An infant with cystic fibrosis and a mother with an eating disorder: A difficult combination

The feeding of an infant with cystic fibrosis and associated malabsorption was made difficult by the mother's attitudes to body shape and food. She had a history of anorexia nervosa. Such parents may require special advice and support. © 1994 by John Wiley & Sons, Inc.     

Cerebral and tumoral blood flow in adult gliomas: a systematic review of results from magnetic resonance imaging

Objective:Blood flow is the rate of blood movement and relevant to numerous processes, though understudied in gliomas. The aim of this review was to pool blood flow metrics obtained from MRI modalities in adult supratentorial gliomas.Methods:MEDLINE, EMBASE and the Cochrane database were queried 01/01/2000–31/12/2019. Studies measuring blood flow in adult Grade II–IV supratentorial gliomas using dynamic susceptibility contrast (DSC) MRI, dynamic contrast enhanced MRI (DCE-MRI) or arterial spin labelling (ASL) were included. Absolute and relative cerebral blood flow (CBF), peritumoral blood flow and tumoral blood flow (TBF) were reported.Results:34 studies were included with 1415 patients and 1460 scans. The mean age was 52.4 ± 7.3 years. Most patients had glioblastoma (n = 880, 64.6%). The most common imaging modality was ASL (n = 765, 52.4%) followed by DSC (n = 538, 36.8%). Most studies were performed pre-operatively (n = 1268, 86.8%). With increasing glioma grade (II vs IV), TBF increased (70.8 vs 145.5 ml/100 g/min, p < 0.001) and CBF decreased (85.3 vs 49.6 ml/100 g/min, p < 0.001). In Grade IV gliomas, following treatment, CBF increased in ipsilateral (24.9 ± 1.2 vs 26.1 ± 0.0 ml/100 g/min, p < 0.001) and contralateral white matter (25.6 ± 0.2 vs 26.0± 0.0 ml/100 g/min, p < 0.001).Conclusion:Our findings demonstrate that increased mass effect from high-grade gliomas impairs blood flow within the surrounding brain that can improve with surgery.Advances in knowledge:This systematic review demonstrates how mass effect from brain tumours impairs blood flow in the surrounding brain parenchyma that can improve with treatment.     

Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration

BackgroundPhysician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes.ObjectiveTo examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment.DesignPatient self-report surveys at treatment initiation linked to medical records.SettingVeterans Health Administration (VA) clinics nationally, 2018–2020.ParticipantsA total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White)Main MeasuresPatient self-reported preferences for medication and psychotherapy on 0–10 self-anchoring visual analog scales (0=“completely unwilling”; 10=“completely willing”). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables.Key ResultsMore patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ²₁=175.3, p<0.001). A total of 32.1% of patients who preferred (7–10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5–24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0–3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4–7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence.ConclusionsMismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07136-2.KEY WORDS: major depression, treatment preferences, treatment adherence, Veterans     

Comparison of Traumatic Intracranial Hemorrhage Expansion and Outcomes Among Patients on Direct Oral Anticoagulants Versus Vitamin k Antagonists

Neurocritical Care - With increasing use of direct oral anticoagulants (DOACs) and availability of new reversal agents, the risk of traumatic intracranial hemorrhage (tICH) requires better...     

Earning Patient Trust: More Than a Question of Signaling

Laura Specker Sullivan's article “Trust, Risk, and Race in American Medicine” is a philosophically grounded and highly practical call for medical professionals to take on the task of comprehending the sources of patients’ mistrust. This is not only a clinical competence but also a moral obligation, in particular, when mistrust is warranted—as with African American patients who rely on medical institutions that have breached and continue to breach the trust of their communities. While Specker Sullivan focuses on how clinicians can signal comprehension once it has already been attained, I wish to step back and examine the nature of the efforts to gain knowledge. The effort to comprehend requires, at a minimum, the following actions: educating oneself about medical racism, examining one's implicit biases, and engaging, with empathic curiosity, with the patient or family members in the clinical encounter at hand.     

Biologic therapies versus surgical management for aspirin-exacerbated respiratory disease: A review of preliminary data,efficacy, and cost

Aspirin-exacerbated respiratory disease (AERD) patients with CRSwNP suffer from reduced quality of life, reduced economic productivity, and higher risk of depression and sleep dysfunction. These patients often require frequent medical and surgical therapy, including functional endoscopic sinus surgery for recalcitrant disease. Given this severity, anti-type 2 biologic treatments are being investigated for use in this subgroup of patients with CRSwNP, including Omalizumab and Dupilumab. Preliminary data suggests that SNOT-22 related quality of life improvements following treatment with biologics are comparable to the current standard of care in the short term, but there is a lack of long-term data and standardized regimen that makes direct comparison difficult. Biologic therapies additionally require continuous use to avoid recurrence, and currently cost many times more than existing medical or surgical therapies.     

Queensland Paediatric Cardiac Service: Lessons from evolution to a unified service in a tertiary children's hospital

We describe a complex change process for the paediatric cardiac service in Queensland that involved transitioning the service out of an essentially adult hospital into one of two children's hospitals in Brisbane. This initial step was complex as the governance was changed from Queensland Health to Mater Health, an independent faith‐based organisation who became the new employer. Six years later, the service was again transitioned; this time to the newly constructed Queensland Children's Hospital, with a Hospital and Health Services Board as the employer under the aegis of Queensland Health. This was a complex journey. As with all change processes there was resistance to change on the part of some individuals. Five years on from the second major change, the service is settled, has an excellent workplace culture, has excellent clinical outcomes and has become research intensive.