[Show abstract][Hide abstract] ABSTRACT: The primary goal of this project was to create and evaluate the utility, validity, and reliability of an instrument assessing resident performance during child and adolescent psychiatry (CAP) training. In three stages, the instrument was developed and evaluated for utility in assessing skills critical to CAP. Items on the Global Assessment Evaluation (GAE) were derived from the six core competencies identified by the American College of Graduate Medical Education (ACGME). Secondary goals included producing an instrument that could be used by other CAP training programs and describing a process that could be followed by training programs to create their own assessment instruments.
Faculty members developed a CAP resident performance evaluation instrument. In a three-stage process, faculty utilized the tool to evaluate residents during and after rotations. Statistical findings guided revisions to improve the utility and reliability of the instrument. For the final version of the GAE, intra-class correlation coefficients were calculated to assess inter-rater reliability, and Principal Components Analysis provided further insight into the dimensions of resident assessment.
The final version of the GAE showed overall and construct validity by capturing significant differences among residents and matched faculty members' overall impressions of resident performance. Intra-class correlation coefficient values for the overall score (0.945) and individual scales showed good reliability. Resident performance was not correlated with rotation site or model of care.
The GAE has proved a valuable instrument in tracking the progress, strengths, and weaknesses in resident performance over the course of training. Data from multiple evaluations over time provide useful information about resident performance in a way that one or few evaluations does not. This finding is consistent with the practice of semiannual reviews and the new Clinical Competency Committees, both of which are required by the ACGME.
No preview · Article · May 2014 · Academic Psychiatry
[Show abstract][Hide abstract] ABSTRACT: Background:
Pregnancy is becoming more common in residency, and about 80% of residents are female. This leads to questions of breastfeeding, work demands, and perception of burden by colleagues. This study was designed to assess experiences of (1) breastfeeding obstetrics residents and (2) their colleagues.
Materials and methods:
This was a cross-sectional study of obstetrics and gynecology residents. Residents were categorized into experience with or no experience with breastfeeding to determine differences.
Responses were obtained from 404 residents in obstetrics. Breastfeeding is common, with 90% of residents knowing a breastfeeding resident and 22% of residents reporting personal experience with breastfeeding. Breastfeeding residents (n=89) felt support from their faculty and fellow residents. More than one in three breastfeeding mothers felt they placed extra demands on colleagues, despite 80% of colleagues reporting that they did not feel that breastfeeding colleagues placed extra demands. A breastfeeding policy was important to 85% of residents, but only 7% believed their program had one. Two-thirds of breastfeeding residents struggled with low milk supply and stopped breastfeeding early.
Despite high levels of perceived support from faculty/fellow residents, breastfeeding residents struggle with low milk supply and work demands that lead to early discontinuation.
No preview · Article · Apr 2013 · Breastfeeding Medicine
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to compare influenza vaccination rates of pregnant women in a public safety-net health system to national coverage rates during the 2009-2010 pandemic influenza season. A chart review of a random sample of deliveries was undertaken to determine rates of coverage and predictors of vaccine coverage of women who obtained prenatal care and delivered in our health system. Rates were calculated from deliveries from when the vaccine was first available through April 30, 2010. Coverage rates were 54% for the seasonal influenza vaccine and 51% for the H1N1 vaccine. Race/ethnicity, insurance status and language spoken did not predict the receipt of either vaccine. When we included only births which occurred through March 12, 2010, as was done in a large population-based study, the rates were 61% and 59%, respectively. Our rates are about 10% higher than the rates reported in that study. Our comprehensive strategy for promoting vaccine coverage achieved higher vaccination rates in a safety-net health system, which serves groups historically less likely to be vaccinated, than those reported for the pregnant population at large.
[Show abstract][Hide abstract] ABSTRACT: To describe a new approach to transgluteal pudendal neurolysis and transposition and to review the outcome in 10 patients who underwent repeat operation because of persistent pudendal neuralgia after failing to improve after initial surgical decompression.
Retrospective analysis (Canadian Task Force classification II-3).
Academic chronic pelvic pain practice at St. Joseph's Hospital and Medical Center in Phoenix, Arizona.
Women and men with persistent pudendal neuralgia after undergoing transgluteal pudendal neurolysis and transposition.
Transgluteal decompression of the pudendal nerve was performed in all 10 patients. In brief, a transgluteal incision was made, and the pudendal nerve was identified via a nerve integrity monitoring system. Adhesiolysis was performed from the piriformis muscle to the distal Alcock canal using a Zeiss NC-4 surgical microscope. The nerve was then enclosed in NeuraWrap Nerve Protector and coated with activated platelet-rich plasma. An ON-Q PainBuster catheter was place along the nerve into the Alcock canal, and 0.5% bupivacaine was infused at 2 mL/hr. The sacrotuberous ligament was repaired using an Achilles or gracillis cadaver ligament. The overlying subcutaneous tissue and skin were then closed.
From June 2008 to March 2010, 10 consecutive patients (7 women and 3 men; age range, 29-81 years) underwent repeat operation with transgluteal decompression of the pudendal nerve. Neuropathic pain was unilateral (n = 8) or bilateral (n = 2), in the clitoris or penis (30%), vulva or scrotum (70%), perineum (40%), and rectum (50%). Of the 10 patients, 1 patient was lost to follow-up. Mean follow-up was 23 months. Eight of 9 patients reported global improvement, with 2 patients reporting complete resolution of symptoms. One patient reported no change. Pain, as measured using an 11-point numerical scale, improved from a mean of 7.2 to 4.0 (p = .02), with 5 patients reporting clinically significant improvement (change, ≥2). Comfortable sitting or maximum time that the patient was able to sit without exacerbation of pain improved in 8 patients, with a change in median time of 5 to 45 minutes (p = .008). Change in the ability to sit correlated well with patient-reported global improvement (correlation coefficient, 0.86). No patient experienced worsening of symptoms.
Patients with persistent pudendal neuralgia after surgical decompression may benefit from repeat operation via our novel approach. Ability to sit correlates well with reported improvement due to surgery.
No preview · Article · Feb 2012 · Journal of Minimally Invasive Gynecology
[Show abstract][Hide abstract] ABSTRACT: Objective: Compare neonatal morbidities in women with no prenatal care, and women with inadequate prenatal care, to those with adequate prenatal care. Methods: Retrospective cohort study of neonatal mor-bidities of 3 exposure groups. Group 1: No prenatal care; Group 2: Inadequate prenatal care; Group 3: Intermediate/adequate prenatal care. Results: 2.5%, 23.3% and 74.1% of subjects (N = 264,138) were in Groups 1, 2 and 3 respectively. Severe neonatal mor-bidity was more common in Group 1, followed by Group 2, and least common in Group 3. After con-trolling for gestational age and birth weight, most of these differences were attenuated and not significant except for the following Group 1 vs Group 3 com-parisons: meconium aspiration, odds ratio (OR) 2.15 and 95% confidence interval (CI) 1.39 -3.33; sus-pected sepsis, OR 1.30 and CI 1.13 -1.49; proven vi-ral sepsis, OR 2.23 and CI 1.24 -4.00. Conclusions: Severe neonatal morbidity was most common in those with no prenatal care followed by those with inade-quate prenatal care. For most neonatal morbidities, this could largely be explained by gestational age and birth weight differences, but for some neonatal mor-bidities (meconium aspirations, viral sepsis and dys-morphic features) the impact of no prenatal care per-sisted after adjustment for these factors.
Preview · Article · Jan 2012 · Open Journal of Obstetrics and Gynecology
[Show abstract][Hide abstract] ABSTRACT: The purpose of our study was to examine rates of consent to participate in research in voluntarily and involuntarily hospitalized psychiatric patients in order to evaluate factors that may influence the decision to participate in research. We used logistic regression models to evaluate differences and found that involuntary patients were less likely to consent to participate. After adjustment for covariates, we found that consent rates did not differ between the involuntary and voluntary population, but that lower Global Assessment of Functioning (GAF) scores and psychosis negatively affected the decision to consent to research. We discuss the implications of our findings.
No preview · Article · Mar 2011 · Journal of Empirical Research on Human Research Ethics
[Show abstract][Hide abstract] ABSTRACT: There is no clear gold standard treatment for childhood posttraumatic stress disorder (PTSD). An annotated bibliography and meta-analysis were used to examine the efficacy of cognitive behavioral therapy (CBT) in the treatment of pediatric PTSD as measured by outcome data from the Child Behavior Checklist (CBCL).
A literature search produced 21 studies; of these, 10 utilized the CBCL but only eight were both 1) randomized; and 2) reported pre- and post-intervention scores.
The annotated bibliography revealed efficacy in general of CBT for pediatric PTSD. Using four indices of the CBCL, the meta-analysis identified statistically significant effect sizes for three of the four scales: Total Problems (TP; -.327; p = .003), Internalizing (INT; -.314; p = .001), and Externalizing (EXT; -.192; p = .040). The results for TP and INT were reliable as indicated by the fail-safe N and rank correlation tests. The effect size for the Total Competence (TCOMP; -.054; p = .620) index did not reach statistical significance.
Limitations included methodological inconsistencies across studies and lack of a randomized control group design, yielding few studies for meta-analysis.
The efficacy of CBT in the treatment of pediatric PTSD was supported by the annotated bibliography and meta-analysis, contributing to best practices data. CBT addressed internalizing signs and symptoms (as measured by the CBCL) such as anxiety and depression more robustly than it did externalizing symptoms such as aggression and rule-breaking behavior, consistent with its purpose as a therapeutic intervention.
No preview · Article · Mar 2011 · Journal of Behavior Therapy and Experimental Psychiatry
[Show abstract][Hide abstract] ABSTRACT: Transient tachypnea of the newborn (TTN) is a common respiratory problem in newborns. This study aims to determine if cesarean delivery (CD) is a risk factor for TTN, and if labor prior to CD decreases this risk. A linked data set consisting of Arizona birth certificates (1994 to 1998) and infants enrolled in a high-risk perinatal program provided 800 TTN cases and 800 controls, stratified by year. The relationships of CD and labor to TTN were examined using logistic regression. CD was associated with an increased risk of TTN, whether it was accompanied by labor (odds ratio [OR] 2.68; 95% confidence interval [CI] 1.62 to 4.45) or not accompanied by labor (OR 2.88; 95% CI 2.01 to 4.13), even after adjusting for confounding variables. Labor did not affect the development of TTN, nor did it modify the association of CD with increased risk for TTN. CD is a risk factor for TTN. Labor prior to CD is not protective for TTN.
No preview · Article · Nov 2010 · American Journal of Perinatology
[Show abstract][Hide abstract] ABSTRACT: In Maricopa County, Arizona, most defendants who are found not competent and not restorable (NCNR) are admitted involuntarily to an acute-care inpatient hospital. Many of these patients would most likely not have met the State's usual admission criteria for acute inpatient care had they not been evaluated in relation to a criminal offense. Is this group treated differently from their peers who are not involved in the criminal justice system? We examined records for 293 NCNR admissions, retrospectively, to assess their admission status and the outcomes of their commitment. We compared them to 280 matched cases of patients admitted involuntarily from the community (non-NCNR). The NCNR group met fewer admission criteria and received court-ordered treatment (COT) 22 percent more often than did the non-NCNR patients. The NCNR patients had longer hospital stays despite being found less dangerous to themselves or others than the community sample. Results suggest that NCNR individuals are treated differently from non-NCNR patients.
No preview · Article · Sep 2010 · The journal of the American Academy of Psychiatry and the Law
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to determine whether computed tomography (CT) is a reliable method of imaging to assess placental injury after acute trauma during pregnancy.
This study was a retrospective review of digital CT images and electronically scanned charts of pregnant trauma patients identified from the hospital trauma registry list.
Using delivery within 36 hours of trauma as the clinical marker for the occurrence of placental abruption, positive radiologic readings showed 86% sensitivity and 98% specificity. The overall accuracy was 96%.
Given that defined patterns on CT can be identified and those can be correlated to actual abruption, CT may be a reliable method for evaluation of placental abruption after maternal trauma, especially in the face of abdominal trauma. Our results show that CT has both good sensitivity and specificity identifying abruption and should be considered for use in the management in the pregnant patient after trauma.
No preview · Article · Mar 2010 · American journal of obstetrics and gynecology
[Show abstract][Hide abstract] ABSTRACT: The objective of the study was to determine knowledge and attitudes regarding preconception care in a low-income Mexican American population.
This was a cross-sectional survey of 305 reproductive-age women at an urban public hospital.
The sample was mostly Hispanic (88%) and pregnant (68%); 35% had not completed high school. Eighty-nine percent agreed that improving preconception health benefits pregnancy. Seventy-seven percent expressed some interest in preconception health care with the obstetrics gynecology office at the preferred location. The average knowledge of preconception care score was 76% (higher score more favorable). Areas of higher knowledge included the effects on pregnancy of folic acid; alcohol use; substance use; and verbal, physical, and sexual abuse; lower knowledge was found for the effects of cat litter and fish products.
There was interest in preconception education and agreement that preconception health has a positive effect on pregnancy. Fewer respondents agreed that it had a good effect than a suburban sample in the same region (89% vs 98%).
No preview · Article · May 2009 · American journal of obstetrics and gynecology
[Show abstract][Hide abstract] ABSTRACT: This study was undertaken to determine individual and institutional level variables predictive of variations in nulliparous term singleton vertex cesarean delivery rates.
Retrospective cohort study of 28,863 nulliparous term singleton vertex births at 40 Arizona hospitals.
The average nulliparous term singleton vertex cesarean delivery rate was 22.0%, the lowest hospital rate was 10.3%, high, 34.2%. The following individual level variables increased the nulliparous term singleton vertex cesarean delivery rate in a multivariable model: increased mother's age, African American race, increased birthweight, labor induction, and the presence of medical conditions such as diabetes and hypertension. Of the institutional variables, after adjustment, the highest level of nursery or a higher percentage of government-paid births was associated with lower risks, whereas delivery at a hospital with the lowest level of care or with an obstetric and gynecology residency was associated with an increased risk of cesarean delivery.
Substantial variations in nulliparous term singleton vertex cesarean delivery rates were seen in this comparative analysis of 40 hospitals.
No preview · Article · Jul 2008 · American journal of obstetrics and gynecology
[Show abstract][Hide abstract] ABSTRACT: As a biostatistician and member of an Institutional Review Board (IRB), my principal role is to help evaluate the scientific merits of research protocols so the Board can accurately judge the ratio of benefits to risks. Investigators, coordinators and the physician members of the IRB are often enthusiastic about the clinical aspects of the studies that come before the Board and eager to see the studies proceed. Because I review protocols from a different perspective, I am sometimes perceived as the Board's "Dr. No." If an IRB includes a biostatistician, he or she is often the only member on the Board to raise methodological questions — questions that sometimes elicit impatience or skepticism from other IRB members. As noted in the Belmont Report, in order to adequately assess the risks and benefits of a protocol, the appropriateness of the research design and analytic plan must be evaluated. 1 Good science is therefore integral to good ethics. The principle of beneficence demands that the scientific merits of a proposed study be examined carefully. A study that lacks scientific merit cannot justify exposing subjects to any but the slightest level of risk. However, neither the Belmont Report nor federal regulations explain how this assessment should be made. If no intervention is being administered as part of the study and no invasive measurements are being taken, then risks to the subjects are minimal, and the IRB can be less concerned about minor flaws in the design or analytic strategy. 2 On the other hand, most funded studies involve interventions and/or invasive measurements, and therefore impose greater than minimal risks.