Early life predictors of adult leisure-time physical inactivity: prospective findings from the 1958 British Birth Cohort

BackgroundLeisure-time physical inactivity has a high prevalence and associated disease burden. Adult inactivity research ignores earlier life factors from which later life influences can originate. We aimed to establish whether early life factors influence adult inactivity.MethodsThe 1958 British Birth Cohort is a nationwide follow-up study of all births during 1 week in March, 1958. The outcome of the present study was leisure-time inactivity, defined as activity frequency of less than once a week, assessed at ages 33 years, 42 years, and 50 years (n=12 776). Early life factors (birth to 16 years) were categorised into three domains (physical, social, behavioural). We assessed stability of inactivity from 33 years to 50 years and associations with adult inactivity using logistic regression of: factors within domains, the three domains combined (ie, multivariable associations), and allowing for adult factors. Missing values were imputed with multiple imputation chained equations.FindingsAt each adult age, about 32% of participants were inactive (31% at 33 years, 34% at 42 years, and 30% at 50 years). 1189 (9%) were inactive at all three ages. In analysis of the three domains simultaneously, factors related to adult inactivity were: short prepubertal stature, poor hand control or physical coordination, and poor cognition (physical); low class at birth, minimal parental education, poor household amenities, parental divorce, and institutional care (social); and inactivity, average or lower sports aptitude, smoking, and externalising and unsociable behaviours (behavioural). Odds ratios for inactivity at age 33 years ranged from 0·86 per SD increase in cognition (95% CI 0·82–0·91) to 1·41 (1·23–1·61) for average or lower sports aptitude. Associations weakened slightly but were mostly maintained after adjustment for adult covariates. After allowing for adult covariates participants with unskilled manual backgrounds had 23% higher odds of inactivity at 50 years than those from professional or managerial backgrounds.InterpretationOur study, based on self-report, focuses only on leisure-time inactivity. However, to have repeat, prospective data on inactivity spanning several decades in adulthood is rare, and leisure-time inactivity is likely to be amenable to modification. Adult inactivity is only moderately stable, providing opportunities for behaviour change. Factors from early life are associated with adult inactivity, allowing for early identification of groups vulnerable to later inactivity.FundingThis work was supported by the Department of Health Policy Research Programme through the Public Health Research Consortium. The Great Ormond Street and University College London Institute of Child Health was supported in part by the Department of Health's National Institute for Health Biomedical Research Centre.     

Sufentanil versus Fentanyl: Efficacy and Patient Satisfaction with Intrathecal Pain Management

Objectives: This study compared fentanyl vs. sufentanil in intrathecal pain pumps. H1: both reduce patient subjective pain ratings. H2: sufentanil is more effective than fentanyl. H3: overall satisfaction with pain control is greater with sufentanil. Materials/Method: This is an archival study of patients in tertiary pain management (N= 97, mean age = 58.77, standard deviation = 14.88). Pain was measured using the subjective units of discomfort scale. Satisfaction with pain control/relief was measured by asking patients each visit if they are satisfied with pain management and is recorded in a “yes”/ “no” manner. Pain ratings were analyzed with repeated measures analysis of variance and satisfaction was analyzed with chi square. Results/Discussion: Sufentanil was found to be marginally more effective, but both medications controlled a significant degree of variance in pain reduction over time. A significantly greater number of patients maintained on sufentanil were satisfied with care than patients on fentanyl.     

The Action Research Program: Experiential Learning in Systems-Based Practice for First-Year Medical Students

Problem: Systems-based practice focuses on the organization, financing, and delivery of medical services. The American Association of Medical Colleges has recommended that systems-based practice be incorporated into medical schools’ curricula. However, experiential learning in systems-based practice, including practical strategies to improve the quality and efficiency of clinical care, is often absent from or inconsistently included in medical education. Intervention: A multidisciplinary clinician and nonclinician faculty team partnered with a cardiology outpatient clinic to design a 9-month clerkship for 1st-year medical students focused on systems-based practice, delivery of clinical care, and strategies to improve the quality and efficiency of clinical operations. The clerkship was called the Action Research Program. In 2013–2014, 8 trainees participated in educational seminars, research activities, and 9-week clinic rotations. A qualitative process and outcome evaluation drew on interviews with students, clinic staff, and supervising physicians, as well as students’ detailed field notes. Context: The Action Research Program was developed and implemented at the University of California, San Francisco, an academic medical center in the United States. All educational activities took place at the university's medical school and at the medical center's cardiology outpatient clinic. Outcome: Students reported and demonstrated increased understanding of how care delivery systems work, improved clinical skills, growing confidence in interactions with patients, and appreciation for patients’ experiences. Clinicians reported increased efficiency at the clinic level and improved performance and job satisfaction among medical assistants as a result of their unprecedented mentoring role with students. Some clinicians felt burdened when students shadowed them and asked questions during interactions with patients. Most student-led improvement projects were not fully implemented. Lessons Learned: The Action Research Program is a small pilot project that demonstrates an innovative pairing of experiential and didactic training in systems-based practice. Lessons learned include the need for dedicated time and faculty support for students’ improvement projects, which were the least successful aspect of the program. We recommend that future projects aiming to combine clinical training and quality improvement projects designate distinct blocks of time for trainees to pursue each of these activities independently. In 2014–2015, the University of California, San Francisco School of Medicine incorporated key features of the Action Research Program into the standard curriculum, with plans to build upon this foundation in future curricular innovations.     

The fungal airway microbiome in cystic fibrosis and non-cystic fibrosis bronchiectasis

BackgroundThe prevalence of fungal disease in cystic fibrosis (CF) and non-CF bronchiectasis is increasing and the clinical spectrum is widening. Poor sensitivity and a lack of standard diagnostic criteria renders interpretation of culture results challenging. In order to develop effective management strategies, a more accurate and comprehensive understanding of the airways fungal microbiome is required. The study aimed to use DNA sequences from sputum to assess the load and diversity of fungi in adults with CF and non-CF bronchiectasis.MethodsNext generation sequencing of the ITS2 region was used to examine fungal community composition (n = 176) by disease and underlying clinical subgroups including allergic bronchopulmonary aspergillosis, chronic necrotizing pulmonary aspergillosis, non-tuberculous mycobacteria, and fungal bronchitis. Patients with no known active fungal disease were included as disease controls.ResultsITS2 sequencing greatly increased the detection of fungi from sputum. In patients with CF fungal diversity was lower, while burden was higher than those with non-CF bronchiectasis. The most common operational taxonomic unit (OTU) in patients with CF was Candida parapsilosis (20.4%), whereas in non-CF bronchiectasis sputum Candida albicans (21.8%) was most common. CF patients with overt fungal bronchitis were dominated by Aspergillus spp., Exophiala spp., Candida parapsilosis or Scedosporium spp.ConclusionThis study provides a framework to more accurately characterize the extended spectrum of fungal airways diseases in adult suppurative lung diseases.     

Integrating gene expression profiling into NCCN high-risk cutaneous squamous cell carcinoma management recommendations: impact on patient management

Abstract

Objective: To integrate gene expression profiling into the management of high-risk cutaneous squamous cell carcinoma (cSCC) within the National Comprehensive Cancer Network (NCCN) guidelines to improve risk-aligned management recommendations.

Methods: A cohort of 300 NCCN-defined high-risk cSCC patients, along with the American Joint Committee on Cancer (AJCC) T stage, Brigham and Women’s Hospital (BWH) T stage, and known patient outcomes were analyzed. Risk classifications using a validated 40-gene expression profile (40-GEP) test and T stage were applied to NCCN patient management guidelines. Risk-directed patient management recommendations within the NCCN guidelines framework were aligned based on risk for metastasis.

Results: Of the 300 NCCN high-risk cSCC patients, 159 (53.0%) were 40-GEP Class 1 and AJCC T1-T2, and 173 (57.7%) were Class 1 and BWH T1-2a, indicating low risk for metastasis and, thereby, suggesting low management intensity. The 40-GEP integration suggested high intensity management for only 24 (8.0%) patients (all Class 2B), and moderate intensity management for the remainder of the cohort.

Conclusions: The 40-GEP test can be integrated within existing NCCN guideline recommendations for managing cSCC patients to help refine risk-directed management decisions. Integration of the 40-GEP test would allow >50% of this NCCN-defined high-risk cohort to be managed with the lowest intensity recommendations within the broad NCCN guidelines. High intensity management was deemed risk-appropriate for a small subpopulation (8.0%). This study demonstrates that the 40-GEP test, in combination with T stage, has clinical utility to impact patient management decisions in NCCN high-risk cSCC for improving risk-aligned management within the NCCN guidelines framework.