Leading the Charge: Effectiveness of a Workshop to Enhance Faculty Education of Health Inequity.

INTRODUCTION: Medical educators in residency programs have unique opportunities to teach health inequities, social determinants of health (SDOH), and implicit bias. However, faculty are not adequately trained to effectively teach these topics. The aim is to assess the effectiveness of a faculty-level workshop to teach health inequity. METHODS: An interactive workshop was designed by an interprofessional faculty from a major urban teaching hospital, addressing SDOH, implicit bias, an "Enhanced Social History," and the benefits of interprofessional care. Before and after completion, workshop participants completed surveys regarding comfort in teaching these concepts. Survey results were analyzed to assess benefits of the intervention. RESULTS: Sixty-four percent of participants completed preworkshop and postworkshop surveys. Participants reported increased contemplation and improved comfort in teaching SDOH, barriers to medical care, and implicit bias. CONCLUSION: Faculty comfort in teaching health inequity increased after this workshop. This may help bridge the gap between the expectation of clinical faculty to evaluate trainee practice of patient-centered, culturally competent care, and faculty possession of and confidence in health inequity teaching skills in clinical settings. Future research should focus on learner- and patient-based outcomes, including teaching time and impact on delivery of care.

Excellent clinical outcomes and retention in care for adults with HIV-associated Kaposi sarcoma treated with systemic chemotherapy and integrated antiretroviral therapy in rural Malawi.

INTRODUCTION: HIV-associated Kaposi sarcoma (HIV-KS) is the most common cancer in Malawi. In 2008, the non-governmental organization, Partners In Health, and the Ministry of Health established the Neno Kaposi Sarcoma Clinic (NKSC) to treat HIV-KS in rural Neno district. We aimed to evaluate 12-month clinical outcomes and retention in care for HIV-KS patients in the NKSC, and to describe our implementation model, which featured protocol-guided chemotherapy, integrated antiretroviral therapy (ART) and psychosocial support delivered by community health workers. METHODS: We conducted a retrospective cohort study using routine clinical data from 114 adult HIV-KS patients who received ART and ≥1 chemotherapy cycle in the NKSC between March 2008 and February 2012. RESULTS: At enrolment 97% of patients (n/N=103/106) had advanced HIV-KS (stage T1). Most patients were male (n/N=85/114, 75%) with median age 36 years (interquartile range, IQR: 29-42). Patients started ART a median of 77 days prior to chemotherapy (IQR: 36-252), with 97% (n/N=105/108) receiving nevirapine/lamivudine/stavudine. Following standardized protocols, we treated 20 patients (18%) with first-line paclitaxel and 94 patients (82%) with bleomycin plus vincristine (BV). Of the 94 BV patients, 24 (26%) failed to respond to BV requiring change to second-line paclitaxel. A Division of AIDS grade 3/4 adverse event occurred in 29% of patients (n/N=30/102). Neutropenia was the most common grade 3/4 event (n/N=17/102, 17%). Twelve months after chemotherapy initiation, 83% of patients (95% CI: 74-89%) were alive, including 88 (77%) retained in care. Overall survival (OS) at 12 months did not differ by initial chemotherapy regimen (p=0.6). Among patients with T1 disease, low body mass index (BMI) (adjusted hazard ratio, aHR=4.10, 95% CI: 1.06-15.89) and 1 g/dL decrease in baseline haemoglobin (aHR=1.52, 95% CI: 1.03-2.25) were associated with increased death or loss to follow-up at 12 months. CONCLUSIONS: The NKSC model resulted in infrequent adverse events, low loss to follow-up and excellent OS. Our results suggest it is safe, effective and feasible to provide standard-of-care chemotherapy regimens from the developed world, integrated with ART, to treat HIV-KS in rural Malawi. Baseline BMI and haemoglobin may represent important patient characteristics associated with HIV-KS survival in rural sub-Saharan Africa.

Telephone follow-up as a primary care intervention for postdischarge outcomes improvement: a systematic review.

OBJECTIVE: Postdischarge telephone follow-up plays an integral part in transitional care efforts in many regions. We systematically reviewed the literature to evaluate the evidence regarding the impact of primary care-based telephone follow-up on postdischarge emergency department visits and hospital readmissions. METHODS: We performed an electronic database search for relevant telephone follow-up studies originating in adult primary care settings. RESULTS: Only 3 studies (N=1765) met entry criteria for this review. None of the studies demonstrated evidence of reduced admissions or emergency department visits from primary care-based telephone follow-ups. All 3 studies reported improved primary care office contact as a result of telephone follow-up intervention. CONCLUSIONS: Despite the growing use of primary care-based telephone follow-up in the postdischarge period, there are no high-quality studies demonstrating its benefit. However, its positive impact on patient engagement holds potentially meaningful implications. In light of recent national health care legislation, the primary care field is ripe for high-quality studies to evaluate the effectiveness of telephone follow-up for patients in the postdischarge period. Particular areas of research focus are discussed.

Hypoglycemia from IGF2 overexpression associated with activation of fetal promoters and loss of imprinting in a metastatic hemangiopericytoma.

CONTEXT: The mechanism of IGF2 overexpression in non-islet-cell tumor hypoglycemia is not understood. OBJECTIVE: We investigated the imprinting control and promoter usage for IGF2 expression to identify a mechanism for increased IGF-II production in non-islet-cell tumor hypoglycemia. PATIENT AND METHODS: A patient with metastatic hemangiopericytoma was studied. Tissue from the original hemangiopericytoma, metastatic tumor, and uninvolved liver was analyzed for IGF-II immunohistochemistry. IGF2, a paternally imprinted gene, shares a control region with maternally imprinted H19, a putative tumor suppressor. IGF-II and H19 mRNA expression was compared in metastatic tumor and uninvolved liver by quantitative RT-PCR. Imprinting of IGF2/H19 genes and IGF2 promoter usage in metastatic tumor was investigated by RT-PCR and sequence analysis, and the methylation pattern in the IGF2/H19 imprinting control region was analyzed. RESULTS: IGF-II protein expression was increased in metastatic tumor vs. uninvolved liver and original tumor. In the metastatic tumor, IGF-II mRNA was increased 60-fold, but H19 mRNA was comparable to uninvolved liver; loss of imprinting of IGF2, but not H19, was identified; no major change in methylation of the IGF2/H19 imprinting control regions was observed; and transcripts from four different IGF2 promoters were detected, compared to two in uninvolved liver. CONCLUSIONS: IGF-2 overexpression, newly acquired in the metastatic tumor, was associated with loss of IGF2 gene imprinting and different promoter usage. The imprinting control mechanism governing the IGF2/H19 locus was intact, as evidenced by normal levels of H19, maintenance of H19 imprinting, and no major change in methylation of the imprinting control regions.