Search

Background: HIV prevalence among female sex workers in Indonesia remains high and large proportions of female sex workers have never been tested for HIV. International research highlights the importance of community-led strategies to increase HIV testing in this population. Little qualitative research has been conducted to address these issues in Indonesia or other Asia-Pacific countries. This paper documents social influences that enhance HIV testing among female sex workers in urban Indonesia. Methods: This was an interpretive qualitative study in Yogyakarta, Denpasar and Bandung. In total, 57 female sex workers participated in 11 focus group discussions, and four participated in individual semi-structured interviews. Deductive and inductive thematic analysis techniques were used to identify narratives of strengths pertaining to uptake of HIV testing. Results: Participants described supportive relationships with peers, community-based organisations and 'bosses'. Participants reported trusted networks with peers within which to share information about HIV testing and receive emotional support. Relationships with community outreach workers facilitated HIV testing through reminders, accompanied visits, and emotional/informational support. Community-based organisations worked with health services to facilitate mobile, community-based testing to overcome employment- and family-related constraints that inhibited women's clinic attendance. 'Bosses' employed a variety of practices to encourage HIV testing among their workers. Conclusions: Relationships, practices and action in community- and workplace-based settings outside formal health service spaces enhanced HIV testing among female sex workers. Community- or workplace-based HIV testing with outreach support from health services, peer-led HIV testing within existing social and work-based networks, and working with bosses to implement HIV prevention strategies can address low HIV testing rates in this key population.

Background HIV prevalence among female sex workers in Indonesia remains high and large proportions of female sex workers have never been tested for HIV. International research highlights the importance of community-led strategies to increase HIV testing in this population. Little qualitative research has been conducted to address these issues in Indonesia or other Asia-Pacific countries. This paper documents social influences that enhance HIV testing among female sex workers in urban Indonesia., Methods: This was an interpretive qualitative study in Yogyakarta, Denpasar and Bandung. In total, 57 female sex workers participated in 11 focus group discussions, and four participated in individual semi-structured interviews. Deductive and inductive thematic analysis techniques were used to identify narratives of strengths pertaining to uptake of HIV testing., Results: Participants described supportive relationships with peers, community-based organisations and 'bosses'. Participants reported trusted networks with peers within which to share information about HIV testing and receive emotional support. Relationships with community outreach workers facilitated HIV testing through reminders, accompanied visits, and emotional/informational support. Community-based organisations worked with health services to facilitate mobile, community-based testing to overcome employment- and family-related constraints that inhibited women's clinic attendance. 'Bosses' employed a variety of practices to encourage HIV testing among their workers., Conclusions: Relationships, practices and action in community- and workplace-based settings outside formal health service spaces enhanced HIV testing among female sex workers. Community- or workplace-based HIV testing with outreach support from health services, peer-led HIV testing within existing social and work-based networks, and working with bosses to implement HIV prevention strategies can address low HIV testing rates in this key population.

Qualitative data were collected from 34 Indonesian female sex workers to understand their engagement with HIV treatment. Influences that enhanced treatment initiation and adherence included women's desires to stay healthy to continue working to provide for families; awareness of the biomedical benefits of treatment; support from bosses, outreach workers, and peer support groups; and flexible, nonjudgmental HIV service provision. Influences inhibiting treatment initiation and adherence included concerns about unwanted disclosure in the workplace and side effects of medication on women's capacity to earn money through sex work; geographical location of services; discrimination and confidentiality concerns in HIV care services. To improve HIV treatment initiation and adherence among Indonesian female sex workers, future responses should explore health promotion messages that engage with women's family and livelihood obligations; increased funding for community-based peer outreach workers; community-based treatment initiation and supply; and advocacy in work environments to secure support for treatment initiatives.

Background: Narrative medicine (NM) interventions have positively influenced empathy and burnout to varying degrees in health-care workers. We systematically reviewed the impact of poetry, a form of NM, on empathy and professional burnout., Methods: A comprehensive search of Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus, from inception to September 25, 2018, for articles published in English, was conducted using search terms related to NM, empathy, professional burnout, and health-care personnel., Results: Of the 401 abstracts independently screened for inclusion by 2 reviewers, 2 quantitative, 3 qualitative studies, and 1 research letter were included. One research letter, focusing on the use of poetry, found it to increase empathy as measured by a nonvalidated questionnaire. All other studies used mixed NM interventions: 2 quantitative studies, using validated surveys, showed an increase in empathy and 2 qualitative studies showed limited to a prominent finding of increased empathy. There were no studies that used poetry exclusively to assess impact on professional burnout. One quantitative study, utilizing a validated survey, revealed no overall reduced burnout among residents, although high attendance participants had moderately reduced burnout postintervention, and one qualitative study noted limited reduction in burnout., Conclusion: There is evidence that poetry as part of a NM intervention may increase empathy and limited evidence that it may reduce professional burnout among health-care workers.

Background: In recent years, gonorrhea notifications have increased in women in Australia and other countries. We measured trends over time and risk factors among Australian Aboriginal and Torres Strait Islander ("Aboriginal") and non-Aboriginal women., Methods: We conducted a cross-sectional analysis of data from 41 sexual health clinics. Gonorrhea positivity at each patient's first visit (first-test positivity) during the period 2009 to 2016 was calculated. Univariate and multivariate analyses assessed risk factors for first-test positivity in Aboriginal and non-Aboriginal women., Results: Gonorrhea positivity decreased among Aboriginal women (7.1% in 2009 to 5.2% in 2016, P < 0.001) and increased among non-Aboriginal women (0.6%-2.9%, P < 0.001). Among Aboriginal women, first-test positivity was independently associated with living in a regional or remote area (adjusted odds ratio [aOR], 4.29; 95% confidence interval [CI], 2.52-7.31; P < 0.01) and chlamydia infection (aOR, 4.20; 95% CI,3.22-5.47; P < 0.01). Among non-Aboriginal women, first-test positivity was independently associated with greater socioeconomic disadvantage (second quartile: aOR, 1.68 [95% CI, 1.31-2.16; P < 0.01]; third quartile: aOR, 1.54 [95% CI, 1.25-1.89; P < 0.01]) compared with least disadvantaged quartile: recent sex work (aOR, 1.69; 95% CI, 1.37-2.08; P < 0.01), recent injecting drug use (aOR, 1.85; 95% CI, 1.34-2.57; P < 0.01), and chlamydia infection (aOR, 2.35; 95% CI, 1.90-2.91; P < 0.01). For non-Aboriginal women, being aged 16 to 19 years (aOR, 0.62; 95% CI, 0.49-0.80; P < 0.01) compared with those ≥30 years was a protective factor., Conclusions: These findings highlight 2 different epidemics and risk factors for Aboriginal and non-Aboriginal women, which can inform appropriate health promotion and clinical strategies.

Objective: To conduct a systematic review and meta-analysis of the long-term impact of infant vaccination on the prevalence of hepatitis B virus (HBV) infection at the population level., Methods: We searched online databases for articles reporting comparisons between population cohorts aged ≥ 15 years who were exposed or unexposed to infant HBV immunization programmes. We categorized programmes as universal or targeted to infants whose mothers were positive for hepatitis B surface antigen (HBsAg). We included studies reporting prevalence of hepatitis B core antibody (HBcAb), HBsAg, or both. We evaluated the quality of the study methods and estimated the relative reduction in the prevalence of infection., Findings: Of 26 studies that met the inclusion criteria, most were from China (20 studies). The prevalence of HBV infection in unvaccinated and universally vaccinated cohorts ranged from 0.6% (116 of 20 305 people) to 16.3% (60/367) and from 0.3% (1/300) to 8.5% (73/857), respectively. Comparing cohorts with universal vaccination to those without vaccination, relative prevalences were 0.24 (95% confidence interval, CI: 0.16-0.35) for HBsAg and 0.23 (95% CI: 0.17-0.32) for HBcAb. For populations with targeted vaccination, relative prevalences were 0.32 (95% CI: 0.24-0.43) and 0.33 (95% CI: 0.23-0.45), respectively., Conclusion: The residual burden of infection in cohorts offered vaccination suggests that longer-term evaluations of vaccination coverage, timeliness and other aspects of programme quality are needed. As HBV-vaccinated infant cohorts reach adulthood, ongoing analysis of prevalence in adolescents and young adults will ensure that elimination efforts are on track.

Background: Like a number of other countries, Australia mandates that a man who has had sex with men is deferred from donation until 12 months has elapsed since the sexual activity. This review examined whether this deferral period is justified by current evidence., Study Design and Methods: Databases (Medline, EMBASE, Scopus) were searched using terms "blood donation" and "gay" or "MSM" and "HIV risk" from the mid-1980s to the present to investigate the history of donor deferral policy and its rationale in Australia., Results: Gay and bisexual men in Australia face a higher risk of human immunodeficiency virus and other blood-borne viruses (BBVs) than other populations. All blood donations, however, are tested for BBVs, and with current testing technologies the window period during which infection may be present but not detected is now less than 1 week. While there is a moral imperative to maintain blood safety, there is also a moral imperative to ensure that differential treatment of population groups with regard to donation eligibility is scientifically justified. Potential social harms that may flow from a dissonance between deferral policy and its evidence base include loss of trust and increased nonadherence to policy., Conclusions: A 12-month deferral for gay and bisexual men exceeds what is required to maintain blood safety. This disparity potentially causes social harm without any additional benefit to public health. Reducing the deferral period to 3 months will not increase health risk to recipients and may have the social benefit of increasing inclusiveness., (© 2017 AABB.)

Background: Recovery from respiratory illness (RI), a common reason for hospitalization, can be protracted for some children because of high illness severity or underlying medical complexity., Objective: We assessed which children hospitalized with RI are the most likely to use post-acute facility care (PAC) for recovery., Methods: Retrospective analysis of 609,800 hospitalizations for patients in 43 US children's hospitals between 2010- 2015 for RI, identified with the Agency for Healthcare Research and Quality Clinical Classification System. Discharge to PAC was identified using Centers for Medicare & Medicaid Services Discharge Status Codes. We compared patient characteristics by PAC use with generalized estimating equations., Results: There were 2660 (0.4%) RI hospitalizations resulting in PAC transfer (n = 2660, 0.4%). Discharges to PAC had greater percentages of technology assistance (83.2% vs 15.1%), neuromuscular chronic condition (57.5% vs 8.9%), and mechanical ventilation (52.7% vs 9.1%), 𝑃 < 0.001 for all. The highest likelihood of PAC use occurred with ≥11 vs no chronic conditions (odds ratio [OR] 11.7 [95% CI, 8.0- 17.2]), ≥9 vs no therapeutic medication classes (OR 4.8 [95% CI, 1.8-13.0]), and existing tracheostomy (OR 3.0, 95% confidence interval [CI], 2.6-3.5). Median (interquartile range [IQR]) acute-care length of stay (LOS) for children most likely to use PAC was 19 (8-56) days; LOS remained long (median 13 [6-41] days) for children with the same attributes (n = 9448) not transferred to PAC., Conclusions: Children with RI who are most likely to use PAC have a high prevalence of multiple chronic conditions, multiple medications, and medical technology. Future investigations should assess the supply of PAC against the demand of hospitalized children with RI who might need it., (© 2017 Society of Hospital Medicine)

Importance: Acute care hospitals are challenged to provide efficient, high-quality care to children who have medically complex conditions and may require weeks or months for recovery. Although the use of home health care (HHC) and facility-based postacute care (PAC) after discharge is well documented for adults, to our knowledge, little is known for children., Objective: To assess the national prevalence of, characteristics of children discharged to, and variation in use across states of HHC and PAC for children., Design, Setting, and Participants: Retrospective analysis of 2,423,031 US acute care hospital discharges in 2012 for patients ages 0 to 21 years from the nationally representative Agency for Healthcare Research and Quality Kids' Inpatient Database., Main Outcomes and Measures: Discharges to HHC (eg, visiting or private-duty home nursing) and PAC (eg, rehabilitation facility) were identified from Centers for Medicare and Medicaid Services Discharge Status Codes. We compared children's characteristics (eg, race/ethnicity and number of chronic conditions) by discharge type using generalized linear regression., Results: The median age of participants was 3 years (interquartile range, 0-13 years), and 45.6% were female. Of 2,423,031 US acute care hospital discharges in 2012 for patients ages 0 to 21 years, 122,673 discharges (5.1%) were to HHC and 26,282 (1.1%) were to PAC facilities. Neonatal care was the most common reason (44.5%, n = 54,589) for acute care hospitalization with discharge to HHC. Nonneonatal respiratory, musculoskeletal, and trauma-related problems, collectively, were the most common reasons for discharge to PAC (42.9%, n = 11,275). When compared with PAC, more discharges to HHC had no chronic condition (34.4% vs 18.0%, P < .001) and fewer discharges to HHC had 4 or more chronic conditions (22.5% vs 37.7%, P < .001). In multivariable analysis, Hispanic children were less likely to use PAC (0.8% vs 1.1%; odds ratio [OR], 0.9 [95% CI, 0.8-0.9]) or HHC (3.3% vs 5.5%; OR, 0.8 [95% CI, 0.7-0.8]) compared with other children. Children with 4 or more chronic conditions compared with no chronic conditions had a higher likelihood of HHC use (11.0% vs 4.4%; OR, 2.9 [95% CI, 2.8-3.0]) and PAC (3.9% vs 0.8%; OR, 4.5 [95% CI, 4.3-4.9]). After case-mix adjustment, there was significant (P < .001) variation across states in HHC (range, 0.4%-24.5%) and PAC (range, 0.4%-4.9%) use., Conclusions and Relevance: Home health care and PAC use after discharge for hospitalized children is infrequent, even for children with multiple chronic conditions. It varies significantly by race/ethnicity and across states. Further investigation is needed to assess reasons for this variation and to determine for which children HHC and PAC are most effective.

Objectives: After discharge from an acute care hospital, some children require ongoing care at a post-acute care hospital. Care transitions occur at both admission to the post-acute care hospital and again at discharge to the home/community. Our objective was to report the current practices used during the admission to and discharge from 7 pediatric post-acute care hospitals in the United States., Methods: Participants from 7 pediatric post-acute care hospitals completed a survey and rated the frequency of use of 20 practices to prepare and support children and their families during both admission to the hospital and at time of discharge to the home/community. For consistency with existing literature, practices were grouped into 4 previously reported categories: assessment, communication, education, and logistics. Descriptive statistics were used to report the frequency of use within practices and between hospitals., Results: Only 2 of 10 admission practices and 3 of 10 discharge practices were reportedly "always" used by all hospitals. Assessment and communication practices were reported to be more frequently used (57%-100% of the time) than education and logistic procedures. Between hospitals, only the reported frequency of use of the discharge practices was statistically significantly different (P = .03)., Conclusions: Variability exists in transition practices among 7 post-acute care pediatric hospitals. This report is the first known to detail the frequency of use of admission and discharge practices for pediatric post-acute care hospitals in the United States., (Copyright © 2014 by the American Academy of Pediatrics.)

Established hospital palliative care consult services (PCCS) have been associated with reduced costs and length of stay, decreased symptom burden, and increased satisfaction with care. Using a retrospective case-control design, we analyzed administrative data of patients seen by PCCS while hospitalized at the Rochester, Minnesota Mayo Clinic hospitals from 2003 to 2008. The PCCS patients were matched to 3:1. A total of 1477 patients seen by the PCCS were matched with 4431 patients not seen. Costs for patients seen and discharged alive were US $35,449 (95% confidence interval [CI] US $34,157-US $36,686) compared to US $37,447 (95% CI US $36,734-US $38,126), without PCCS consultation. Costs for PCCS patients that died during hospitalization were US $54,940 (95% CI US $51,483-US $58,576) and non-PCCS patients were US $79,660 (95% CI US $76,614-US $83,398).

In this descriptive study, we examined changes in invasive and non-invasive airway support; studied the rates of home discharge vs. long-term care or acute hospitalization; and examined the relationship between the level of airway support and discharge to home for 92 children (<3 years of age) with 104 admission-discharge episodes to a consortium of pediatric rehabilitation hospitals over a one-year period. We found a significant reduction (p < 0.001) in the level of airway support between admission and discharge. In 21 of 47 (45%) episodes, children weaned from mechanical ventilation to a less restrictive type of support. Sixty percent of the children had final discharges to home. There was a significant, though fair correlation (Spearman Rho = -0.344, p = 0.001) between home discharge and level of airway support. These outcomes data provide a multi-site baseline for understanding expected changes in airway support and home discharge rates of young children who are admitted to a post-acute inpatient program.

Multiple published studies in recent years have provided results and information that hospitalists can apply directly to patient care. This update summarizes some important articles published over the past 18 months. Article summaries are categorized into perioperative care, infectious disease, diagnosis of venous thromboembolism, end of life care, and guidelines for the management of patients with COPD or atrial fibrillation.

Two papers in this issue of Neuron examine new aspects of Semaphorin signaling via Plexin receptors. Winberg et al. present evidence that the transmembrane protein Off-track (OTK) interacts biochemically and genetically with Plexin A and is important for Sema 1a repulsive signaling. Hu et al. examine the coupling of Plexin B to Rac and RhoA and propose that Plexin B signaling involves inhibition of Rac function by direct sequestration and simultaneous activation of RhoA.

Medical morbidity associated with hip fractures in the elderly population is considerable. The all-cause mortality rate is 24% at 12 months. The functional limitations of survivors can be pronounced. As the American population ages, hip fractures will substantially affect the utilization of hospital resources. Several issues, including preoperative clearance and related surgical timing, deep venous thrombosis prophylaxis, delirium, nutrition, and urinary tract management, are important in the care of these patients. A close partnership between orthopedic surgeons and clinicians provides the best strategy of care for the subset of patients with multisystemic complications.

A children's hospital in the midwest initiated widespread changes in care delivery to provide care that is truly family-centered in practice. The role of nurses, from nursing administration to the staff nurse level, has been a key element in initiating and implementing the institution's move to family-centered care. A Family Advisory Council, composed of hospital personnel and families, identifies family needs and recommends new programs and approaches. Participants in a nursing leadership retreat designated family-centered care as a priority and piloted several innovative programs. Nursing commitment has encouraged other disciplines and departments to initiate family-centered practices as well.

The function of Class II molecules in proliferation was explored by treating human cell lines with three distinct anti-DR monoclonal antibodies (MABs). Dose-dependent, specific inhibition of eight DR+ cell lines of different origin and lineage was found. Inhibition was durable (i.e., cells did not become resistant to the anti-DR MABs despite prolonged treatment) yet reversible. The mechanism of inhibition was not due to differentiation or killing but was cytostatic. Inhibition was temporally associated with decreases in nuclear size and irregularity and appeared to be due to a non-phase-specific cell cycle arrest.