Communicating to promote informed decisions in the context of early pregnancy loss

ObjectiveTo evaluate residents’ ability to engage standardized patients in informed decision making during a pregnancy loss scenario.MethodsForty patient encounters between interns and standardized patients were coded to assess informed decision-making practices, exploration of unexpressed concerns, and support provision.ResultsInterns engaged in minimum informed decision making but did not address all of the communicative elements necessary for informed decisions, and most elements were only partially addressed. Patients in this study did not receive information about all management options, their concerns were not addressed, and there was limited support communicated for their decision.ConclusionThis study offers an initial assessment of a communicative approach to evaluate and improve decision making during early pregnancy loss. A comprehensive approach to making informed decisions must include discussion of all management options, exploration of patient preferences and concerns, and support for the patient’s decision.Practice implicationsPhysicians could benefit from communication skills training to communicate more effectively with patients to help them make more informed decisions.     

A Higher Dose of Dasatinib May Increase the Possibility of Crossing the Blood–brain Barrier in the Treatment of Patients With Philadelphia Chromosome–positive Acute Lymphoblastic Leukemia

PurposeDasatinib is a second-generation tyrosine kinase inhibitor with higher central nervous system (CNS) penetration compared with imatinib and nilotinib in in vitro studies. However, limited clinical data are available regarding the dosage and CNS penetration of dasatinib. The purpose of this study was to investigate the actual ability of dasatinib to cross the blood–brain barrier in patients with Philadelphia chromosome–positive acute lymphoblastic leukemia (Ph⁺ ALL).MethodsPlasma and cerebrospinal fluid (CSF) samples collected from Ph⁺ ALL patients treated with dasatinib were analyzed by using an LC-MS/MS assay.FindingsOrally administered dasatinib 100 mg once daily was well absorbed by the patient but penetrated poorly into the CSF. The use of a higher drug dosage (140 mg/d) may increase systemic drug exposure and enhance the penetration of dasatinib into the CSF.ImplicationsBased on this study, the use of a higher dosage of dasatinib (140 mg/d) is recommended in patients at high risk of CNS relapse or patients who need treatment for CNS leukemia. ClinicalTrials.gov identifier: NCT02523976.     

Validation of the Knowledge of Genome Sequencing (KOGS) scale in cancer patients

IntroductionThe Knowledge of Genome Sequencing (KOGS) questionnaire was recently developed to measure knowledge of genomic sequencing (GS), with preliminary psychometric data supporting its reliability and validity. The aim of this study was to test the reliability and validity of the KOGS in a larger sample, and to confirm its utility in a cancer setting.MethodsThe Genetic Cancer Risk in the Young (RisC) study recruits participants with a personal history of cancer, to investigate heritable cancer causes and future cancer risk using germline GS. Participants (n = 261) in a psychosocial substudy of RisC completed a questionnaire after consent to RisC but before GS, including the KOGS, the Intolerance of Uncertainty Scale, the Chew health literacy scale and items assessing demographic and disease variables. Confirmatory factor analysis (CFA), Cronbach alpha and correlational analyses were undertaken.ResultsThe CFA testing a single-factor model yielded a good model fit, χ2/df = 2.43, comparative fit index (CFI) = 0.97, root mean square error of approximation (RMSEA) = 0.07 and weighted mean root square (WRMR) = 1.03. Factor loadings of all items were above 0.60 and ranged between.66 and.93. The single factor score demonstrated excellent internal consistency (α = 0.82). KOGS scores were significantly associated with health literacy (r = 0.23, p < .001), having a university education [t(258) = ?4.53, p < .001] and having a medical or science background [t(259) = ?3.52, p < .001] but not with speaking a language other than English at home, time since diagnosis, previous genetic counselling/testing or intolerance of uncertainty.DiscussionThis study confirmed a single-factor structure for the KOGS, and its reliability and validity in a cancer population. Associations with measures of health literacy and education were significant and positive as expected, supporting the KOG’s construct validity. Previous genetic counselling may not be sufficient to provide specific knowledge of GS.     

Clinicians’ accounts of communication with patients in end-of-life care contexts: A systematic review

ObjectiveCommunication between patients and end-of-life care providers requires sensitivity given the context and complexity involved. This systematic review uses a narrative approach to synthesise clinicians’ understandings of communication in end-of-life care.MethodsA systematic, narrative synthesis approach was adopted given the heterogeneity across the 83 included studies. The review was registered prospectively on PROSPERO (ID: CRD42019125155). Medline was searched for all articles catalogued with the MeSH terms “palliative care,” “terminal care” or “end-of-life care,” and “communication”. Articles were assessed for quality using a modified JQI-QARI tool.ResultsThe findings highlight the centrality and complexity of communication in end-of-life care. The challenges identified by clinicians in relation to such communication include the development of skills necessary, complexity of interpersonal interactions, and ways in which organisational factors impact upon communication. Clinicians are also aware of the need to develop strategies for interdisciplinary teams to improve communication.ConclusionTraining needs for effective communication in end-of-life contexts are not currently being met.Practice ImplicationsClinicians need more training to address the lack of skills to overcome interactional difficulties. Attention is also needed to address issues in the organisational contexts in which such communication occurs.     

The role of sodium intake in nephrolithiasis: epidemiology,pathogenesis, and future directions

The prevalence of nephrolithiasis has doubled over the last decade and the incidence in females now approaches that of males. Since dietary salt is lithogenic, a purported mechanism common to both genders is excess dietary sodium intake vis-a-vis processed and fast foods. Nephrolithiasis has far-reaching societal implications such as impact on gross domestic product due to days lost from work (stone disease commonly affects working adults), population-wide carcinogenic diagnostic and interventional radiation exposure (kidney stone disease is typically imaged with computed tomographic imaging and treated under imaging guidance and follow-up), and rising healthcare costs (surgical treatment will be indicated for a number of these patients). Therefore, primary prevention of kidney stone disease via dietary intervention is a low-cost public health initiative with massive societal implications. This primer aims to establish baseline epidemiologic and pathophysiologic principles to guide clinicians in sodium-directed primary prevention of kidney stone disease.