Doctor, what's wrong with me? Factors that delay the diagnosis of colorectal cancer

Objective

To examine the influence of patient and physician communication factors on diagnostic delay (DD).

Methods

242 patients diagnosed with colorectal cancer (CRC) in the past 6 months who experienced symptoms prior to diagnosis were administered a 2-h semi-structured qualitative interview to assess communication with health care provider and ease of access to care, among other factors. Patient-provided information was verified via review of medical records.

Results

The factors associated with DD > 2 months included lower income (OR = 0.56, p = 0.03), having regular physician prior to receiving a cancer diagnosis (OR = 2.52, p = 0.03), having a physician who used temporizing communication strategies during the consultation (OR = 2.41, p = 0.02), receiving an initial alternate diagnosis (OR = 3.36, p = 0.02), experiencing referral delay (OR = 3.61, p = < 0.001), and experiencing follow-up delay of any kind (OR = 3.32, p = 0.01).

Conclusion

Excellent communication skills that appropriately probe for relevant social and economic patient information, assist patients in distinguishing and elaborating on symptoms, and provide clear rationale and instructions for future steps, will speed along the diagnosis process and could be the difference between early and late stage CRC.

Practice implications

Increased understanding of physician communication and practice styles that contribute to DD could have a positive impact on decreasing the morbidity and mortality from this disease.     

Relationship between improvements in heart failure patient disease specific knowledge and clinical events as part of a randomized controlled trial

Objective

To examine the changes in performance on heart failure knowledge assessments administered before and after discharge education.

Methods

We conducted a randomized controlled trial comparing the effects of a 1-h, one-on-one teaching session with a nurse educator to the standard discharge process in patients with systolic heart failure. Patients completed a 30 point heart failure knowledge questionnaire (HFKQ) prior to and 3 months after the education intervention.

Results

Patients randomized to the nurse education intervention (n = 113) demonstrated significantly higher total HFKQ score increases compared to patients receiving the standard discharge process (n = 114) (median, IQR 1, 0 to 4 vs 0, −2 to 2, p = 0.007). Patients experiencing death or rehospitalization in the subsequent 6 months were found to have significantly lower HFKQ scores (10, 7 to 12 vs 11, 8 to 13, p = 0.002) compared to patients without a clinical event.

Conclusion

Heart failure nurse education at the time of hospital discharge results in improved patient knowledge and reduced risk of readmission.

Practice implications

Health care personnel should encourage education sessions for heart failure patients. Resources possibly need to be allocated for nurse led education sessions in heart failure patients as it improves outcomes and knowledge.     

Patient-physician social concordance, medical visit communication and patients' perceptions of health care quality

Social characteristics (e.g. race, gender, age, education) are associated with health care disparities. We introduce social concordance, a composite measure of shared social characteristics between patients and physicians.

Objective

To determine whether social concordance predicts differences in medical visit communication and patients’ perceptions of care.

Methods

Regression analyses were used to determine the association of patient-provider social concordance with medical visit communication and patients’ perceptions of care using data from two observational studies involving 64 primary care physicians and 489 of their patients from the Baltimore, MD/Washington, DC/Northern Virginia area.

Results

Lower patient-physician social concordance was associated with less positive patient perceptions of care and lower positive patient affect. Patient-physician dyads with low vs. high social concordance reported lower ratings of global satisfaction with office visits (OR = 0.64 vs. OR = 1.37, p = 0.036) and were less likely to recommend their physician to a friend (OR = 0.61 vs. OR = 1.37, p = 0.035). A graded-response was observed for social concordance with patient positive affect and patient perceptions of care.

Conclusion

Patient-physician concordance across multiple social characteristics may have cumulative effects on patient-physician communication and perceptions of care.

Practice implications

Research should move beyond one-dimensional measures of patient-physician concordance to understand how multiple social characteristics influence health care quality.     

Physician practice patterns of obesity diagnosis and weight-related counseling

Methods

We analyzed cross-sectional clinical encounter data. Obese adults were obtained from the 2005 National Ambulatory Medical Care Survey (N = 2458).

Results

A third of obese adults received an obesity diagnosis (28.9%) and approximately a fifth received counseling for weight reduction (17.6%), diet (25.2%), or exercise (20.5%). Women (OR = 1.54; 95% CI: 1.14, 2.09), young adults ages 18-29 (OR = 2.61; 95% CI: 1.37, 4.97), and severely/morbidly obese individuals (class II: OR 2.08; 95% CI: 1.53, 2.83; class III: OR 4.36; 95% CI: 3.09, 6.16) were significantly more likely to receive an obesity diagnosis. One of the biggest predictors of weight-related counseling was an obesity diagnosis (weight reduction: OR = 5.72; 95% CI: 4.01, 8.17; diet: OR = 2.89; 95% CI: 2.05, 4.06; exercise: OR = 2.54; 95% CI: 1.67, 3.85). Other predictors of weight-related counseling included seeing a cardiologist/other internal medicine specialist, a preventive visit, or spending more time with the doctor (p < 0.05).

Conclusions

Most obese patients do not receive an obesity diagnosis or weight-related counseling.

Practice implications

Preventive visits may provide a key opportunity for obese patients to receive weight-related counseling from their physician.     

Hepatitis C virus viral kinetics during α-2a or α-2b pegylated interferon plus ribavirin therapy in liver transplant recipients with different immunosuppression regimes

Background

Predictors of sustained virological response (SVR) to antiviral therapy post-liver transplantation (LT) for chronic hepatitis C are needed. In non-transplanted patients, viral kinetics can predict SVR.

Objectives

To determine the early viral kinetics in LT recipients with different immunosuppression (tacrolimus - Tac- vs. cyclosporine - CsA-) during treatment with peg-IFN + RBV.

Study design

Prospective pilot study in HCV-1b infected patients: (LT CsA n = 8; Tac n = 8; non-LT n = 4), treated with IFN α-2a vs. α-2b (180 μg or 1.5 μg/kg, respectively) once weekly plus weight-based RBV. Median CsA or Tac baseline trough levels were 141 and 7.70 ng/mL, respectively. HCV-RNA was quantified before treatment and after 3, 6, 12 h; days 1-6; and weeks 4, 12, 24, 48 and 78 (follow-up).

Results

Different kinetics were observed: early viral load declines with shoulder phase (n = 12), delayed monophasic without first phase (n = 5, all CsA), and biphasic (n = 1) or flat (n = 1), without influence of IL28B rs12979860 donor/recipient alleles. In LT, median declines (log₁₀ UI/mL) at week 4 were −3.62 and −1.49 for Tac vs. CsA; and −2.10 vs.−1.50 for IFN α-2a vs. α-2b (NS), with a trend for faster declines in Tac patients. Generalized additive models suggested a cut-off for predicting response in LT patients of 30 days for Tac, but beyond day 40 for CsA.

Conclusion

In LT, the viral kinetics during peg-IFN + RBV treatment is delayed. HCV-RNA at 48 h. may not be predictive of response, and CsA-immunosupressed patients with delayed monophasic declines may potentially achieve ETVR and SVR despite unfavourable or absent early viral load declines.     

Exercise and severe depression: preliminary results of an add-on study

Background

Physical exercise has been extensively researched as a therapeutic option for treatment of major depression.

Methods

In a randomized controlled trial, we analyze the effects of aerobic physical exercise as an add-on strategy for treatment of severe depressed inpatients. The exercise has a “Dose” of 16.5 kcal/kg/week, three times a week during all the hospitalization.

Results

Our preliminary results show that there is no significant difference in scores of Hamilton in the second week between groups (Mean[SD] = 8.2[5.96] × 11.18[5.03], p = 0.192). However, there is a significant reduction in Hamilton scores of patients in exercise group at discharge (Mean[SD] = 5.93[4.46] × 9.45[3.56], p = 0.041). Regarding Quality of Life (QoL), no significant difference were found between groups in the second week in physical domain (Mean[SD] = 56.98[8.96] × 54.54[9.18], p = 0.511) and psychological domain (Mean[SD] = 50.88[13.88] × 42.04[12.42], p = 0.106). However, there is a significant difference in psychological domain (Mean[SD] = 55.88[9.92] v 41.66[13.04], p = 0.004) and a trend but no statistical significance in the physical (Mean[SD] = 58.80[9.14] × 52.12[8.70], p = 0.07) at discharge.

Limitations

Many patients receive different treatment strategies, like ECT (1 patient at exercise group × 3 at control group). Other limitation is the small number of participants included until this moment.

Conclusion

Our preliminary results suggest that physical exercise could be a feasible and effective add-on strategy for treatment of severe depressed inpatients, improving their depressive symptoms and QoL.     

Provider factors and patient-reported healthcare discrimination in the Diabetes Study of California (DISTANCE)

Objective

We examined provider-level factors and reported discrimination in the healthcare setting.

Methods

With data from the Diabetes Study of Northern California (DISTANCE) - a race-stratified survey of diabetes patients in Kaiser Permanente Northern California - we analyzed patient-reported racial/ethnic discrimination from providers. Primary exposures were characteristics of the primary care provider (PCP, who coordinates care in this system), including specialty/type, and patient-provider relationship variables, including racial concordance.

Results

Subjects (n = 12,151) included 20% black, 20% Latino, 23% Asian, 30% white, and 6% other patients, with 2-8% reporting discrimination by racial/ethnic group. Patients seeing nurse practitioners as their PCP (OR = 0.09; 95% CI: 0.01-0.67) and those rating their provider higher on communication (OR = 0.70; 95% CI: 0.66-0.74) were less likely to report discrimination, while those with more visits (OR = 1.10; 95% CI: 1.03-1.18) were more likely to report discrimination. Racial concordance was not significant once adjusting for patient race/ethnicity.

Conclusions

Among diverse diabetes patients in managed care, provider type and communication were significantly related to patient-reported discrimination.

Practice implications

Given potential negative impacts on patient satisfaction and treatment decisions, future studies should investigate which interpersonal aspects of the provider-patient relationship reduce patient perceptions of unfair treatment.     

Kaposi's Sarcoma and Human Herpesvirus 8 in Cuba: Evidence of subtype B expansion

Objective

To evaluate the temporal distribution (1991-2009) and associated variation of KSHV subtypes in Cuba.

Method

Phylogenetic characterization based on the KSHV K1 gene was performed using 90 KSHV positive samples.

Results

Molecular characterization confirmed the prevalence of a wide range of KSHV subtypes (A: n=48 [A5=12]; C: n=15; B: n=22; and E: n=5). In the current study, we observed a significant increase in HHV-8 subtype B after 2004 (p=0.0063). This Subtype B in Cuba was associated with: heterosexual behaviour (OR: 3.63, CI: 1,2-10,98; p=0.03), with the antecedent of acquiring HIV/KSHV in Africa (p=0.0003), with nodular stage of KS lesions (OR 4.2, CI: 1.1 to 15.7; p=0.04).

Conclusion

Our study is the first to report KSHV Subtype B expansion in Cuba, that might be reflective of a change in human behavioural pattern.     

Association of age, health literacy, and medication management strategies with cardiovascular medication adherence

Objective

To examine patients’ use of medication management strategies (e.g., reminders, pill boxes), and to determine how their use influences the relationship between patient characteristics and medication adherence.

Methods

Retrospective and cross-sectional study of 434 patients with coronary heart disease, examining both refill adherence and self-reported adherence.

Results

The most common strategy for managing refills was seeing a near empty pill bottle (89.9%), and for managing daily medications, it was associating medications with daily events (80.4%). Age < 65 (OR = 1.7), as well as marginal (OR = 2.0) or inadequate health literacy (OR = 1.9), was independently associated with low refill adherence. Patients <65 also had lower self-reported adherence (OR = 1.8). Adjustment for use of medication management strategies did not substantially change these relationships. Reliance on reminders from friends or family to take medications, or waiting to refill a medicine only when the bottle was near empty, each were associated with 3-fold greater odds of non-adherence.

Conclusion

Age <65 and marginal or inadequate health literacy were independently associated with medication non-adherence. Use of medication management strategies did not explain these relationships.

Practice implications

The strategies which patients report using to assist with managing medication refills and daily medication use may be ineffective.     

Tyrosine kinase B protein expression is reduced in the cerebellum of patients with bipolar disorder

Background

The role of the cerebellum in coordinating mental activity is supported by its connections with cerebral regions involved in cognitive/affective functioning, with decreased activities on functional neuroimaging observed in the cerebellum of schizophrenia patients performing mental tasks. Brain-derived neurotrophic factor (BDNF)-induced activation of tyrosine kinase B (TrkB) is essential to synaptic plasticity. We hypothesized that alterations in BDNF and TrkB expression in the cerebellum were associated with schizophrenia and affective disorders.

Methods

We employed immunohistochemistry and immunoblotting to quantify protein expression of BDNF and TrkB in the cerebellum of patients with schizophrenia, bipolar disorder, and major depression compared to controls (n = 15 each).

Results

While TrkB immunoreactivity in each of the molecular and granule-cell layers was reduced in all 3 disease groups (12-34%) compared to the control (P = 0.018 and 0.038, respectively, ANOVA), only the reduction in bipolar disorder remained statistically significant upon Tukey-Kramer post hoc analyses (P = 0.019 and 0.021, respectively). Apparent decreases in BDNF immunoreactivity in all 3 disease groups (12-30%) compared to the control were not statistically significant. TrkB immunoreactivity was not significantly associated with any of the demographic, clinical, and postmortem variables. Immunoblotting displayed an 85-kDa TrkB-immunoreactive band, consistent with a truncated isoform, in all 60 cases.

Limitations

On immunoblotting, apparent decreases in 85-kDa-TrkB levels in all 3 disease groups compared to the control were not statistically significant.

Conclusions

Our finding of reduced TrkB expression in bipolar disorder suggests that dysregulation of TrkB-mediated neurotrophin signaling in the cerebellum may play a role in the pathophysiology of this disease.     

Genome-wide association analysis of gender differences in major depressive disorder in the Netherlands NESDA and NTR population-based samples

Background

Major depressive disorder (MDD) is a universally prevalent, genetic, and environment dependent mental condition that disables people of every culture, race, gender, and age. While the gender differences for MDD have been widely reported in literature, few genome-wide analyses of gender differences have been reported to date.

Methods

We conducted a genome-wide association analysis of gender differences for MDD using the Netherlands NESDA and NTR population-based samples (1726 cases and 1630 controls). PLINK software was used to analyze the genome-wide association data of Perlegen 600 K SNP Chips.

Results

We identified 40 male-specific and 56 female-specific MDD associated SNPs with P-values less than 10^− 4. The best male-specific SNP was rs9352774 (P = 2.26 × 10^− 6) within LGSN gene while the best female-specific SNP was rs2715148 (P = 5.64 × 10^− 7) within PCLO gene. We also found 38 SNPs showing gene × gender interactions in influencing MDD (P < 10^− 4). The best SNP was rs12692709 (P = 5.75 × 10^− 6) near FIGN gene at 2q24.3 while the next best SNP was rs11039588 (P = 1.16 × 10^− 5) within OR4B1 gene.

Limitations

The findings from this study need be replicated in other populations.

Conclusions

These results provide genetic basis for gender differences in MDD and will serve as a resource for replication in other populations to elucidate the potential role of these genetic variants in MDD.     

Predictors of weight loss communication in primary care encounters

Objective

Evidence suggests that physicians’ use of motivational interviewing (MI) techniques helps patients lose weight. We assessed patient, physician, relationship, and systems predictors of length of weight-loss discussions and whether physicians’ used MI techniques.

Methods

Forty primary care physicians and 461 of their overweight or obese patients were audio recorded and surveyed.

Results

Weight-related topics were commonly discussed (nutrition 78%, physical activity 82%, and BMI/weight 72%). Use of MI techniques was low. A multivariable linear mixed model was fit to time spent discussing weight, adjusting for patient clustering within physician. More time was spent with obese patients (p = .0002), by African American physicians (p = .03), family physicians (p = .02), and physicians who believed patients were embarrassed to discuss weight (p = .05). Female physicians were more likely to use MI techniques (p = .02); African American physicians were more likely to use MI-inconsistent techniques (p < .001).

Conclusion

Primary care physicians routinely counsel about weight and are likely to spend more time with obese than with overweight patients. Internists spend less time on weight. Patient and systems factors do not seem to influence physicians’ use MI techniques.

Practice implications

All physicians, particularly, male and African American physicians, could increase their use of MI techniques to promote more weight loss among patients.     

Knowing the ABCs: a comparative effectiveness study of two methods of diabetes education

Objective

To test an active-learning, empowerment approach to teaching patients about the “diabetes ABCs” (hemoglobin A₁C, systolic blood pressure, and low density lipoprotein cholesterol).

Methods

84 (97%) diabetic patients who participated in a randomized effectiveness trial of two clinic-based group educational methods and completed a post-intervention assessment. The empowerment arm participated in a group session that incorporated two educational innovations (a conceptual metaphor to foster understanding, and team-based learning methods to foster active learning). The traditional diabetes education arm received a didactic group session focused on self-management and educational materials about the diabetes ABCs. Participants in both arms received individual review of their current ABC values.

Results

A questionnaire evaluated knowledge, understanding, and recall of the diabetes ABCs was administered three months after enrollment in the study. At three months, participants in the empowerment group demonstrated greater understanding of the diabetes ABCs (P < 0.0001), greater knowledge of their own values (P < 0.0001), and greater knowledge of guideline-derived target goals for the ABCs compared with participants in the traditional arm (P < 0.0001).

Conclusion

An active-learning, empowerment-based approach applied to diabetes education can lead to greater understanding and knowledge retention.

Practice implications

An empowerment approach to education can facilitate informed, activated patients and increase performance of self-management behaviors.     

The effect of spousal communication on contraceptive use in Central Terai, Nepal

Objective

Family planning has several social and health benefits; it can reduce maternal mortality and the number of unplanned pregnancies, as well as increase educational and economic opportunities [1] and [2]. Utilizing quantitative data from an endline household survey (July 2009) and data from focus group discussions, the Centre for Development and Population Activities (CEDPA) seeks to determine whether spousal communication increases contraceptive use among married women of child-bearing age in Nepal's Central Terai region.

Methods

Quantitative household survey and qualitative focus group discussions.

Results

Women who discuss family planning with their husbands (OR = 7.254), perceive husband approval on family planning (OR = 5.558) and have born a son (OR = 2.239) are more likely to use a modern contraceptive method. Qualitative data show that several other considerations can be motivating factors for contraceptive uptake.

Conclusion

While results do not explain the direction of causality, it is clear that spousal discussion and partner approval are significant in a woman's decision to use modern contraceptives in the Central Terai region of Nepal.

Practice implications

More research needs to be conducted on the effect of spousal communication and contraceptive use, in particular, the role of frequency, quality, and content of spousal communication, as well as individual motivations.     

Evaluation of auditory, visual and olfactory event-related potentials for comparing interspersed- and single-stimulus paradigms

Background

An interspersed-stimulus paradigm (ISP) for event-related potential (ERP) recordings in which different sensory modality stimuli are presented within the same test session was developed to minimize recording time and facilitate modality comparison. The present study compared the ISP with a single-stimulus paradigm (SSP), using auditory, visual, and olfactory stimuli.

Method

Normal participants (n = 16) were assessed on two independent test occasions to obtain data on inter-paradigm and test-retest reliability. Peak amplitude/latency and area measures were obtained for the N1, P2 and P3 peaks for each paradigm.

Results

Except for larger auditory and visual P3 peaks and smaller visual P2 peaks in the ISP, no significant differences in amplitudes or latencies were found between the two paradigms. Correlation coefficients between paradigms were generally fairly high (amplitude mean r = 0.76; latency r = 0.42). Test-retest reliability within paradigms for amplitudes (ISP r = 0.70; SSP r = 0.68) and latencies (ISP r = 0.44; SSP r = 0.42) was similar across paradigms.

Conclusion

The findings suggest that the ISP, compared to the SSP, produces, in general, highly comparable auditory, visual, and olfactory peak amplitudes and latencies, and comparable reliability estimates, even though the ISP takes much less time to record (25 vs. 50 min). The larger auditory and visual P3 peaks and smaller visual P2 peaks in the ISP may be attributable to a less predictable stimulus environment. Thus, this method enables systematic comparisons of ERP peaks across sensory modalities while reducing testing time. Practical implications are discussed.     

Validity of a low literacy version of the Decisional Conflict Scale

Objective

To evaluate the psychometric properties of the 4-factor low literacy Decisional Conflict Scale (DCS-LL) with men eligible for prostate cancer screening (PCS).

Methods

We used baseline (T0; n = 149) and post-intervention (T2; n = 89) data from a randomized, controlled trial of a PCS decision aid to assess internal consistency reliability and construct, discriminant, and factor validity.

Results

There was evidence of excellent internal consistency reliability (α’s ≥ .80) and fair construct validity (most r's ≥ .40) for the DCS-LL except for the Supported subscale. The DCS-LL was able to discriminate between men who had decided and those who had not. There was evidence for the original 4-factor model at T0 but exploratory analysis suggested a 3-factor solution at T0 and T2 with Informed and Value Clarity as one factor.

Conclusion

For men eligible for PCS, feeling informed and feeling clear about values may not reflect distinct cognitive processes. Feeling supported may not be a factor contributing to uncertainty.

Practice Implications

Research should address whether current DCS subscales best represent the factors that contribute to uncertainty for PCS and for other screening decisions. Research should also explore the influence of health literacy on the factor structure of the DCS-LL.     

Evaluating an intervention to increase cancer knowledge in racially diverse communities in South Carolina

Objective

To conduct a cancer education intervention with racially diverse communities in South Carolina.

Methods

The study was conducted at eight different sites in six counties in SC. The intervention included a 3-h general cancer knowledge and 30-min prostate cancer knowledge component. Pre- and post-intervention surveys were administered. Maximum scores were 31, 10 and 5 for the general cancer knowledge, prostate cancer knowledge and perceived self-efficacy in patient-physician interaction instruments, respectively. Analyses were completed using SPSS 16.0, SAS 9.1.3, and R v2.6.1.

Results

The study sample consisted of 164 predominantly African American participants. Most of the participants who reported age were 50+ years (62.5%). Among those who reported income, 46.1% had an annual household income <$40,000. The mean general cancer knowledge pre-test score was 26.2 (standard deviation (SD) 3.7) with a mean post-intervention increase of 2.15 points (p < 0.01). The mean pre-test prostate cancer knowledge score was 7.3 (SD 2.0) with a post-intervention increase of 0.48 points (p < 0.01). Perceived self-efficacy in patient-physician interaction scores had a ceiling effect.

Conclusion

General cancer knowledge and prostate cancer knowledge scores increased following the intervention.

Practice Implications

The intervention was successful in the short-term. It could be continued by community members.