Santa Clara Valley Health and Hospital System

This article provides an overview of the rationale for diabetes preconception care interventions for women with diabetes and the efficacy in reducing the excess occurrence of major congenital malformations. The problems with broad use of individualized preconception care are considered. In addition, suggestions are made for the implementation of more comprehensive interventions in the community and usual diabetes care settings, to address the multiple ongoing challenges in the prevention of structural anomalies associated with preexisting diabetes. Based on the published evidence, successful preconception care can be considered to include: achievement of individualized target standardized glycosylated hemoglobin levels, adequate nutrition, and minimizing hypoglycemia before and after discontinuing effective contraception and during the transition to early prenatal care.

BACKGROUND: People living with human immunodeficiency virus (HIV) may have numerous risk factors for acquiring coronavirus disease 2019 (COVID-19) and developing severe outcomes, but current data are conflicting. METHODS: Health-care providers enrolled consecutively, by nonrandom sampling, people living with HIV (PWH) with lab-confirmed COVID-19, diagnosed at their facilities between 1 April and 1 July 2020. Deidentified data were entered into an electronic Research Electronic Data Capture (REDCap) system. The primary endpoint was a severe outcome, defined as a composite endpoint of intensive care unit (ICU) admission, mechanical ventilation, or death. The secondary outcome was the need for hospitalization. RESULTS: There were 286 patients included; the mean age was 51.4 years (standard deviation, 14.4), 25.9% were female, and 75.4% were African American or Hispanic. Most patients (94.3%) were on antiretroviral therapy, 88.7% had HIV virologic suppression, and 80.8% had comorbidities. Within 30 days of testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), 164 (57.3%) patients were hospitalized, and 47 (16.5%) required ICU admission. Mortality rates were 9.4% (27/286) overall, 16.5% (27/164) among those hospitalized, and 51.5% (24/47) among those admitted to an ICU. The primary composite endpoint occurred in 17.5% (50/286) of all patients and 30.5% (50/164) of hospitalized patients. Older age, chronic lung disease, and hypertension were associated with severe outcomes. A lower CD4 count (<200 cells/mm3) was associated with the primary and secondary endpoints. There were no associations between the ART regimen or lack of viral suppression and the predefined outcomes. CONCLUSIONS: Severe clinical outcomes occurred commonly in PWH with COVID-19. The risks for poor outcomes were higher in those with comorbidities and lower CD4 cell counts, despite HIV viral suppression. CLINICAL TRIALS REGISTRATION: NCT04333953.

OBJECTIVE: To estimate whether prophylactic antibiotics at the time of repair of third- or fourth-degree perineal tears after vaginal delivery prevent wound infection and breakdown. METHODS: This was a prospective, randomized, placebo-controlled study. Patients who sustained third- or fourth-degree perineal tears after a vaginal delivery were recruited for the study. Each patient was given a single intravenous dose of a second-generation cephalosporin (cefotetan or cefoxitin) or placebo before repair of third- or fourth-degree perineal tears. Obstetricians and patients were blinded to study drug. The perineum was inspected for evidence of infection or breakdown at discharge from the hospital and at 2 weeks postpartum. Primary end points were gross disruption or purulent discharge at site of perineal repair by 2 weeks postpartum. RESULTS: One hundred forty-seven patients were recruited for the study. Of these, 83 patients received placebo and 64 patients received antibiotics. Forty patients (27.2%) did not return for their 2-week appointment. Of the patients seen at 2 weeks postpartum, 4 of 49 (8.2%) patients who received antibiotics and 14 of 58 (24.1%) patients who received placebo developed a perineal wound complication (P=.037). There were no differences between groups in parity, incidence of diabetes, operative delivery, or third-degree compared with fourth-degree lacerations. CONCLUSION: By 2 weeks postpartum, patients who received prophylactic antibiotics at the time of third- or fourth-degree laceration repair had a lower rate of perineal wound complications than patients who received placebo. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clincaltrials.gov, NCT00186082. LEVEL OF EVIDENCE: I.

We reviewed 106 patients referred to our institution for treatment of peripheral tuberculous adenitis to establish the epidemiologic, clinical, and pathologic manifestations of this disease. Tuberculous lymphadenitis occurred predominantly in young, foreign-born women a mean of 5 years after arrival in the United States. Tuberculin skin tests were positive in 94% of cases. Lymphadenopathy occurred most frequently in the neck (57%) or supraclavicular area (26%) and involved 1-3 nodes. Forty (38%) patients had an abnormal chest radiograph consistent with granulomatous infection. Culture-positive pulmonary tuberculosis was diagnosed in 41% of those patients with abnormal chest radiographs. Fine needle aspiration was an essential step in the evaluation and diagnosis of tuberculous lymphadenitis. Granulomas were seen in 61% of fine needle aspirates and 88% of surgical biopsies. Positive cultures for Mycobacterium tuberculosis were obtained from 62% of fine needle aspirate samples and 71% of excisional biopsies. The presence of necrosis and/or neutrophilic inflammation in tissue samples correlated with culture positivity. Given the high yield of positive cultures from fine needle aspirates, surgery was rarely indicated as an initial step in immunocompetent adults. In this cohort, 101 patients received a final diagnosis of peripheral tuberculous lymphadenitis. Eighty-two percent received their entire therapy under direct observation, and response to antituberculous therapy was uniformly successful. Paradoxical expansion of adenopathy was seen in 20% of all patients and was more commonly noted in human immunodeficiency virus-seropositive patients. We present a diagnostic algorithm based on our experience.

Studies are needed to characterize the reproducibility of QuantiFERON-TB Gold (QFT-G) for targeted U.S. screening populations. Members of northern California households were tested with the QFT-G in-tube assay (QFT-G-IT) at two home visits 3 months apart. Reproducibility and agreement with the tuberculin skin test (TST) were assessed. Monte Carlo simulation was used to evaluate the role of test-related error. Of 63 individuals (49 adults and 14 children) completing QFT-G-IT at both time points, 79% were foreign-born (98% from Latin America) and 68% reported Mycobacterium bovis BCG vaccination. At the baseline visit, 23 (37%) were TST positive and 15 (24%) were QFT-G-IT positive (kappa = 0.48 [+/- 0.11]). At 3 months, 3/48 (6.3%; 95% confidence interval [95CI], 2 to 17) of those initially QFT-G-IT negative converted, and 5/15 (33%; 95CI, 15 to 58) of those initially QFT-G-IT positive reverted. Among the 8 individuals with inconsistent QFT-G-IT results, the maximum gamma interferon response at either visit was 0.68 IU/ml versus means of 4.99 (+/- 3.74) and 6.95 (+/- 5.6) for 10 persistent positives at the first and second visits, respectively. Expected false-reversion and -conversion rates were 32% (90CI, 25 to 39%) and 6.95% (90CI, 4.6 to 9.8%) when the sensitivity and specificity were assumed to average 70% and 98%, respectively. Transient responses to QFT-G-IT are common, and low positive results need to be interpreted with caution. Further studies are needed to characterize the predictive value of the test for U.S. foreign-born and other targeted screening populations.

CONTEXT: Temperature instability is a serious but potentially preventable morbidity in preterm infants. Admission temperatures below 36°C are associated with increased mortality and late onset sepsis. OBJECTIVE: The goal of our quality-improvement effort was to increase preterm infants' admission temperatures to above 36°C by preventing heat loss in the immediate postnatal period. DESIGN: This quality-improvement initiative used the rapid-cycle Plan-Do-Study-Act approach. Preterm infants born at less than 33 weeks' gestation with very low birth weight less than 1500 g who were born at a Regional Level III Neonatal Intensive Care Unit (NICU) in San Jose, CA, were enrolled. Our intervention involved standardizing the management of thermoregulation from predelivery through admission to the NICU. Data on admission temperature were collected prospectively. MAIN OUTCOME MEASURES: The primary outcome measure was hypothermia, defined as temperature below 36°C on admission to the NICU. RESULTS: The hypothermia rate was reduced from 44% in early 2006 to 0% by 2009. There was a slight increase to 6% in 2010. Subsequently, with further real-time feedback, we were able to sustain 0% hypothermia through 2011. Our hypothermia rate remained substantially lower than state and national hypothermia benchmarks that have shown moderate improvement over the same period. CONCLUSION: We reduced hypothermia in very low-birth-weight infants using a standardized protocol, multidisciplinary team approach, and continuous feedback. Sustaining improvement is a challenge that requires real-time progress evaluation of outcomes and ongoing staff education.

PRIMARY OBJECTIVE: To examine return to driving and variables associated with that activity in a longitudinal database. RESEARCH DESIGN: Retrospective analysis of a large, national database. METHODS AND PROCEDURES: The sample was comprised of people with predominantly moderate-severe traumatic brain injury (TBI) enrolled in the TBI Model System national database at 16 centres and followed at 1 (n = 5942), 2 (n = 4628) and 5 (n = 2324) years after injury. MAIN OUTCOMES AND RESULTS: Respondents were classified as driving or not driving at each follow-up interval. Five years after injury, half the sample had returned to driving. Those with less severe injuries were quicker to return to driving, but, by 5 years, severity was not a factor. Those who were driving expressed a higher life satisfaction. Functional status at rehabilitation discharge, age at injury, race, pre-injury residence, pre-injury employment status and education level were associated with the odds of a person driving. CONCLUSIONS: Half of those with a moderate-severe TBI return to driving within 5 years and most of those within 1 year of injury. Driving is associated with increased life satisfaction. There are multiple factors that contribute to return to driving that do not relate to actual driving ability.

BACKGROUND AND OBJECTIVE: Central venous catheters in the NICU are associated with significant morbidity and mortality because of the risk of central line-associated bloodstream infections (CLABSIs). The purpose of this study was to determine the effect of catheter dwell time on risk of CLABSI. METHODS: Retrospective cohort study of 13,327 infants with 15,567 catheters (93% peripherally inserted central catheters [PICCs], 7% tunneled catheters) and 256,088 catheter days cared for in 141 NICUs. CLABSI was defined using National Health Surveillance Network criteria. We defined dwell time as the number of days from line insertion until either line removal or day of CLABSI. We generated survival curves for each week of dwell time and estimated hazard ratios for CLABSI at each week by using a Cox proportional hazards frailty model. We controlled for postmenstrual age and year, included facility as a random effect, and generated separate models by line type. RESULTS: Median postmenstrual age was 29 weeks (interquartile range 26-33). The overall incidence of CLABSI was 0.93 per 1000 catheter days. Increased dwell time was not associated with increased risk of CLABSI for PICCs. For tunneled catheters, infection incidence was significantly higher in weeks 7 and 9 compared with week 1. CONCLUSIONS: Clinicians should not routinely replace uninfected PICCs for fear of infection but should consider removing tunneled catheters before week 7 if no longer needed. Additional studies are needed to determine what daily maintenance practices may be associated with decreased risk of infection, especially for tunneled catheters.

With continuing emigration from endemic countries, screening for parasitic infections remains a priority in U.S. communities serving refugee and immigrant populations. We report the prevalence of helminths and protozoa as well as demographic risk factors associated with these infections among 533 refugees seen at the Santa Clara County, California, Refugee Clinic between October 2001 and January 2004. Stool parasites were identified from 14% of refugees, including 9% found to have one or more protozoa and 6% found to have at least one helminth. Most common protozoan infections were Giardia lamblia (6%) and Dientamoeba fragilis (3%), and for helminths, hookworm (2%). Protozoa were more frequent in refugees < 18 years of age (OR: 2.2 [1.2-4.2]), whereas helminths were more common in refugees from South Central Asia (OR: 8.0 [2.3-27.7]) and Africa (OR: 5.9 [1.6-21.6]) when compared with refugees from Eastern Europe and the Middle East. Among helminths, Ascaris lumbricoides and hookworm were concentrated among South Central Asians (6 of 7 and 10 of 11 cases, respectively), whereas Strongyloides stercoralis was predominantly found in Africans (5 of 7 cases). Although predeparture empirical treatment programs in Saharan Africa may have helped to reduce prevalence among arriving refugees from this region, parasitic infection is still common among refugees to the United States with helminth infections found in more specific populations. As refugees represent only a fraction of recent immigrants from endemic countries, current studies in nonrefugee groups are also needed.

PURPOSE: We sought to identify genes of clinical significance to predict survival and the risk for colorectal liver metastasis (CLM), the most common site of metastasis from colorectal cancer (CRC). PATIENTS AND METHODS: We profiled gene expression in 31 specimens from primary CRC and 32 unmatched specimens of CLM, and performed Significance Analysis of Microarrays (SAM) to identify genes differentially expressed between these two groups. To characterize the clinical relevance of two highly-ranked differentially-expressed genes, we analyzed the expression of secreted phosphoprotein 1 (SPP1 or osteopontin) and lymphoid enhancer factor-1 (LEF1) by immunohistochemistry using a tissue microarray (TMA) representing an independent set of 154 patients with primary CRC. RESULTS: Supervised analysis using SAM identified 963 genes with significantly higher expression in CLM compared to primary CRC, with a false discovery rate of <0.5%. TMA analysis showed SPP1 and LEF1 protein overexpression in 60% and 44% of CRC cases, respectively. Subsequent occurrence of CLM was significantly correlated with the overexpression of LEF1 (chi-square p = 0.042), but not SPP1 (p = 0.14). Kaplan Meier analysis revealed significantly worse survival in patients with overexpression of LEF1 (p<0.01), but not SPP1 (p = 0.11). Both univariate and multivariate analyses identified stage (p<0.0001) and LEF1 overexpression (p<0.05) as important prognostic markers, but not tumor grade or SPP1. CONCLUSION: Among genes differentially expressed between CLM and primary CRC, we demonstrate overexpression of LEF1 in primary CRC to be a prognostic factor for poor survival and increased risk for liver metastasis.

The purpose of our study was to determine changes in spinal mobility for women aged 20 to 84 years. Anterior flexion, right and left lateral flexion, and extension were measured on 109 healthy women. The modified Schober method was used to measure anterior flexion. Standard goniometry was used to measure lateral flexion and extension. The results of the study indicated that spinal mobility decreases with advancing age. The most significant (p less than .05) differences occurred between the two youngest and the two oldest age categories. Data gathered in this study indicate that physical therapists should consider the effects of age on spinal mobility when assessing spinal range of motion. A simple, objective method for measuring spinal mobility is presented. Suggestions for future research are given.

This study explored the level of antihypertensive medication adherence and examined certain demographic attributes and influential factors in relation to antihypertensive medication nonadherence among Chinese American elders using a descriptive cross-sectional survey design. Findings revealed that 52% of the elderly Chinese Americans adhered to their antihypertensive medications. Gender, education, years of residency in the United States, years of diagnosed hypertension, and perceived safety of taking antihypertensive medications did not contribute to the differences in medication adherence. Forgetfulness, medication adverse effects, language difficulties, and cultural barriers were the influential factors that hinder antihypertensive medication adherence. Developing effective and culturally appropriate strategies for Chinese American elders is recommended.

OBJECTIVE: The study was designed to assess the use of newer sidestream microstream end tidal carbon dioxide (ETCO(2) ) device in predicting blood carbon dioxide (PCO(2) ) measurements in very low birth weight (VLBW = birth weight <1,500 g) and non-VLBW NICU neonates. STUDY DESIGN: Sidestream microstream ETCO(2) detectors were allowed time to calibrate and reach steady state prior to blood gas measurements. Blood CO(2) (PCO(2) ) and simultaneous ETCO(2) were recorded. Ratio of dead space to tidal volume (VD/VT) was calculated using modified Bohr's equation. Correlation coefficient, estimates of difference, standard deviation, and 95% limits of agreement between ETCO(2) and PCO(2) concentrations were calculated. RESULTS: Two hundred eighty-six paired samples were collected from 48 ventilated NICU patients. Average PCO(2) and ETCO(2) were 58.4 and 50.6 with a correlation of 0.76. Subgroup analysis showed a correlation of 0.73 in 204 paired blood from 34 VLBW infants and 0.82 in 82 paired samples from non-VLBW infants. Estimates of difference ± standard deviation between PCO(2) and ETCO(2) concentrations in these three groups, respectively (ALL, VLBW, and non-VLBW) were 7.84 ± 9.96, 8.2 ± 10.16, and 6.95 ± 9.45. The correlation coefficient significantly improved in the VLBW group to 0.86 with dead space to tidal volume ratio (VD/VT) <30% (0.86 vs. 0.42; P < 0.001). CONCLUSION: ETCO(2) measurements using sidestream microstream technology in VLBW demonstrated that the correlation of ETCO(2) and PCO(2) was moderate, but the agreement was less than adequate (bias > 5 mmHg in all groups). The results improved with lower VD/VT, suggesting that sidestream capnography is more reliable in conditions of less severe lung disease.

BACKGROUND: There are few population-based studies of cardiovascular risk factors, knowledge, and related behaviors among Vietnamese Americans. OBJECTIVE: To describe cardiovascular risk factors, knowledge, and related behaviors among Vietnamese Americans and compare the results to non-Hispanic whites. DESIGN: Comparison of data from two population-based, cross-sectional telephone surveys. PARTICIPANTS: Vietnamese Americans in Santa Clara County, California, and non-Hispanic whites in California, aged 18 and older. MEASUREMENTS: Survey measures included sociodemographics, diagnoses, body mass index, fruit and vegetable intake, exercise, and tobacco use. Knowledge of symptoms of heart attack and stroke was collected for Vietnamese Americans. MAIN RESULTS: Compared to non-Hispanic whites (n = 19,324), Vietnamese Americans (n = 4,254) reported lower prevalences of obesity, diabetes mellitus, coronary heart disease, and hypertension, and similar prevalences of stroke and hypercholesterolemia. Fewer Vietnamese Americans consumed fruits and vegetables five or more times daily (27.8% vs 16.3%, p < 0.05), and more reported no moderate or vigorous physical activity (12.1% vs 40.1%, p < 0.05). More Vietnamese men than non-Hispanic White men were current smokers (29.8% vs 19.0%, p < 0.05). Vietnamese Americans who spoke Vietnamese were more likely than those who spoke English to eat fruits and vegetables less frequently, engage in no moderate or vigorous physical activity, and, among men, be current smokers. Only 59% of Vietnamese Americans knew that chest pain was a symptom of heart attack. CONCLUSIONS: There are significant disparities in risk factors and knowledge of symptoms of cardiovascular diseases among Vietnamese Americans. Culturally appropriate studies and interventions are needed to understand and to reduce these disparities.

Abstract Background Neonatal hypoxic-ischemic encephalopathy (HIE) affects as many as 100,000 infants each year in China. Therapeutic hypothermia reduces HIE related mortality and long-term neurodevelopmental disabilities. National guidelines for HIE management were published a decade ago. This study aimed to investigate the current status of HIE diagnosis and treatment in China. Method This prospective cross-sectional national survey used a questionnaire evaluating practices related to HIE management. Descriptive statistics and Chi-square or Fisher’s exact test were used, and a p -value of &lt; 0.05 was considered significant. Results The 273 hospitals that completed the survey were located in 31 of the 34 provincial districts in China. Eighty-eight percent of the hospitals were Level III hospitals, and 74% treated 10 or more HIE cases annually. Awareness rates of the national guidelines for HIE diagnosis, HIE treatment, and therapeutic hypothermia protocol were 85, 63, and 78%, respectively. Neurological manifestations and blood gas were used as HIE diagnostic criteria by 96% (263/273) and 68% (186/273) of the hospitals, respectively. Therapeutic hypothermia was used in 54% (147/273) of hospitals. The percentage of general hospitals that implemented therapeutic hypothermia (43%, 71/165) was significantly lower than that in maternity and infant hospitals (67%, 49/73) ( χ 2 = 11.752, p = 0.001) and children’s hospitals (77%, 27/35) ( χ 2 = 13.446, p &lt; 0.001). Reasons for not providing therapeutic hypothermia included reduction of HIE cases in recent years (39%), high cost of cooling devices and treatment (31%), lack of training (26%), and safety concerns (4%). Among the hospitals that provided therapeutic hypothermia, 27% (39/147) were in full compliance with the recommended protocol. Eighty-one percent (222/273) of the hospitals treated HIE infants with putative neuroprotective agents alone or in combination with cooling. Ninety-one percent of the hospitals had long-term neurodevelopmental follow-up programs for infants with HIE. Conclusions There is significant heterogeneity in HIE diagnosis and treatment in China. Therapeutic hypothermia has not become a standard of care for neonatal HIE nationwide. Unproven agents are widely used for HIE treatment. Nationwide standardization of HIE management and dissemination of therapeutic hypothermia represent the opportunities to reduce mortality and improve long-term neurodevelopmental outcomes of children affected by HIE.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To assess the impact of mean arterial blood pressure (MAP) during surgical intervention for spinal cord injury (SCI) on motor recovery. SETTING: Level-one Trauma Hospital and Acute Rehabilitation Hospital in San Jose, CA, USA. METHODS: Twenty-five individuals with traumatic SCI who received surgical and acute rehabilitation care at a level-one trauma center were included in this study. The Surgical Information System captured intraoperative MAPs on a minute-by-minute basis and exposure was quantified at sequential thresholds from 50 to 104 mmHg. Change in International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) motor score was calculated based on physiatry evaluations at the earliest postoperative time and at discharge from acute rehabilitation. Linear regression models were used to estimate the rate of recovery across the entire MAP range. RESULTS: = 0.181, p = 0.034). ISNCSCI motor scores increased 0.039 for each minute of exposure to the MAP range 70-94 mmHg during the operative procedure; this represents a significant correlation between intraoperative time with MAP 70-94 and subsequent motor recovery. Blood pressure exposures above or below this range did not display a positive association with motor recovery. CONCLUSIONS: Hypertension as well as hypotension during surgery may impact the trajectory of recovery in individuals with SCI, and there may be a direct relationship between intraoperative MAP and motor recovery.

Biallelic pathogenic variants in the TANGO2 (transport and Golgi organization 2 homolog) gene have been identified as causing a rare metabolic disorder characterized by susceptibility to recurrent rhabdomyolysis, lactic acidosis, encephalopathy, and life-threatening tachyarrhythmias. Recently published reports suggest variable clinical severity and phenotypes. This study details five new patients from two families with biallelic pathogenic variants in the TANGO2 gene identified by whole exome sequencing and includes the largest number of affected individuals from a single family reported to date. We document significant intrafamilial variability and highlight that milder phenotypes may be underrecognized. We present biochemical and clinical data to help highlight the features that aid in consideration of this condition in the differential with disorders of fatty acid oxidation. We also present a comprehensive literature review summarizing the molecular, clinical, and biochemical findings for 92 individuals across 13 publications. Of the 27 pathogenic variants reported to date, the recurrent exons 3-9 deletion represents the most common variant seen in 42% of individuals with TANGO2 deficiency. Common clinical features seen in >70% of all individuals include acute metabolic crisis, rhabdomyolysis, neurologic abnormalities, developmental delay, and intellectual disability. Findings such as elevated creatine kinase, hypothyroidism, ketotic hypoglycemia, QT prolongation, or abnormalities of long-chain acylcarnitines and urine dicarboxylic acids should raise clinical suspicion for this life-threatening condition.

The financial and capacity pressures facing healthcare systems call for new strategies to deliver high-quality, efficient services. 'Coproduction' is a concept gaining recognition as an approach to create patient partnerships that enable better functioning healthcare systems. Yet, this framing obscures coproduction's 'everyday and unavoidable' character, already part of healthcare service delivery. This paper aims to understand these everyday and unavoidable dimensions of coproduced healthcare services by drawing upon thematic and process analyses of a 15-month ethnography of 45 patients in three HIV clinics in New York. A 'health practices' approach guided exploring patients' activities, their effects on clinical processes, and the conditions surrounding their performances. By constructing a typology of activity types - Building, Accepting, and Objecting - and tracing patients' descriptions of activity performances, the paper shows how coproduction is forged by making and relying upon clinic-based relationships, and for patients also with a broader human community. These dynamics reveal how patients' bodily and temporal understandings are brought into and shape coproduced services. From these insights, we recommend that healthcare practitioners incorporate into their coproduction analytic methods and perspectives to engage patients as capable and aware individuals, who can support clinic efficiencies while producing new delivery possibilities.

The authors organized a lay health worker (LHW) outreach program with Vietnamese women that produced significant increases in Pap testing. The program was conducted by five partner agencies and 50 LHWs and involved 1,005 women. This article reports on the roles of the agencies and coordinators, the selection of LHWs, the processes LHWs used in identifying and recruiting participants, the ways they conducted their outreach work, and their strategies for maintaining participation. The article also reports on the LHWs' perspectives about how they benefited and what they found to be most rewarding and challenging about being a LHW. Based on the analysis of this information, the authors present a conceptual framework for understanding how different contextual factors shape the processes and capacity-building benefits of LHW outreach, describing four contextual domains that shape LHW outreach: the sociocultural domain and organizational domain, which overlap in the programmatic domain, all of which are framed by the structural domain. This analysis provides an approach for understanding how lay health work is shaped by a broader context.

Consumers have greater access to data, information, and tools to support the management of their health than ever before. While the sheer quantity of these resources has increased exponentially over the past decade, the accuracy of consumer-facing resources is variable, and the value to the individual consumer remains uncertain. In general, the quality of these resources has improved, mostly because of improvements in web and mobile technologies and efforts to restructure health care delivery to be more patient centered. We describe the major initiatives that have led to consumers' increased access to both their own health data and performance data for health care providers and hospitals. We explore how search engines and crowdsourced review websites help and hinder the dissemination of medically accurate information. We highlight emerging examples of websites and apps that enable consumers to make medical decisions more in concert with their preferences. We conclude by describing key limitations of consumer-facing resources and making recommendations for how they may best be curated and regulated.