Is there shared decision making when the provider makes a recommendation?

Objective

To compare the amount of shared decision making in breast cancer surgery interactions when providers do and do not make a treatment recommendation.

Methods

We surveyed breast cancer survivors who were eligible for mastectomy and lumpectomy. Patients reported whether the provider made a recommendation and the recommendation given. They completed items about their interaction including discussion of options, pros, cons, and treatment preference. A total involvement score was calculated with higher scores indicating more shared decision making.

Results

Most patients (85%) reported that their provider made a recommendation. Patients who did not receive a recommendation had higher involvement scores compared to those who did (52% vs. 39.1%, p = 0.004). Type of recommendation was associated with involvement. Patients given different recommendations had the highest total involvement scores followed by those who received mastectomy and lumpectomy recommendations (65.5% vs. 42.5% vs. 33.2%, respectively, p < 0.001).

Conclusion

Providers were less likely to present a balanced view of the options when they gave a recommendation for surgery. Patients who received a recommendation for lumpectomy had the lowest involvement score.

Practice implications

Providers need to discuss both mastectomy and lumpectomy and elicit patients’ goals and treatment preferences regardless of whether or not a recommendation is given.     

Diagnostic performance of four SARS-CoV-2 antibody assays in patients with COVID-19 or with bacterial and non-SARS-CoV-2 viral respiratory infections

European Journal of Clinical Microbiology & Infectious Diseases - SARS-CoV-2 antibody assays are used for epidemiological studies and for the assessment of vaccine responses in highly...     

Disentangling levels of mother–infant neuroendocrine attunement and longitudinal relations with maternal risk and protective factors

Scientific understanding of mother–infant HPA axis attunement has been limited by discrepant methods for assessing attunement that often conflate different levels of association. We sought to refine the conceptualization of attunement by investigating whether mother–infant cortisol attunement exists as coupling of response trajectories within an acute stress episode, separate from shared developmental patterns and/or overall dyadic similarity in cortisol levels, and whether the degree of attunement depends on within‐ or between‐dyad differences in maternal risk and protective factors. We examined these questions using a longitudinal study with mother/infant salivary cortisol during dyadic stressors at 6, 12, and 18 months postnatal. A three‐level hierarchical linear model showed that sample‐wide associations between mother and infant cortisol were not significant at any level, suggesting normative lack of attunement; however, there was significant variability in degree of attunement across dyads. Concurrent levels of family resources and social support satisfaction predicted lower mother–infant cortisol attunement within the session, and overall (mean) parenting stress predicted the opposite. Follow‐up analyses showed this was typically due to an increase in infants’ (but not their mothers’) within‐session cortisol response slopes with increasing support and decreasing stress. Implications for the role of mother–infant cortisol attunement in intergenerational stress transmission are discussed.     

Resolution of Persistent COVID-19 After Convalescent Plasma in a Patient with B Cell Aplasia

Journal of Clinical Immunology -     

Clickable Poly(ethylene glycol)‐Microsphere‐Based Cell Scaffolds

Clickable poly(ethylene glycol) (PEG) derivatives are used with two sequential aqueous two‐phase systems to produce microsphere‐based scaffolds for cell encapsulation. In the first step, sodium sulfate causes phase separation of the clickable PEG precursors and is followed by rapid geleation to form microspheres in the absence of organic solvent or surfactant. The microspheres are washed and then deswollen in dextran solutions in the presence of cells, producing tightly packed scaffolds that can be easily handled while also maintaining porosity. Endothelial cells included during microsphere scaffold formation show high viability. The clickable PEG‐microsphere‐based cell scaffolds open up new avenues for manipulating scaffold architecture as compared with simple bulk hydrogels.

     

Venous sinus stenting for the treatment of isolated pulsatile tinnitus: Results of a prospective trial

ObjectivesThis prospective study evaluates the effectiveness and safety of venous sinus stenting for patients with isolated pulsatile tinnitus and lateral sinus stenosis.MethodsPatients with isolated pulsatile tinnitus and lateral sinus stenosis with a minimum trans stenotic gradient of 4 mm Hg were treated with stenting. Pulsatile tinnitus before and after treatment was assessed with the Tinnitus Handicap Inventory (THI). Periprocedural adverse events, neurological complications, clinical and radiographic follow-up were also recorded.ResultsA total of 42 patients (41 females and 1 male) were included in the study (median age of 37.5 years). Thirty patients had post-stenotic fusiform and 12 had post-stenotic saccular venous sinus aneurysm. In addition to stenting, coils were used to treat the patients with saccular venous aneurysms. The median follow-up was 5 months (range 1 to 34 months). Most patients had complete (39/42) or near-complete (2/42) resolution of their pulsatile tinnitus post-procedure. There were no serious adverse events.ConclusionStenting of the lateral venous sinus is a safe and effective treatment for patients with isolated pulsatile tinnitus due to venous sinus stenosis.     

Juvenile and adenomatous gastrointestinal polyposis

Summary This is the fourth report of a case showing an association between juvenile and adenomatous polyposis. Starting at age 14, this patient underwent multiple polypectomies and gastrointestinal resections over a 15-year period. Although initial biopsies were diagnosed as juvenile polyps, later biopsies showed both adenomatous polyps and large polypoid masses with a mixture of juvenile and adenomatous features. Several typical small hyperplastic polyps were also found in the stomach. This case contrasts with the previous three cases in that the gastrointestinal tract is more widely involved and in that there is an unusual marked hyperplasia of argentaffin-and argyrophil-positive cells. The case reported here strengthens the relation between adenomatous polyposis and juvenile polyposis.     

Influence of Cytokines on the Growth Kinetics and Immunophenotype of Daughter Cells Resulting From the First Division of Single CD34+Thy-1+lin- Cells

There is a need to determine whether culture conditions may existfor ex vivo expansion of hematopoeitic stem cells (HSC), which favorsolely proliferative self-renewal of HSC as opposed to proliferationwith differentiation. Using single cells, we studied the effects ofindividual and combinations of cytokines in serum-free medium on thekinetics of the first cell doubling and the resulting phenotype of eachof individual daughter cell. CD34⁺Thy-1⁺lincells were plated 1 cell per well in Terasaki plates inserum-free medium containing cytokines. Each well containing a singlecell was monitored daily over 7 days for maintenance, division, or death. When division occurred in an individual well, the phenotype ofthe daughter cells was determined by staining with anti-CD34 fluorescein isothiocyanate (FITC)- and phycoerythrin (PE)-conjugated lineage specific antibodies. The cumulative percent of wells with anundivided single cell, wells in which the cell had divided, and wellsin which the cell had died were scored. The number of doublets withconserved phenotype (CD34⁺lin) wascompared to those wells with one or more differentiated daughter cells(CD34⁺lin⁺). Over 7 days, cells cultured insingle factors showed that between 13% (interleukin-6 [IL-6]) and29% (thrombopoietin [TPO]) of the cells were undivided, between 13%(IL-1) and 35% (TPO) of the cells doubled, and between 35% (TPO) andgreater than 60% (IL-11, IL-1, or hepatocyte growth factor[HGF]) died. When combinations of cytokines were usedover 7 days, between 5% (FLT-3 ligand [FLT-3L], stemcell factor [SCF], IL-3, IL-6, granulocytecolony-stimulating factor [G-CSF],  nerve growth factor[NGF]) and 22% (FLT-3L + HGF) of the cellsremained undivided, between 15% (HGF, IL-1, IL-11, G-CSF) and 68%(SCF + TPO) of the cells had doubled and between 27% (FLT-3L + TPO) and 70% (HGF, IL-1, IL-11, G-CSF) died. The combination of FLT-3L + TPO induced the highest total percent (64.6%) of cells withconserved phenotype (percent conserved doublets + percent with 1 cellconserved), followed by SCF + TPO, (50%) and the combination ofFLT-3L, SCF, IL-3, IL-6, G-CSF, NGF (53%). These combinations alsoproduced the highest yield of cells with conserved phenotype after onedivision (FLT-3L + TPO  81 cells/100 initial cells, SCF + TPO  68 cells/100 initial cells) (P = .01). Observation of thetime of the initial cell division and phenotype of the daughter cellsallowed us to identify candidate combinations of cytokines that promotemaintenance of lin cells (TPO), or recruit the primitivecells to divide and undergo phenotypic self-renewal (FLT-3L + TPO,SCF + TPO).