Dietitians' perspectives of the barriers and enablers to delivering patient-centred care.

BACKGROUND: Patient-centred care (PCC) is widely recognised as being important with respect to the delivery of quality health care. However, limited research has explored PCC in the dietetic context. In particular, dietitians' views of the barriers and enablers to delivering a patient-centred approach have not been investigated. Therefore, the present study aimed to explore primary care dietitians' perspectives of the barriers and enablers to delivering PCC. METHODS: The present study was situated in a constructivist-interpretivist paradigm and used qualitative methods. Both convenience and snowball sampling were used to recruit Australian Accredited Practising Dietitians (APD) who were working in primary care. Individual semi-structured interviews explored dietitians' perspectives of the barriers and enablers to delivering PCC. Data were analysed thematically. RESULTS: Twelve APDs were interviewed between March and April 2018. Seven themes were discovered: (i) challenges in defining PCC; (ii) valuing PCC; (iii) enacting PCC; (iv) requiring additional education in PCC; (v) evaluating one's own practice; (vi) workplace pressures and constraints; and (vii) keeping up with expectations. CONCLUSIONS: These findings suggest that: (i) the meaning of PCC in dietetics should be clarified to ensure it is being practiced consistently; (ii) undergraduate curricula require a greater emphasis on PCC so that dietitians graduate with the necessary knowledge and skills; (iii) there is a need for more professional development training to facilitate uptake of PCC in practice; and (iv) quantitative measurement of PCC using validated instruments is needed to evaluate PCC in the dietetic setting. Addressing some of these factors may assist dietitians to adopt these practices.

An actuatable soft reservoir modulates host foreign body response.

The performance of indwelling medical devices that depend on an interface with soft tissue is plagued by complex, unpredictable foreign body responses. Such devices-including breast implants, biosensors, and drug delivery devices-are often subject to a collection of biological host responses, including fibrosis, which can impair device functionality. This work describes a milliscale dynamic soft reservoir (DSR) that actively modulates the biomechanics of the biotic-abiotic interface by altering strain, fluid flow, and cellular activity in the peri-implant tissue. We performed cyclical actuation of the DSR in a preclinical rodent model. Evaluation of the resulting host response showed a significant reduction in fibrous capsule thickness (P = 0.0005) in the actuated DSR compared with non-actuated controls, whereas the collagen density and orientation were not changed. We also show a significant reduction in myofibroblasts (P = 0.0036) in the actuated group and propose that actuation-mediated strain reduces differentiation and proliferation of myofibroblasts and therefore extracellular matrix production. Computational models quantified the effect of actuation on the reservoir and surrounding fluid. By adding a porous membrane and a therapy reservoir to the DSR, we demonstrate that, with actuation, we could (i) increase transport of a therapy analog and (ii) enhance pharmacokinetics and time to functional effect of an inotropic agent. The dynamic reservoirs presented here may act as a versatile tool to further understand, and ultimately to ameliorate, the host response to implantable biomaterials.

Sources of stress for residents and recommendations for programs to assist them.

Bridging the gap between graduation from medical school and being board eligible in a medical specialty is a lengthy and arduous process. The fact that stress is typical during the residency training period is well-documented in the literature, as are its many situational, professional, and personal sources, which the author reviews: heavy work-load, sleep deprivation, difficult patients, poor learning environments, relocation issues, isolation and social problems, financial concerns, cultural and minority issues, information overload, and career planning issues. Stress can also stem from and exacerbate gender-related issues and problems for significant others, spouses, and family members. The author also describes less commonly documented sources of stress-often overlooked or postponed so long that stresses are inevitable for all concerned. These are associated with residents who perform marginally and in some cases should not have been passed on from medical school, or who are studying specialties not compatible with their skills and personalities, or who foster severe interpersonal problems on the job. Common effects of stress include anxiety, depression, obsessive-compulsive trends, hostility, and alcohol and substance abuse. To respond to the problems that these many stressors present to residents, the Accreditation Council for Graduate Medical Education (ACGME) requires that all post-medical-school medical training programs make assistance services available for all residents. The author outlines essential elements of an assistance program, states how important such problems can be in saving both residents and their institutions needless difficulties and costs, and presents important issues for the consideration of all involved in residents' training.

Hind limb malformations in free-living northern leopard frogs (Rana pipiens) from Maine, Minnesota, and Vermont suggest multiple etiologies.

BACKGROUND: Reports of malformed frogs have increased throughout the North American continent in recent years. Most of the observed malformations have involved the hind limbs. The goal of this study was to accurately characterize the hind limb malformations in wild frogs as an important step toward understanding the possible etiologies. METHODS: During 1997 and 1998, 182 recently metamorphosed northern leopard frogs (Rana pipiens) were collected from Minnesota, Vermont, and Maine. Malformed hind limbs were present in 157 (86%) of these frogs, which underwent necropsy and radiographic evaluation at the National Wildlife Health Center. These malformations are described in detail and classified into four major categories: (1) no limb (amelia); (2) multiple limbs or limb elements (polymelia, polydactyly, polyphalangy); (3) reduced limb segments or elements (phocomelia, ectromelia, ectrodactyly, and brachydactyly; and (4) distally complete but malformed limb (bone rotations, bridging, skin webbing, and micromelia). RESULTS: Amelia and reduced segments and/or elements were the most common finding. Frogs with bilateral hind limb malformations were not common, and in only eight of these 22 frogs were the malformations symmetrical. Malformations of a given type tended to occur in frogs collected from the same site, but the types of malformations varied widely among all three states, and between study sites within Minnesota. CONCLUSIONS: Clustering of malformation type suggests that developmental events may produce a variety of phenotypes depending on the timing, sequence, and severity of the environmental insult. Hind limb malformations in free-living frogs transcend current mechanistic explanations of tetrapod limb development.

Strategies for assessing the implications of malformed frogs for environmental health.

The recent increase in the incidence of deformities among natural frog populations has raised concern about the state of the environment and the possible impact of unidentified causative agents on the health of wildlife and human populations. An open workshop on Strategies for Assessing the Implications of Malformed Frogs for Environmental Health was convened on 4-5 December 1997 at the National Institute of Environmental Health Sciences in Research Triangle Park, North Carolina. The purpose of the workshop was to share information among a multidisciplinary group with scientific interest and responsibility for human and environmental health at the federal and state level. Discussions highlighted possible causes and recent findings directly related to frog deformities and provided insight into problems and strategies applicable to continuing investigation in several areas. Possible causes of the deformities were evaluated in terms of diagnostics performed on field amphibians, biologic mechanisms that can lead to the types of malformations observed, and parallel laboratory and field studies. Hydrogeochemistry must be more integrated into environmental toxicology because of the pivotal role of the aquatic environment and the importance of fates and transport relative to any potential exposure. There is no indication of whether there may be a human health factor associated with the deformities. However, the possibility that causal agents may be waterborne indicates a need to identify the relevant factors and establish the relationship between environmental and human health in terms of hazard assessment.

Outcome of renal transplantation in children less than two years of age.

Twenty-two renal transplants were performed in 21 children less than two years of age at Children's Hospital. Fourteen were from living related donors and eight were from cadaveric donors. The five year patient and graft survivals of these recipients were compared to all other pediatric recipients between two and 18 years of age who received renal transplants over the same time period. Five year graft survival for recipients less than two years of age was 86% following living-related donor transplantation and 38% following cadaver donor transplantation. Older pediatric recipients aged between two and 18 years had a five year graft survival of 73% following living-related donor renal transplantation, which was similar to that for recipients less than two years of age. Although older cadaveric recipients had a comparable five year graft survival to younger recipients, at 42%, the patterns of graft loss were different. Graft failures in young recipients occurred within the first seven months post-transplant, whereas the older recipient's grafts failed more gradually. Actuarial five-year patient survival in recipients less than two years of age was 86% following living-related donor renal transplantation and 70% following cadaver-donor renal transplantation. Recipients less than two years of age had a poorer patient survival than older recipients following both living-related donor renal transplantation (P = 0.06) and cadaver-donor renal transplantation (P less than 0.05). These findings suggest that the graft survival of living-related donor renal transplantation in recipients less than two years of age is better than that of cadaver-donor renal transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Regional brain glucose metabolism in neuroacanthocytosis.

Two brothers with neuroacanthocytosis had [18F]-2-fluoro-2-deoxyglucose PET scans showing marked glucose hypometabolism of the caudate and putamen. MRIs showed no evidence of atrophy or modification of signal intensity in these structures. Decreased glucose utilization of the striatum can underlie hyperkinetic movement disorders of various etiologies.

Severe primary hyperparathyroidism in a neonate with two hypercalcemic parents: management with parathyroidectomy and heterotopic autotransplantation.

A neonate with severe primary hyperparathyroidism was successfully managed by parathyroidectomy and heterotopic autotransplantation (one third of one gland of the infant was implanted in the forearm). In vitro studies of parathyroid tissue from the infant revealed a severe defect in parathyroid suppressibility. Postoperatively, the infant had modest hypercalcemia, normal serum immunoreactive parathyroid hormone levels, hypermagnesemia, and relative hypocalciuria. The parents were related and both had asymptomatic hypercalcemia with mean serum immunoreactive parathyroid hormone levels that were within the normal range. Similar to the findings in the infant postoperatively, relative hypocalciuria in the presence of hypercalcemia was found in the mother; in contrast, the father had hypercalciuria. The presumed dominantly transmitted hypercalcemia in this kindred is consistent with familial hypocalciuric hypercalcemia with a confounding factor of ethanol possibly accounting for the hypercalciuria in the father.

Progressive tubulointerstitial renal disease in infancy with associated hepatic abnormalities.

Clinical, pathologic, and biochemical data are reported in two male infants who had rapidly progressive renal failure, enlarged kidneys, hepatosplenomegaly, and fat malabsorption. One infant, studied prior to the onset of significant renal insufficiency, manifested renal Fanconi syndrome, hyperparathyroidism, and marked hypocalcemia. After a brief period of dialysis, both received renal transplants. Neither has clinical evidence of reoccurrence of the renal disorder in the transplant, but both still have hepatic abnormalities. Morphologic features present in both patients include a renal lesion characterized by tubulointerstitial injury with a tubulocystic component and hepatic abnormalities with bile duct proliferation, portal fibrosis, and inflammation. These cases do not readily conform to any single published diagnostic category, including nephronophthisis-congenital hepatic fibrosis or infantile polycystic kidney disease, and appear to be unique.

The medical and surgical management of typhlitis in children with acute nonlymphocytic (myelogenous) leukemia.

The treatment of acute leukemia in childhood has been increasingly successful. Infectious complications are the major cause of morbidity and mortality among these patients receiving aggressive chemotherapy. In particular, neutropenic enterocolitis or typhlitis has had a reported mortality of 50% to 100%. The authors reviewed a series of 77 previously untreated patients with acute myelogenous leukemia begun on treatment from March 1976 to June 1984 to better define the characteristics of typhlitis and its optimum management. Twenty-five patients had episodes of typhlitis, characterized by fever, abdominal pain, and tenderness, occurring during periods of neutropenia. Ten of these patients had watery diarrhea as a major additional symptom, and nine patients had a significant episode of gastrointestinal bleeding. In seven instances, blood culture results were positive, all for intestinal flora. The episodes of typhlitis occurred most frequently during the induction therapy (19 patients). Five patients experienced typhlitis during maintenance therapy, and one patient had acute appendicitis. Two patients had typhlitis during their reinduction therapy, and of note, one had had abdominal symptoms during her initial induction. All patients were treated initially with broad-spectrum antibiotics and bowel rest. Four criteria have been used for surgical intervention: (1) persistent gastrointestinal bleeding after resolution of neutropenia and thrombocytopenia and correction of clotting abnormalities; (2) evidence of free intraperitoneal perforation; (3) clinical deterioration requiring support with vasopressors, or large volumes of fluid, suggesting uncontrolled sepsis; and (4) development of symptoms of an intra-abdominal process, in the absence of neutropenia, which would normally require surgery. Using these criteria, five patients required surgical intervention for typhlitis or its sequelae and one for acute appendicitis. There was one perioperative death resulting from miliary tuberculosis. Among the 21 patients managed medically, there was 1 death resulting from typhlitis in a patient in whom surgery was deferred because of her multiple failures to enter remission.

Maintenance of vascular access patency in pediatrics.

The patency of vascular access shunts and fistulae has been prolonged by a combined surgical and radiological approach that includes percutaneous transluminal angioplasty (PTA), surgical revision, thrombectomy, and thrombolysis. Over the last 3 years, 35 vascular accesses in 27 patients were found to have angiographic abnormality. PTA was performed 32 times on 19 accesses and 7 PTAs resulted in patent accesses by the end of the study. Surgical revision was performed 9 times on 8 accesses and 2 of the surgical revisions resulted in a patent access by the end of the study. Concerning Thomas femoral shunts, PTA prolonged the patency by 2.2 months and surgical revision by 3.8 months per procedure. Concerning arteriovenous (AV) fistulae, PTA prolonged the patency by 4.3 months and surgical revision by 3.5 months per procedure. A combination of procedures effectively doubles the duration of patency of Thomas femoral shunts and almost triples the duration of patency of AV fistulae in children. Forty-one percent of these accesses remain open 1 year following the initiation of these procedures.

The preliminary evaluation of Mn DTPA as a potential contrast agent for nuclear magnetic resonance imaging.

The pharmacokinetics of 54Mn administered as Mn-diethylenetriamine pentaacetic acid (DTPA) are being investigated to determine if tissue-specific uptake of manganese could be observed while increasing urinary excretion. This chelation and increased excretion should reduce toxicity. In order to obviate the need for repetitive quantitative nuclear magnetic resonance imaging (NMR) we have substituted tracer amounts of a radioisotope of manganese, Mn-54, for the stable ion. By 6 hours, 58 +/- 7% of the injected dose had been excreted in the urine. Peak liver accumulation occurred within 30 minutes (0.50 +/- 0.14% injected dose/g X kg body weight). The pancreas also showed a relatively high accumulation of tracer (0.25 +/- 0.04%/g X kg body weight), reaching a peak at 4 hours. The pancreas to liver ratios were highest at 6 hours (0.7). There was also a substantial accumulation of the manganese in bile. The blood concentration fell very rapidly with little tracer remaining in the blood at 1 hour. Based on these pharmacokinetics, imaging experiments were conducted before, immediately after, and 9 or 24 hours postinjection. These images showed enhanced kidneys and, later (at 9 hours), an excellent parenchymal-collecting system differentiation. The gallbladder was negatively enhanced. The liver showed either increased or decreased signal strength relative to skeletal muscle depending on the pulse sequence used. We conclude that Mn++, administered as Mn-DTPA, merits further investigation as an NMR contrast agent.

The surgical management of fungal pulmonary infections in children with acute myelogenous leukemia.

Infections are the primary cause of complications and death in patients with acute myelogenous leukemia. Current aggressive treatment protocols have improved patient survival but produce extended periods of profound neutropenia during which the patients are particularly susceptible to opportunistic infections. Candida and Aspergillus species are the most common of the fungi causing invasive infections in these patients. In a group of 77 previously untreated children with acute myelogenous leukemia begun on treatment from March 1976 to June 1984, four patients developed localized fungal infections of the lung. These initially appeared as pulmonary infiltrates on chest roentgenograms during periods of severe neutropenia (three during remission induction and one after intensive consolidation therapy). Endobronchial cultures failed to identify the infectious organism in all cases. Computerized axial tomography best defined the cavitary nature of the lesions in 2 patients. All four patients underwent surgical resection, both to establish a diagnosis (three patients) and as part of therapy. There was no operative morbidity. The organisms involved were Aspergillus (2), Torulopsis (1), and Penicillium (1). Three patients were cured of their fungal infections. The fourth patient failed to enter remission and died of a cerebral fungal abscess that developed shortly after thoracotomy. We report these cases to encourage early surgical intervention in leukemics with a localized pulmonary process consistent with a fungal infection. Resection of the primary focus obviates the risk of life threatening pulmonary hemorrhage or dissemination of the fungus and allows for early reinstitution of chemotherapy which is vital to these patients' survival.

Stage IV-N: a favorable subset of children with metastatic neuroblastoma.

Among children over 1 year of age with Evans Stage IV neuroblastoma, there appears to be a small group with a relatively favorable prognosis. These patients have extensive lymph node metastases (cervical/axillary/thoracic/abdominal/pelvic), but no extranodal metastases. Three of six such patients (50%) are long-term disease-free survivors, compared with none of 40 patients with extranodal metastatic disease (p less than 0.0002). Patients with only lymph node metastases (Stage "IV-N") may have a biologically more favorable tumor that is curable with conventional, intensive multimodality therapy.

Improved survival in neuroblastoma using multimodality therapy.

One hundred and thirty-six patients with neuroblastoma have been treated at our center from 1970 to 1982, using various combinations of surgery, radiation therapy, and chemotherapy. Choice of therapy was individualized but depended primarily on age and stage. The overall disease-free survival was 60% (minimum follow-up of one year). Patients with stage I disease and younger patients with stage II disease usually received less intensive therapy and fared extremely well (100% survival). Patients with stage III disease and older patients with stage II disease also did extremely well (survival of 85% and 90%, respectively). These patients may have benefited from intensive treatment with all three modalities. Patients under one year of age with stage IV neuroblastoma were treated with surgery and multiagent chemotherapy, and 92% (11/12) survived free of disease. Patients over one year old with stage IV disease represented the only group for which therapy was unsuccessful (10% survival). With combination approaches and with more effective multiagent chemotherapeutic regimens, a real impact on the survival of older stage II patients, stage III patients, and younger stage IV patients appears to have been made. However, older stage IV patients are rarely cured with conventional therapy, and better approaches will be needed for this group.

Neuroblastoma: the Joint Center for Radiation Therapy/Dana-Farber Cancer Institute/Children's Hospital experience.

The treatment results for 118 patients with neuroblastoma seen at the Joint Center for Radiation Therapy/Dana-Farber Cancer Institute/Children's Hospital from 1970 to 1980 were analyzed. Patients were treated with a combination of surgery, radiation therapy, and chemotherapy depending on stage and age. Disease-free survival was excellent in all patient groups except those over one year of age with stage IV disease, a group for which currently available therapy cures only a small proportion of patients. Patients with stage III disease and older patients with stage II disease did extremely well (survival of 81% and 89%, respectively) and may have benefited from intensive treatment with all three modalities. Survival for infants (under one year) with stage IV neuroblastoma (90%) has clearly improved with intensive combination chemotherapy. With combination approaches and newer, more effective systemic regimens, a real impact on survival appears to have been made in the last decade. Better approaches will be necessary to cure more than an occasional older patient with stage IV disease.