A practical approach to reporting treatment abandonment in pediatric chronic conditions

Treatment abandonment, the failure to complete therapy that is required for definitive disease control, frequently causes treatment failure for pediatric patients in low‐ and middle‐income countries with chronic conditions, particularly cancer. Other forms of incomplete treatment affecting children in all settings, such as nonadherence and loss to follow‐up, are often confused with treatment abandonment. Unclear definitions of incomplete treatment dramatically affect reported outcomes. To facilitate disease‐specific and cross‐sector analyses, we outline a practical approach to categorize forms of incomplete treatment, present distinct semantic categories with case examples and provide an algorithm that could be tailored to disease‐ and context‐specific needs. Pediatr Blood Cancer 2015;62:565–570. © 2015 Wiley Periodicals, Inc.     

Living life to the fullest: Well elders’ views of hip fracture

Using a sample of 60 healthy older adults attending senior centers, this study examines elders’ perceptions of the consequences of hip fracture, reports of their physical health, feelings of efficacy in avoiding falls, and reports of depression. Results indicate that these active older adults generally do not feel vulnerable to hip fracture and expect to recover and regain mobility and independence in a timely fashion should they suffer a hip fracture. Moreover, elders in the study who do not view hip fracture as having substantial negative impact on their lives also report lower levels of depression and higher levels of perceived falls efficacy than do elders who view future hip fracture as a more debilitating health event. Study results are discussed in the context of theories of perceived invulnerability as a form of adaptive coping for elders. Implications of findings for caregivers, researchers, and practitioners are also discussed. Catherine H. Stein, Ph.D. is a clinical-community psychologist whose research focuses on marginalized population.     

Physician Burnout and Patient-Physician Communication During Primary Care Encounters

Background  Although previous studies suggest an association between provider burnout and suboptimal self-reported communication, no studies relate physician burnout to observed patient-physician communication behaviors. Objective  To investigate the relationship between physician burnout and observed patient-physician communication outcomes in patient-physician encounters. Design  Longitudinal study of enrollment data from a trial of interventions to improve patient adherence to hypertension treatment. Setting  Fifteen urban community-based clinics in Baltimore, MD. Participants  Forty physicians and 235 of their adult hypertensive patients, with oversampling of ethnic minorities and poor persons. Fifty-three percent of physicians were women, and the average practice experience was 11.2 years. Among the 235 patients, 66% were women, 60% were African-American, and 90% were insured. Measurements  Audiotape analysis of communication during outpatient encounters (one per patient) using the Roter Interaction Analysis System and patients’ ratings of satisfaction with and trust and confidence in the physician. Results  The median time between the physician burnout assessment and the patient encounter was 15.1 months (range 5.6–30). Multivariate analyses revealed no significant differences in physician communication based on physician burnout. However, compared with patients of low-burnout physicians, patients of high-burnout physicians gave twice as many negative rapport-building statements (incident risk ratio 2.06, 95% CI 1.58 – 2.86, p < 0.001). Physician burnout was not significantly associated with physician or patient affect, patient-centeredness, verbal dominance, or length of the encounter. Physician burnout was also not significantly associated with patients’ ratings of their satisfaction, confidence, or trust. Conclusions  Physician burnout was not associated with physician communication behaviors nor with most measures of patient-centered communication. However, patients engaged in more rapport-building behaviors. These findings suggest a complex relationship between physician burnout and patient-physician communication, which should be investigated and linked to patient outcomes in future research.     

Myocardial infarction: Is bepridil,a new calcium antagonist,able to improve the course of the acute phase?

Summary Several calcium antagonists are useful in the treatment of ischemic heart disease. This open randomized study was designed to determine the effects of bepridil, a new long-acting calcium antagonist with antiarrhythmic properties, on the course of acute myocardial infarction (AMI). Two hundred patients with AMI of less than 48 hours duration (average 10.9 hours) were randomly assigned to two treatment groups: The first one was treated with bepridil (BEP, n=100), and the second one was considered as a control group, using isosorbide dinitrate at a low dosage (ISDN, n=100). BEP was administered intravenously for 48 hours at a dosage of 4 mg/kg/day; at the same time, an oral dose of 200 mg t.i.d. was started and continued for 21 days. In the control group, ISDN was given orally at the low dosage of 5 mg every 4 hours for 21 days. An uneventful course was seen in 28 BEP patients versus 15 in the control group (p<0.05). Mortality and recurrence of angina were lower in the BEP group than in the control group, but the difference is not significant. On the other hand, moderate and severe hemodynamic complications did not occur in 80 BEP patients versus 65 in the control group (p<0.05). Ventricular arrhythmias occurred in 36 BEP patients versus 50 in the control group (p<0.05). Antiarrhythmic therapy was required in 14 BEP patients versus 61 in the control group (p<0.001). These results show that bepridil seems capable of improving the hemodynamics and arrhythmologic course of AMI.     

A role for insulin-like growth factor-I in the regulation of human thyroid cell growth by thyrotrophin

Human thyroid epithelial cells in monolayer culture were found to release radioimmunoassayable insulin-like growth factor-I (IGF-I) over a 48-h culture period in serum-free medium. In the presence of supraphysiological concentrations of TSH (1-100 mU/ml) known to be inhibitory to DNA synthesis by human thyroid cells, the release of IGF-I was found to be inhibited in six thyroid cultures studied. In only one out of the six was IGF-I release increased in the presence of physiological mitogenic concentrations of TSH (0.1-100 microU/ml). Human thyroid fibroblasts, established by long-term culture of thyroid epithelial cells under fibroblast-selective conditions, also secreted IGF-I which was unaffected by the presence of TSH at both low and high concentrations. Using a monoclonal antibody against human IGF-I, monolayer cultures of both human thyroid epithelial cells and human thyroid fibroblasts showed positive immunocytochemical staining for IGF peptide. However, fixed sections of intact thyroid tissue only showed positive staining for IGF peptide associated with the fibrous layers surrounding the thyroid follicle, with no staining of the follicular epithelial cells. The growth of human thyroid epithelial cells was also found to be increased by IGF-I (25-100 ng/ml) added in medium plus 1% fetal calf serum as assessed by the incorporation of [3H]thymidine into DNA. In the presence of a monoclonal antibody to IGF-I the increase in [3H]thymidine uptake in response to IGF-I was abolished as was that seen in response to TSH.(ABSTRACT TRUNCATED AT 250 WORDS)     

The effect of vancomycin and third-generation cephalosporins on prevalence of vancomycin-resistant enterococci in 126 U.S. adult intensive care units

BACKGROUND: Patient-specific risk factors for acquisition of vancomycin-resistant enterococci (VRE) among hospitalized patients are becoming well defined. However, few studies have reported data on the institutional risk factors, including rates of antimicrobial use, that predict rates of VRE. Identifying modifiable institutional factors can advance quality-improvement efforts to minimize hospital-acquired infections with VRE. OBJECTIVE: To determine the independent importance of any association between antimicrobial use and risk factors for nosocomial infection on rates of VRE in intensive care units (ICUs). DESIGN: Prospective ecologic study. SETTING: 126 adult ICUs from 60 U.S. hospitals from January 1996 through July 1999. PATIENTS: All patients admitted to participating ICUs. MEASUREMENTS: Monthly use of antimicrobial agents (defined daily doses per 1000 patient-days), nosocomial infection rates, and susceptibilities of all tested enterococci isolated from clinical cultures. RESULTS: Prevalence of VRE (median, 10%; range, 0% to 59%) varied by type of ICU and by teaching status and size of the hospital. Prevalence of VRE was strongly associated with VRE prevalence among inpatient non-ICU areas and outpatient areas in the hospital, ventilator-days per 1000 patient-days, and rate of parenteral vancomycin use. In a weighted linear regression model controlling for type of ICU and rates of VRE among non-ICU inpatient areas, rates of vancomycin use (P < 0.001) and third-generation cephalosporin use (P = 0.02) were independently associated with VRE prevalence. CONCLUSIONS: Higher rates of vancomycin or third-generation cephalosporin use were associated with increased prevalence of VRE, independent of other ICU characteristics and the endemic VRE prevalence elsewhere in the hospital. Decreasing the use rates of these antimicrobial agents could reduce rates of VRE in ICUs.     

De Novo Mutations in the Motor Domain of KIF1A Cause Cognitive Impairment,Spastic Paraparesis,Axonal Neuropathy,and Cerebellar Atrophy

KIF1A is a neuron‐specific motor protein that plays important roles in cargo transport along neurites. Recessive mutations in KIF1A were previously described in families with spastic paraparesis or sensory and autonomic neuropathy type‐2. Here, we report 11 heterozygous de novo missense mutations (p.S58L, p.T99M, p.G102D, p.V144F, p.R167C, p.A202P, p.S215R, p.R216P, p.L249Q, p.E253K, and p.R316W) in KIF1A in 14 individuals, including two monozygotic twins. Two mutations (p.T99M and p.E253K) were recurrent, each being found in unrelated cases. All these de novo mutations are located in the motor domain (MD) of KIF1A. Structural modeling revealed that they alter conserved residues that are critical for the structure and function of the MD. Transfection studies suggested that at least five of these mutations affect the transport of the MD along axons. Individuals with de novo mutations in KIF1A display a phenotype characterized by cognitive impairment and variable presence of cerebellar atrophy, spastic paraparesis, optic nerve atrophy, peripheral neuropathy, and epilepsy. Our findings thus indicate that de novo missense mutations in the MD of KIF1A cause a phenotype that overlaps with, while being more severe, than that associated with recessive mutations in the same gene.     

High School Athletes' Parents' Perceptions and Knowledge of the Skills and Job Requirements of the Certified Athletic Trainer

ContextParents play a crucial role in determining medical services for their children, and it is important they understand the scope of practice and skills of the athletic trainer (AT).ObjectiveTo understand parents'' perceptions and knowledge of the skills and job requirements of the secondary school AT.DesignCross-sectional study.SettingSport meetings and banquets at 5 high schools in southwest Michigan during the fall, winter, and spring seasons.ResultsOf the 539 parents who responded, 28% responded yes, and 72% responded no to having experience with an AT for their own injuries. When asked if they had experience with an AT due to their child''s injuries, 60% responded yes. We found a difference among the 3 categories of experience for perception scores (P = .002) and knowledge scores (P < .001).ConclusionsIn the absence of past experience with an AT, parents'' perceptions and knowledge of the skills and job requirements of the secondary school AT are limited. Athletic trainers should educate parents on their professional roles, which may enhance their ability to provide better health care.Key Words: secondary schools, awareness, guardians

Key Points

• Parents have varying perceptions of athletic trainers based upon past experiences.
• Parents view the athletic trainer as a valued member of the secondary school health care team.
• Parents who have limited past experience with athletic trainers rate emergency care as the primary job responsibility.

Over the past 20 years, secondary school sport participation among students in the United States has consistently increased.¹ To ensure the proper care of these athletes, the American Medical Association recommended that all secondary schools provide athletic training services.² In addition to the athletic trainer (AT), the National Athletic Trainers'' Association has recommended that an athletic health care team (AHCT) be established that includes an AT, school nurse, physician, and other health care professionals.^3,4 The AHCT''s primary purpose is to work with the athletic director, coaches, and parents to ensure that appropriate medical care is provided for all athletes.To work congruently in providing the best possible care for secondary school student-athletes, members of the AHCT, along with athletic directors, coaches, and parents, must understand the variety of responsibilities of the AT. Previous investigations^5–7 showed that physicians and administrators have a basic understanding of the roles of ATs, but conversely, coaches did not fully recognize the scope of the ATs'' credentials or certification requirements. Additionally, when emergency medical service personnel were questioned, they too showed an incomplete comprehension of ATs'' roles as health care providers, predominantly in sport-related emergency care.⁸ These investigations led to a general consensus on misconceptions of ATs'' roles and responsibilities, likely stemming from a lack of experience with an AT in a secondary school setting.Less studied but perhaps one of the most important groups affiliated with the health care of the secondary school athlete is parents. Parents had a basic idea of the roles of an AT but lacked full understanding of the athletic training profession.⁹ Because parents play a crucial part in determining medical services for their children in the secondary school setting, they must have a thorough understanding of the scope of practice and skills of ATs in order for their children to receive the best medical care possible. Therefore, the purposes of our study were to further investigate parents'' overall perceptions and knowledge of the secondary school AT and to determine whether parents'' past experiences with ATs influenced their overall perceptions and knowledge of the athletic training profession and professional practice domains.     

Rapid Detection of Rare Deleterious Variants by Next Generation Sequencing with Optional Microarray SNP Genotype Data

Autozygosity mapping is a powerful technique for the identification of rare, autosomal recessive, disease‐causing genes. The ease with which this category of disease gene can be identified has greatly increased through the availability of genome‐wide SNP genotyping microarrays and subsequently of exome sequencing. Although these methods have simplified the generation of experimental data, its analysis, particularly when disparate data types must be integrated, remains time consuming. Moreover, the huge volume of sequence variant data generated from next generation sequencing experiments opens up the possibility of using these data instead of microarray genotype data to identify disease loci. To allow these two types of data to be used in an integrated fashion, we have developed AgileVCFMapper, a program that performs both the mapping of disease loci by SNP genotyping and the analysis of potentially deleterious variants using exome sequence variant data, in a single step. This method does not require microarray SNP genotype data, although analysis with a combination of microarray and exome genotype data enables more precise delineation of disease loci, due to superior marker density and distribution.