The design of a decision aid about diabetes medications for use during the consultation with patients with type 2 diabetes

Objective

To describe the process used to develop a medication choice decision aid (DA) for patients with type 2 diabetes.

Methods

We developed the DA through active collaboration with patients, clinicians, and designers, direct observations of clinical encounters, literature review, and collaborative development of design criteria. Insights from these processes informed the iterative creation of prototypes that were reviewed and field tested in actual consultations.

Results

The goal of the DA was to facilitate a conversation between the clinician and the patient about diabetes medication options. Four iterations of the DA were developed and field-tested before arriving at issue cards that organized the data for five medications around glucose control, hypoglycemia, weight changes, daily routine, self-monitoring and side effects. These cards successfully generated conversations during consultations. An ongoing clinical trial will determine if this DA affects patient adherence and outcomes.

Conclusions

A collaboratively developed DA designed to create a conversation about diabetes medications may lead to more patient-centered treatment choices.

Practice implications

If effective, this DA could replace disease-centered treatment algorithms for patient-centered conversations that enhance the management of patients with type 2 diabetes.     

Frequent amplification of a chr19q13.41 microRNA polycistron in aggressive primitive neuroectodermal brain tumors

We discovered a high-level amplicon involving the ehrl9ql3.41 microRNA （miRNA） duster （C19MC） in 11/45 （approximately 25%） primary CNS-PNET, which results in striking overexpression of nfiR-517c and 520g. Constitutive expression of miR-517c or 520g protnotes in vitro and in vivo oncogenicity, modulates cell survival, and robustly enhances growth of untransformed human neural stem cells （hNSCs） in part by upregulating WNT pathway signaling and restricting differentiation of hNSCs.     

Dietary advanced glycation end-products,its pulmonary receptor,and high mobility group box 1 in aspiration lung injury

Background

Gastric aspiration is a significant cause of acute lung injury and acute respiratory distress syndrome. Environmental risk factors, such as a diet high in proinflammatory advanced glycation end-products (AGEs), may render some patients more susceptible to lung injury after aspiration. We hypothesized that high dietary AGEs increase its pulmonary receptor, RAGE, producing an amplified pulmonary inflammatory response in the presence of high mobility group box 1 (HMGB1), a RAGE ligand and an endogenous signal of epithelial cell injury after aspiration.

Materials and methods

CD-1 mice were fed either a low AGE or high AGE diet for 4 wk. After aspiration injury with acidified small gastric particles, bronchoalveolar lavage and whole-lung tissue samples were collected at 5 min, 1 h, 5 h, and 24 h after injury. RAGE, soluble RAGE (sRAGE), HMGB1, cytokine and chemokine concentrations, albumin levels, neutrophil influx, and lung myeloperoxidase activity were measured.

Results

We observed that high AGE-fed mice exhibited greater pulmonary RAGE levels before aspiration and increased bronchoalveolar lavage sRAGE levels after aspiration compared with low AGE-fed mice. Lavage HMGB1 levels rose immediately after aspiration, peaking at 1 h, and strongly correlated with sRAGE levels in both dietary groups. High AGE-fed mice demonstrated higher cytokine and chemokine levels with increased pulmonary myeloperoxidase activity over 24 h versus low AGE-fed mice.

Conclusions

This study indicates that high dietary AGEs can increase pulmonary RAGE, augmenting the inflammatory response to aspiration in the presence of endogenous damage signals such as HMGB1.     

Osteopontin can act as an effector for a germline mutation of BRCA1 in malignant transformation of breast cancer‐related cells

Breast cancer‐associated 1 (BRCA1) plays an important role in breast cancer initiation and progression through its functions in the cell cycle and DNA repair processes; however, its role in metastatic development in human breast cancer is still poorly understood. We have previously shown that osteopontin (OPN) expression was suppressed by wild‐type BRCA1 (Wt.BRCA1) and that a natural mutant allele of BRCA1 (Mut.BRCA1) diminished the effect of Wt.BRCA1 on OPN in vitro. In this study, we show that while Wt.BRCA1 suppresses OPN‐induced metastasis in a rat syngeneic system, Mut.BRCA1 enhances the development of metastasis through OPN, suggesting that OPN and BRCA1 work closely to regulate metastatic development in the rat. To test whether these findings are relevant to human breast cancer, we have investigated the relationship between BRCA1, OPN, and metastatic properties in human breast cancer‐related cells. Using western blot analysis, we show that Wt.BRCA1 suppresses, while Mut.BRCA1 enhances, OPN protein expression; and in parallel that Wt.BRCA1 suppresses, while Mut.BRCA1 enhances, OPN‐mediated in vitro properties associated with the metastatic state in both MCF‐7 and MDA MB435s cells. Overall, these results suggest that Mut.BRCA1 can elicit some of the changes involved in metastatic progression in human breast cancer via the overexpression of OPN. (Cancer Sci 2010)     

Upside-down orbitopathy: unilateral orbital dependent-tissue oedema causing total visual loss

The case is reported of a 24‐year‐old man who was involved in a road traffic accident and became trapped upside down with the right side of his face being the most dependent part of his body. Marked hemifacial tissue oedema was associated with right acute compressive orbitopathy and vascular compromise. Acute dysfunction of all orbital nerves was found on examination. Such neuropathy is usually related to the consequences of direct trauma, fractures or haemorrhage; however, computed tomography scanning demonstrated no evidence of orbital fracture or haemorrhage. Immediate anterior surgical orbital decompression was performed in the emergency room in addition to high dose intravenous steroids. Dependent orbital tissue oedema is proposed as a mechanism of compressive orbitopathy with consequent ischaemic damage to all orbital nerves, total visual loss and complete ophthalmoparesis. Good recovery of other orbital nerves has occurred and the globe has reperfused. Despite intervention, no visual function has returned.     

Assessment challenges in competency-based education: A case study in health professions education

There is a growing demand for health sciences faculty with formal training in education. Addressing this need, the University of Michigan Medical School created a Master in Health Professions Education (UM-MHPE). The UM-MHPE is a competency-based education (CBE) program targeting professionals. The program is individualized and adaptive to the learner’s situation using personal mentoring. Critical to CBE is an assessment process that accurately and reliably determines a learner’s competence in educational domains. The program’s assessment method has two principal components: an independent assessment committee and a learner repository. Learners submit evidence of competence that is evaluated by three independent assessors. The assessments are presented to an Assessment Committee who determines whether the submission provides evidence of competence. The learner receives feedback on the submission and, if needed, the actions needed to reach competency. During the program’s first year, six learners presented 10 submissions for review. Assessing learners in a competency-based program has created challenges; setting standards that are not readily quantifiable is difficult. However, we argue it is a more genuine form of assessment and that this process could be adapted for use within most competency-based formats. While our approach is demanding, we document practical learning outcomes that assess competence.     

Sensitivity and Utility of Parathyroid Scintigraphy in Patients with Primary Versus Secondary and Tertiary Hyperparathyroidism

Introduction Parathyroid scintigraphy (PS) may be used to localize hyperactive parathyroid glands preoperatively. Performance of PS in the setting of secondary and tertiary hyperparathyroidism (HPT) is not well quantified. The performance of PS in secondary/tertiary HPT versus primary HPT may reflect physiologic as well as radiopharmaceutical kinetic differences between multigland hyperplasia versus adenoma. The aim of this study was to review the performance of PS in secondary/tertiary HPT with a comparison to that for primary HPT. Moreover, we evaluated (1) the sensitivity of PS in detecting enlarged glands, and (2) PS detectability as a function of gland weight. Methods We performed a retrospective review of the Mayo Clinic database from 2000 to 2004. We identified 40 patients with secondary or tertiary HPT as well as a matched control group of 40 patients with primary HPT who had had preoperative PS and underwent parathyroid surgery. Results Parathyroid scintigraphy correctly localized all enlarged glands in 88% of patients in the primary HPT group. PS correctly identified both the number and locations of all hyperplastic glands in only 28% of the secondary/tertiary HPT patients. PS failed to identify one enlarged gland in 23% of the patients and two or more enlarged glands in 40% of the patients. PS correctly detects the largest gland in 88% of the patients with secondary and tertiary HPT. The mean gland weight detectable by PS was 612 ± 120 mg for primary HPT. In secondary/tertiary HPT, glands detected by PS had a mean weight of 950 ± 109 mg, whereas the mean weight was 276 ± 34 mg for undetected glands (P < 0.002). Conclusions Parathyroid scintigraphy is a sensitive study for localizing parathyroid glands preoperatively in primary HPT patients. Its sensitivity is low in secondary and tertiary HPT patients. Thus PS has limited value as a preoperative localization study in secondary/tertiary HPT patients.     

The Prognostic Value of 2-Deoxy-2-[18F]Fluoro-<Emphasis Type="SmallCaps">d</Emphasis>-Glucose Positron Emission Tomography in Patients With Suspected Residual or Recurrent Medullary Thyroid Carcinoma

Purpose  

To explore the prognostic value of 2-deoxy-2-[18F]fluoro-d-glucose (FDG) positron emission tomography (PET) in patients with suspected residual or recurrent medullary thyroid carcinoma (MTC).     

An overview of the ACE project—Advocating for Clinical Excellence: Transdisciplinary palliative care education

Background. Excellence in palliative care demands attention to the multidimensional aspects of patient and family suffering, yet too few psycho-oncology professionals report adequate preparation in this vital area. Methods. A total of 148 competitively selected psychologists, social workers, and spiritual care professionals participated in intensive educational courses to enhance their palliative care delivery, leadership, and advocacy skills. Extensive process and outcome evaluations measured the effectiveness of this educational program. Results. To date, 2 national courses have been completed. The courses received strong overall evaluations, with participants rating increased confidence in defined palliative care skills. Conclusions. The initial results of this innovative National Cancer Institute-funded transdisciplinary training for psycho-oncology professionals affirm the need and feasibility of the program. See the Advocating for Clinical Excellence Project Web site (www.cityofhope.org/ACEproject) for additional course information.