: http://orcid.org/0000-0002-2992-4771. Resident in internal medicine and pediatrics, Duke University Medical Center, Durham, North Carolina; ORCID: http://orcid.org/0000-0001-5202-1231
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Larsen DP, Wesevich A, Lichtenfeld J, Artino AR, Brydges R, Varpio L. Tying knots: an activity theory analysis of student learning goals in clinical education. Med Educ 2017; 51:687-698. [PMID: 28401571 DOI: 10.1111/medu.13295] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 09/22/2016] [Accepted: 01/23/2017] [Indexed: 06/07/2023]
Abstract
CONTEXT Learning goal programmes are often created to help students develop self-regulated learning skills; however, these programmes do not necessarily consider the social contexts surrounding learning goals or how they fit into daily educational practice. OBJECTIVES We investigated a high-frequency learning goal programme in which students generated and shared weekly learning goals with their clinical teams in core Year 3 clerkships. Our study explores: (i) how learning goals were incorporated into the clinical work, and (ii) the factors that influenced the use of students' learning goals in work-based learning. METHODS We conducted semi-structured interviews with 14 students and 14 supervisors (attending physicians and residents) sampled from all participating core clerkships. Interviews were coded for emerging themes. Using cultural historical activity theory and knotworking as theoretical lenses, we developed a model of the factors that influenced students' learning goal usage in a work-based learning context. RESULTS Students and supervisors often faced the challenge of reconciling contradictions that arose when the desired outcomes of student skill development, grading and patient care were not aligned. Learning goals could function as tools for developing new ways of acting that overcame those contradictions by facilitating collaborative effort between students and their supervisors. However, for new collaborations to take place, both students and supervisors had to engage with the goals, and the necessary patients needed to be present. When any one part of the system did not converge around the learning goals, the impact of the learning goals programme was limited. CONCLUSIONS Learning goals are potentially powerful tools to mediate interactions between students, supervisors and patients, and to reconcile contradictions in work-based learning environments. Learning goals provide a means to develop not only learners, but also learning systems.
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Affiliation(s)
- Douglas P Larsen
- Department of Neurology, School of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Austin Wesevich
- School of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Jana Lichtenfeld
- Department of Pediatrics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Antony R Artino
- Division of Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Ryan Brydges
- Department of Medicine & The Wilson Centre, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lara Varpio
- Division of Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Wesevich A, Mtande T, Saidi F, Cromwell E, Tweya H, Hosseinipour MC, Hoffman I, Miller WC, Rosenberg NE. Role of male partner involvement in ART retention and adherence in Malawi's Option B+ program. AIDS Care 2017; 29:1417-1425. [PMID: 28355926 DOI: 10.1080/09540121.2017.1308464] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Malawi's Option B+ program provides all HIV-infected pregnant women free lifelong antiretroviral therapy (ART), but challenges remain regarding retention and ART adherence, potentially due to male partner barriers. We explored relationships between male partner involvement and Option B+ retention and adherence. In 2014, a randomized controlled trial in Malawi compared male recruitment strategies for couple HIV testing and counseling (cHTC) at an antenatal clinic. This secondary analysis was conducted among the entire cohort (N = 200) of women, irrespective of randomization status. We assessed whether cHTC attendance, early disclosure of HIV-positive status, and partner ART reminders were associated with retention and adherence at one month after starting treatment. Retention was defined as attending HIV clinic follow-up within one day of running out of pills. Adherence was defined as taking ≥95% of ARTs by pill count. We used binomial regression to calculate adjusted risk ratios (aRR) and 95% confidence intervals (CI). Median female age was 26 years. Most women (79%) were retained; of these, 68% were adherent. Receiving cHTC was associated with improved retention (aRR 1.33, 95% CI 1.12, 1.59). Receiving male partner ART reminders was weakly associated with retention (aRR 1.16, 95% CI 0.96, 1.39). Disclosure within one day was not associated with retention (aRR 1.08, 95% CI: 0.91, 1.28). Among those who were retained, these three behaviors were not associated with improved 95% adherence. CHTC could play an important role in improving Option B+ retention. Increasing cHTC participation and enhancing adherence-related messages within cHTC are important.
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Affiliation(s)
- Austin Wesevich
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
| | - Tiwonge Mtande
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
| | - Friday Saidi
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
| | - Elizabeth Cromwell
- b Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , USA
| | - Hannock Tweya
- c Lighthouse Trust , Lilongwe , Malawi.,d The International Union Against Tuberculosis and Lung Disease , Paris , France
| | - Mina C Hosseinipour
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi.,e Department of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , USA
| | - Irving Hoffman
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi.,e Department of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , USA
| | - William C Miller
- b Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , USA.,e Department of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , USA
| | - Nora E Rosenberg
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi.,b Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , USA.,e Department of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , USA
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Wesevich A, Chipungu J, Mwale M, Bosomprah S, Chilengi R. Health Promotion Through Existing Community Structures: A Case of Churches' Roles in Promoting Rotavirus Vaccination in Rural Zambia. J Prim Care Community Health 2016; 7:81-7. [PMID: 26792908 DOI: 10.1177/2150131915622379] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Rural populations, particularly in Africa, suffer worse health outcomes from poor health services access. Community health workers (CHWs) effectively improve health outcomes, but the best means for CHWs reaching rural populations is unknown. Since Zambia is predominantly Christian, this study explored the use of CHWs through churches as an existing community structure for promoting preventive health behaviors, specifically rotavirus vaccine uptake. METHODS A noncontrolled cross-sectional study of 32 churches receiving a packaged intervention of diarrhea prevention and treatment messaging was conducted with repeated time points of data collection over 13 months (2013-2014) in the Kafue District of Zambia. Two churches were selected for each of the 17 catchment areas, and CHWs were identified and trained in the intervention of promoting 4 key messages related to diarrhea prevention and treatment: hand washing with soap, exclusive breast-feeding, rotavirus vaccination, and treating diarrhea with oral rehydration solution and zinc. The intervention was conducted within existing church's women's groups, and data was collected on attendance and the distribution of Rota Cards for tracking rotavirus immunizations. RESULTS Nineteen (59%) churches completed the study, and CHWs delivered health messages at a total of 890 women's group meetings. The overall reach of the intervention was to 37.0% of church-attending women, and the efficacy was 67.7% (317 of 468 Rota Cards collected at health centers). DISCUSSION Implementing community health programs is often expensive and unsustainable, but the reach and efficacy levels achieved through existing structures like churches are encouraging in resource-constrained countries. Churches can be effective channels for delivering health prevention strategies to often difficult-to-reach rural populations. Further research is needed to investigate the impact of the intervention on health outcomes.
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Affiliation(s)
- Austin Wesevich
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia Washington University in St. Louis, St. Louis, MO, USA
| | - Jenala Chipungu
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Mercy Mwale
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Samuel Bosomprah
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
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