Comparing Pediatric Surgeons' and Palliative Care Pediatricians' Palliative Care Practices and Perspectives in Pediatric Surgical Patients.

PURPOSE: The nature of interactions between surgical and pediatric palliative care (PPC) teams caring for seriously ill children is unknown. This study compares pediatric surgeons' and PPC physicians' perspectives and practices regarding PPC in surgical patients. METHODS: A survey was administered to members of the American Pediatric Surgical Association and Pediatric Interest Group of the American Academy of Hospice and Palliative Medicine. RESULTS: One hundred twenty-four pediatric surgeons (31% female, 17.2 mean years of experience) and 71 PPC physicians (69% female, 10.1 mean years of experience) participated. Forty-three percent of surgeons reported consulting PPC often for children with serious illnesses. However, most PPC physicians (67%), said they are rarely/never consulted by surgeons (p = 0.002). PPC physicians were more likely to report that PPC involvement was too late (43% vs 21%, p = 0.005). More surgeons than PPC physicians felt that an appropriate time for PPC consultation was during serious illness deterioration (30% vs 7%, p = 0.05), whereas PPC physicians preferred consultation at diagnosis (54% vs 34%, p = 0.05). More PPC physicians (67%) than surgeons (17%) agreed that invasive interventions could be considered a form of PPC (p = 0.002). The most reported barrier to PPC consultation by surgeons (29%) was concern that parents would think the surgical team was giving up. PPC physicians were more likely to perceive barriers to consultation by surgeons than surgeons themselves (p < 0.001). CONCLUSION: While pediatric surgeons value PPC involvement, surgical culture and misperception of parental resistance to PPC involvement lead to palliative care consultation only when illness acuity and severity are high, the possibility of curability is low, and death seems imminent. Seeking to understand patient and family priorities in care, managing patient and parental psychological distress, and treating non-surgical symptoms are areas where PPC can improve patient care. Barriers to PPC use and self-reported knowledge gaps in PPC provision may be mitigated by formalized PPC training for surgeons and intentional collaboration between the two groups. TYPE OF STUDY: Survey. LEVEL OF EVIDENCE: N/A.

Community-Delivered Collaborative and Proactive Solutions and Parent Management Training for Oppositional Youth: A Randomized Trial.

The aim of this study was to examine the relative effectiveness of Collaborative and Proactive Solutions (CPS) and Parent Management Training (PMT) for youth with oppositional defiant disorder (ODD) in a community setting. Based on a semistructured diagnostic interview, 160 youth with ODD (ages 7-14; 72% male; ethnicity representative of the wider Australian population) were randomized to CPS (n = 81) or PMT (n = 79) for up to 16 weekly sessions. The primary hypothesis was that participants in the CPS group, treated in a community setting, would exhibit significant improvement in ODD, equivalent to that of an evidence-based treatment, PMT. Assessment was conducted at baseline, post-intervention, and at 6-month follow-up, using independently rated semistructured diagnostic interviews, parent ratings of ODD symptoms, and global ratings of severity and improvement. Analyses were conducted with hierarchical growth linear modeling, ANCOVA, and equivalence testing using an intent-to-treat sample. Both treatments demonstrated similar outcomes, with 45-50% of youth in the nonclinical range after treatment, and 67% considered much improved. No differences were found between groups, and group equivalency was shown on the independent clinician and parent-rated measures. Gains were maintained at the 6-month follow-up. In conclusion, CPS works as effectively as the well-established treatment, PMT, for youths with ODD, when implemented in a community-based setting. As such, CPS provides a viable choice for families who seek alternate treatments.

Surgical Intervention in Patients Receiving Pediatric Palliative Care Services.

BACKGROUND AND OBJECTIVES: Many patients receiving pediatric palliative care (PPC) present with surgically treatable problems. The role of surgery in the care of these patients, however, has not yet been defined. We conducted a cohort study of children receiving PPC to assess the incidence, type, and likely purpose of surgical interventions performed after the initiation of PPC. METHODS: We performed a cohort analysis of surgical interventions performed on children enrolled in an ongoing, multicenter, prospective cohort study. Patients aged <30 years receiving PPC services were eligible for inclusion in the study. Analyses included descriptive and comparative statistics, as well as logistic regression models. RESULTS: After initiation of PPC, 81.1% (n = 488) of patients had undergone at least 1 surgical intervention (range, 1-71) with a median of 4 interventions (interquartile range, 1-9). The most frequent surgical interventions were feeding tubes, endoscopic biopsy, tracheostomy, bone marrow biopsy, tunneled catheters, bronchoscopy, and chest tube placement, followed by sternum closure, abdominal closure, atrial and ventricular septal defect repairs, and heart transplantation. Children who underwent surgical interventions were statistically less likely to die while receiving PPC (29% vs 40%, P < .03). CONCLUSIONS: Most children receiving PPC services undergo at least 1 surgical intervention, and many undergo numerous interventions. Undergoing intervention is not futile because surgical intervention is associated with longer survival. Various patient populations that are more likely, as well as less likely, to undergo surgical intervention warrant specific focus.

The Evolving Landscape of Global Surgery: A Qualitative Study of North American Surgeons' Perspectives on Faith-Based and Academic Initiatives.

Faith-based missions have played a large role in surgical care delivery in low- and middle-income countries (LMIC). As global surgery is now an academic discipline, this pilot study sought to understand how different faith ideologies influence surgeon motivations and subsequent culture of the global surgery landscape. Interviews were conducted with North American surgeons who pursue global surgery significantly in their career. Points of discussion included early influences, obstacles, motivations, philosophy and approach to global surgery work, and experiences with faith-based (FBO) and non-faith-based organizations (NFBO). Notes were transcribed and thematic analysis performed. Sixteen surgeons were interviewed (11 men, 5 women, ages 39-75 years-old). Surgeons had worked in 32 countries with FBO and NFBO in intermittent or long-term capacity. Religious upbringing and current affiliations included Atheism, Protestant Christianity, Catholicism, Hinduism, Judaism, Mormonism, Islam, and nonreligious spirituality. Early influences included international upbringing (n = 7), emphasis on service (n = 9), and exposure to the religious mission concept (n = 6). The most common core motivation among all participants was addressing disparities (n = 10). Some believed that FBO and NFBO have different goals (n = 4), and only surgeons identifying with Christianity believed the goals are similar (n = 3). Participants expressed that FBO are exclusive (n = 4) and focused on proselytization (n = 6) while NFBO are humanitarian (n = 3) but less integrated into the community (n = 4). Global surgeons have shared early influences, obstacles, and desire to address disparities. Perceptions of FBO and NFBO differed based on religious background. This pilot study will inform future studies regarding the collaborations of FBO and NFBO to improve global surgical care.

Predation risk differentially affects aphid morphotypes: impacts on prey behavior, fecundity and transgenerational dispersal morphology.

To avoid predation, prey initiate anti-predator defenses such as altered behavior, physiology and/or morphology. Prey trait changes in response to perceived predation risk can influence several aspects of prey biology that collectively contribute to individual success and thus population growth. However, studies often focus on single trait changes in a discrete life stage or morphotype. We assessed how predation risk by Harmonia axyridis affects several important traits in the aphid, Myzus persicae: host plant preference, fecundity and investment in dispersal. Importantly, we examined whether these traits changed in a similar way between winged (alate) and wingless (apterous) adult aphid morphotypes, which differ in morphology, but also in life-history characteristics important for reproduction and dispersal. Host plant preference was influenced by the presence of H.axyridis odors in choice tests; wingless aphids were deterred by the odor of plants with H.axyridis whereas winged aphids preferred plants with H.axyridis present. Wingless aphids reared in the presence of ladybeetle cues produced fewer offspring in the short-term, but significantly more when reared with exposure to predator cues for multiple generations. However, winged aphid fecundity was unaffected by H.axyridis cues. Lastly, transgenerational plasticity was demonstrated in response to predation risk via increased formation of winged aphid morphotypes in the offspring of predator cue-exposed wingless mothers. Importantly, we found that responses to risk differ across aphid polyphenism and that plasticity in aphid morphology occurs in response to predation risk. Together our results highlight the importance of considering how predation risk affects multiple life stages and morphotypes.

Bound Together: Allyship in the Art of Medicine.

In the setting of the immense social, political, medical, and cultural challenges of last year, medicine has been made acutely aware of its participation in inequity and in response offers allyship as a framework for clinicians to pursue change, using tools already apart of the practice of medicine. Allyship in the workplace can be summarized as a strategic mechanism used by individuals to become collaborators who fight injustice and promote equity through supportive personal relationships and public acts of sponsorship and advocacy. The idea of allyship may be intimidating, particularly for practitioners and leaders who do not belong to the communities they endeavor to support. But as the article unpacks, practitioners need not look any further for how to be allies than what they practice every day: lifelong learning; humility in complications; an expectation of imperfection; and, bound together with those who suffer, persistence in the pursuit of healing.

In-home interpersonal violence: Sex based prevalence and outcomes.

INTRODUCTION: There is a shortage of data on intimate partner and interpersonal violence in sub-Saharan Africa. We, therefore, sought to characterize patterns of sex-based risk of in-home interpersonal violence in Malawi. METHODS: We performed a retrospective analysis of the Kamuzu Central Hospital Trauma Registry data from 2009 to 2017 on adult patients presenting the emergency room following assault. Data variables collected include basic demographics, injury characteristics, and outcomes. We performed a bivariate analysis for covariates based on sex and Poisson regression analysis to estimate the risk of domestic violence and sex-based mortality. RESULTS: The in-home assault interpersonal violence was 37.1% (n = 10,854) of the total assault cohort and 37.4% (n = 4056) were female. Women were more likely to be assaulted at home (n = 4065, 69.6%)compared to men. The overall prevalence of in-home interpersonal violence over eight years was 9.09%, with the prevalence in men and women being 7.85 and 12.38%, respectively. Women injured following in-home interpersonal violence assaults were less severely injured. Women were more likely to be injured following slaps, punches, or kicks (n = 950, 41.2%) and men were more likely to be injured by an object, 41.0% with a blunt object (n = 1658) and 37.9% by a knife or another sharp object (n = 1532). For patients experiencing in-home interpersonal violence, overall mortality is 1.8% and 0.5% for men and women, respectively (p < 0.001). After controlling for covariates, the relative risk for In-home interpersonal violence was 2.25 (p < 0.001) times higher for women. Still, men had a 3.3 times risk of mortality following in-home interpersonal violence (p < 0.001). CONCLUSION: Interpersonal violence is a global problem. In Malawi, women are more likely to be victims of in-home interpersonal violence. However, men are more likely to die following in-home interpersonal violence. Prevalence of in-home interpersonal violence is likely an underestimation.

Missions, Humanitarianism, and the Evolution of Modern Global Surgery.

Modern global surgery, which aims to provide improved and equitable surgical care worldwide, is a product of centuries of international care initiatives, some borne out of religious traditions, dating back to the first millennium. The first hospitals (xenodochia) were established in the 4th and 5th centuries CE by the early Christian church. Early "missions," a term introduced by Jesuit Christians in the 16th century to refer to the institutionalized expansion of faith, included medical care. Formalized Muslim humanitarian medical care was marked by organizations like the Aga Khan Foundation and the Islamic Association of North America in the 20th century. Secular medical humanitarian programs developed in the 19th century, notably with the creation of the International Committee of the Red Cross (1863) and the League of Nations Health Organization (1920) (which later became the World Health Organization [1946]). World War II catalyzed another proliferation of nongovernmental organizations, epitomized by the quintessential humanitarian health provider, Médecins Sans Frontières (1971). "Global health" as an academic endeavor encompassing education, service, and research began as an outgrowth of departments of tropical medicine and international health. The American College of Surgeons brought a surgical focus to global health beginning in the 1980s. Providing medical care in distant countries has a long tradition that parallels broad themes in history: faith, imperialism, humanitarianism, education, and service. Surgery as a focus of academic global health is a recent development that continues to gain traction.

Social and financial barriers may contribute to a "hidden mortality" in Uganda for children with congenital anomalies.

BACKGROUND: The true incidence of congenital anomalies in sub-Saharan Africa is unknown. Owing to complex challenges associated with congenital anomalies, many affected babies may never present to a health facility, resulting in an underestimation of disease burden. METHODS: Interviews were conducted with Ugandans between September 2018 and May 2019. Responses from community members versus families of children with congenital anomalies were compared. RESULTS: A total of 198 Ugandans were interviewed (91 family members, 80 community members). All participants (N = 198) believed that seeking surgical care would lead to poverty, 43% (n = 84) assumed fathers would abandon the child, and 26% (n = 45) thought a child with a congenital anomaly in their community had been left to die. Causes of anomalies were believed to be contraceptive methods (48%, n = 95), witchcraft (17%, n = 34), or drugs (10%, n = 19). Of family members, 25 (28%) were advised to allow the child to die. Families with affected children were more likely to have a lower income (P < .001), believe anomalies could be treated (P = .007), but thought that allowing the child to die was best for the family (32% vs 9%; P < .0001). Monthly household income <50,000 Uganda shillings ($13 United States dollars) was a significant predictor of the father leaving the family (P = .024), being advised to not pursue medical care (P = .046), and believing that God should decide the child's fate (P = .047). CONCLUSION: Families face significant financial and social pressures when deciding to seek surgical care for a child with a congenital anomaly. Many children with anomalies may die and never reach a health facility to be counted, thus contributing to a hidden mortality.

Predictors of Burnout and Depression in Surgeons Practicing in East, Central, and Southern Africa.

BACKGROUND: Surgeons are at risk of burnout and depression, which can lead to medical errors, inefficiency, exhaustion, conflicts, and suicide. Significant challenges exist in sub-Saharan Africa that may increase the prevalence of burnout and depression, but no formal evaluation has identified stressors specific to this environment. METHODS: A survey was distributed to all members of the College of Surgeons of East, Central, and Southern Africa (COSECSA). Burnout, depression, and stressors were assessed with validated measures: Maslach Burnout Inventory for Medical Personnel, Patient Health Questionnaire (PHQ) 9, and Holmes-Rahe Life Stress Inventory. RESULTS: There were 131 participants (98 African and 33 non-African surgeons). The incidence of moderate to severe depression was 48% (n = 63), and the incidence of burnout was as high as 38% (n = 48). There were no significant differences between African and non-African surgeons in marital status, number of children, partners in practice, or distribution of time. More African surgeons experienced birth of a child (18% versus 3%, P = 0.04) but had less workplace conflict (7.1% versus 10.7%, P = 0.045) than non-African surgeons. African surgeons more consistently felt they were positively influencing others (P = 0.008), enjoyed working with patients (P = 0.009), and were more satisfied (P = 0.04). For all surgeons, predictors of increased PHQ-9 depression were serious professional conflict (P = 0.02), difficulty accessing childcare (P = 0.04), and racial discrimination (P = 0.003). In the Maslach model, predictors of burnout were difficulty accessing childcare (P = 0.05) and denial of promotion based on gender (P = 0.006). CONCLUSIONS: Burnout and depression in surgeons practicing in East, Central, and Southern Africa are substantial. Despite significant challenges, African surgeons tended to have a more positive outlook on their work. Improvements can be made to reduce burnout and depression by focusing on work conditions, equality of promotion opportunities, workplace conflict management, childcare support, and increasing the numbers of surgeons in practice.

The development and implementation of a pilot CBT for early psychosis service: achievements and challenges.

AIM: Cognitive behaviour therapy (CBT) is a clinically indicated treatment for first-episode psychosis. Despite this, CBT for early psychosis is not routinely available as part of standard mental health services in Australia. The aim of this pilot project was to develop a CBT for early psychosis service to be provided as an adjunct to existing community mental health services. This study examined the feasibility of this service model, delivered in a real-world setting. A secondary aim was to explore the effectiveness of this service, as measured by clinical and functional outcomes. METHODS: Participants living in northern Sydney, Australia, and who had recently experienced a first episode of psychosis, were offered up to 20 sessions of individual CBT. Service feasibility was measured via attrition rates, therapy attendance and referrer feedback. Measures of psychosis, depression, anxiety and psychosocial functioning, were assessed pretreatment, after six and 12 sessions, and at 3 months post-treatment. RESULTS: Nineteen clients attended treatment to completion. Survey feedback from referrers affirmed the positive impact of the service on clients' recovery. Additionally, clients showed improvements in symptoms of psychosis over the first three time points. Psychosocial functioning also shifted from the moderately to mildly impaired range by the end of treatment. CONCLUSIONS: The CBT for early psychosis service has been successfully integrated into the mental health landscape of northern Sydney. Outcomes of this pilot project are discussed with reference to the achievements of the service, as well as the obstacles encountered, and how they were overcome.

Identification of quantitative trait loci and candidate genes for cadmium tolerance in Populus.

Understanding genetic variation for the response of Populus to heavy metals like cadmium (Cd) is an important step in elucidating the underlying mechanisms of tolerance. In this study, a pseudo-backcross pedigree of Populus trichocarpa Torr. & Gray and Populus deltoides Bart. was characterized for growth and performance traits after Cd exposure. A total of 16 quantitative trait loci (QTL) at logarithm of odds (LOD) ratio ≥ 2.5 were detected for total dry weight, its components and root volume. Major QTL for Cd responses were mapped to two different linkage groups and the relative allelic effects were in opposing directions on the two chromosomes, suggesting differential mechanisms at these two loci. The phenotypic variance explained by Cd QTL ranged from 5.9 to 11.6% and averaged 8.2% across all QTL. A whole-genome microarray study led to the identification of nine Cd-responsive genes from these QTL. Promising candidates for Cd tolerance include an NHL repeat membrane-spanning protein, a metal transporter and a putative transcription factor. Additional candidates in the QTL intervals include a putative homolog of a glutamate cysteine ligase, and a glutathione-S-transferase. Functional characterization of these candidate genes should enhance our understanding of Cd metabolism and transport and phytoremediation capabilities of Populus.

Can training normalize atypical passive auditory ERPs in children with SRD or SLI?

This study tested if training can normalize atypical passive auditory event-related potentials in the N1-P2 time window in children with specific reading disability (SRD) or specific language impairment (SLI). Children with SRD or SLI and untrained controls were tested for their behavioral responses and N1-P2 windows to tones, backward-masked tones, vowels, and consonant-vowels. Children with SRD or SLI with poor behavioral responses to one of these sounds trained to discriminate that sound for 30 minutes a day, 4 days a week, for 6 weeks. Post-training measures revealed that training normalized atypical behavioral responses but not atypical N1-P2 windows.

Histone deacetylase inhibitors mediate post-transcriptional regulation of p21WAF1 through novel cis-acting elements in the 3' untranslated region.

Histone deacetylase inhibitors (HDACIs) are promising anti-tumor agents that selectively induce cell cycle arrest, differentiation and/or apoptosis of tumor cells. Fundamentally, HDACIs are proposed to function by activating the transcription of genes, including the potent cyclin dependent kinase inhibitor p21(WAF1). However, HDACIs primarily increase p21(WAF1) expression at the post-transcriptional level in HepG2 cells, implying that these anti-tumor agents regulate genes at multiple levels. Here, two novel cis-acting elements in the 3' untranslated region (UTR) of p21(WAF1) are identified that control the ability of HDACIs to induce p21(WAF1) mRNA stabilization. Collectively, these studies highlight the complexity of HDACIs in gene regulation.

A vacuolar arsenite transporter necessary for arsenic tolerance in the arsenic hyperaccumulating fern Pteris vittata is missing in flowering plants.

The fern Pteris vittata tolerates and hyperaccumulates exceptionally high levels of the toxic metalloid arsenic, and this trait appears unique to the Pteridaceae. Once taken up by the root, arsenate is reduced to arsenite as it is transported to the lamina of the frond, where it is stored in cells as free arsenite. Here, we describe the isolation and characterization of two P. vittata genes, ACR3 and ACR3;1, which encode proteins similar to the ACR3 arsenite effluxer of yeast. Pv ACR3 is able to rescue the arsenic-sensitive phenotypes of yeast deficient for ACR3. ACR3 transcripts are upregulated by arsenic in sporophyte roots and gametophytes, tissues that directly contact soil, whereas ACR3;1 expression is unaffected by arsenic. Knocking down the expression of ACR3, but not ACR3;1, in the gametophyte results in an arsenite-sensitive phenotype, indicating that ACR3 plays a necessary role in arsenic tolerance in the gametophyte. We show that ACR3 localizes to the vacuolar membrane in gametophytes, indicating that it likely effluxes arsenite into the vacuole for sequestration. Whereas single-copy ACR3 genes are present in moss, lycophytes, other ferns, and gymnosperms, none are present in angiosperms. The duplication of ACR3 in P. vittata and the loss of ACR3 in angiosperms may explain arsenic tolerance in this unusual group of ferns while precluding the same trait in angiosperms.

The metacognitive model of generalized anxiety disorder in children and adolescents.

Worry is a common phenomenon in children and adolescents, with some experiencing excessive worries that cause significant distress and interference. The metacognitive model of generalized anxiety disorder (Wells 1995, 2009) was developed to explain cognitive processes associated with pathological worry in adults, particularly the role of positive and negative beliefs about worry. This review evaluates the application of the model in understanding child and adolescent worry. Other key issues reviewed include the link between cognitive and metacognitive development and worry, and the measurement of worry and metacognitive worry in young people. Implications of these findings and directions for future research are discussed.

Atypical brain responses to sounds in children with specific language and reading impairments.

This study tested if children with specific language impairment (SLI) or children with specific reading disability (SRD) have abnormal brain responses to sounds. We tested 6- to 12-year-old children with SLI (N =19), children with SRD (N =55), and age-matched controls (N =36) for their passive auditory event-related potentials (ERPs) to tones, rapid tones, vowels and consonant-vowels. Thirty-eight percent of the children with SLI or SRD had less typical passive auditory ERPs in the N1-P2 window to sounds in general, rather than to tones, rapid tones, vowels or consonant-vowels specifically. The ERPs of these children were significantly 'flatter' in the N1-P2 region than normal. All the children with flatter ERPs in the N1-P2 region had poor non-word reading. A subgroup of these poor non-word readers also had poor non-word repetition. These findings support the hypothesis that impaired auditory processing is a causal risk factor for both SLI and SRD.