"He did girls' things!" Hong Kong and Canadian children's reasoning about moral judgments of peers' gendered behaviors.

Children show less positivity toward gender-nonconforming (GN) than gender-conforming (GC) peers. Yet, little is known about children's reasoning about peers of varying gender expressions, including age-, gender-, and culture-related influences. We investigated how children aged 4- to 5- and 8- to 9-years-old in Hong Kong and Canada (N = 678) reason about their moral judgments of GC and GN peers. After viewing vignettes describing GC and GN boys and girls, we asked children whether each target peer's behavior was right or wrong and why they thought so. We coded children's reasoning using a new coding scheme developed via inductive content analysis. Overall, children's most commonly used reasoning styles were global standard, personal choice, gender stereotypes, "don't know," and others' welfare. Children used more gender stereotype-related reasoning when they were older and from Hong Kong, appraising the GN boy, or when they perceived the target's behavior as wrong. In contrast, children reasoned based on personal choice more when they were from Canada or when they perceived the target's behavior as right. These findings inform how age-, gender-, and culture-related factors are associated with children's reasoning about the acceptability or appropriateness of varying kinds of childhood gendered behavior. They provide insights regarding children's appraisals of different gender expressions by illuminating not only how they view GC and GN peers but also, from their own perspectives, why they do so. These insights have implications for strategies aimed at decreasing gender-related biases and increasing children's acceptance of gender diversity. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Barriers and facilitators to implementation and sustainment of guideline-recommended depression screening for patients with breast cancer in medical oncology: a qualitative study.

OBJECTIVES: Implementation of guideline-recommended depression screening in oncology presents numerous challenges. Implementation strategies that are responsive to local context may be critical elements of adoption and sustainment. We evaluated barriers and facilitators to implementation of a depression screening program for breast cancer patients in a community medical oncology setting as part of a cluster randomized controlled trial. METHODS: Guided by the Consolidated Framework for Implementation Research, we employed qualitative methods to evaluate clinician, administrator, and patient perceptions of the program using semi-structured interviews. We used a team-coding approach for the data; thematic development focused on barriers and facilitators to implementation using a grounded theory approach. The codebook was refined through open discussions of subjectivity and unintentional bias, coding, and memo applications (including emergent coding), and the hierarchical structure and relationships of themes. RESULTS: We conducted 20 interviews with 11 clinicians/administrators and 9 patients. Five major themes emerged: (1) gradual acceptance and support of the intervention and workflow; (2) compatibility with system and personal norms and goals; (3) reinforcement of the value of and need for adaptability; (4) self-efficacy within the nursing team; and (5) importance of identifying accountable front-line staff beyond leadership "champions." CONCLUSIONS: Findings suggest a high degree of acceptability and feasibility due to the selection of appropriate implementation strategies, alignment of norms and goals, and a high degree of workflow adaptability. These findings will be uniquely helpful in generating actionable, real-world knowledge to inform the design, implementation, and sustainment of guideline-recommended depression screening programs in oncology. TRIAL REGISTRATION: ClinicalTrials.gov #NCT02941614.

Effect of a Community-Based Medical Oncology Depression Screening Program on Behavioral Health Referrals Among Patients With Breast Cancer: A Randomized Clinical Trial.

Importance: Implementation of guideline-recommended depression screening in medical oncology remains challenging. Evidence suggests that multicomponent care pathways with algorithm-based referral and management are effective, yet implementation of sustainable programs remains limited and implementation-science guided approaches are understudied. Objective: To evaluate the effectiveness of an implementation-strategy guided depression screening program for patients with breast cancer in a community setting. Design, Setting, and Participants: A pragmatic cluster randomized clinical trial conducted within Kaiser Permanente Southern California (KPSC). The trial included 6 medical centers and 1436 patients diagnosed with new primary breast cancer who had a consultation with medical oncology between October 1, 2017, through September 30, 2018. Patients were followed up through study end date of May 31, 2019. Interventions: Six medical centers in Southern California participated and were randomized 1:1 to tailored implementation strategies (intervention, 3 sites, n = 744 patients) or education-only (control, 3 sites, n = 692 patients) groups. The program consisted of screening with the 9-item Patient Health Questionnaire (PHQ-9) and algorithm-based scoring and referral to behavioral health services based on low, moderate, or high score. Clinical teams at tailored intervention sites received program education, audit, and feedback of performance data and implementation facilitation, and clinical workflows were adapted to suit local context. Education-only controls sites received program education. Main Outcomes and Measures: The primary outcome was percent of eligible patients screened and referred (based on PHQ-9 score) at intervention vs control groups measured at the patient level. Secondary outcomes included outpatient health care utilization for behavioral health, primary care, oncology, urgent care, and emergency department. Results: All 1436 eligible patients were randomized at the center level (mean age, 61.5 years; 99% women; 18% Asian, 17% Black, 26% Hispanic, and 37% White) and were followed up to the end of the study, insurance disenrollment, or death. Groups were similar in demographic and tumor characteristics. For the primary outcome, 7.9% (59 of 744) of patients at tailored sites were referred compared with 0.1% (1 of 692) at education-only sites (difference, 7.8%; 95% CI, 5.8%-9.8%). Referrals to a behavioral health clinician were completed by 44 of 59 patients treated at the intervention sites (75%) intervention sites vs 1 of 1 patient at the education-only sites (100%). In adjusted models patients at tailored sites had significantly fewer outpatient visits in medical oncology (rate ratio, 0.86; 95% CI, 0.86-0.89; P = .001), and no significant difference in utilization of primary care, urgent care, and emergency department visits. Conclusions and Relevance: Among patients with breast cancer treated in community-based oncology practices, tailored strategies for implementation of routine depression screening compared with an education-only control group resulted in a greater proportion of referrals to behavioral care. Further research is needed to understand the clinical benefit and cost-effectiveness of this program. Trial Registration: ClinicalTrials.gov Identifier: NCT02941614.

Children's bias in appraisals of gender-variant peers.

Past research suggests that children have biased negative appraisals of gender-variant (GV) peers (i.e., peers who display behaviors/interests that do not align with gender stereotypes). In the current study, Canadian cisgender 4- and 5-year-olds and 8- and 9-year-olds (N = 183; 48.6% girls), who were ethnically diverse (36% White European heritage) and from mostly middle- to upper-income families, viewed vignettes depicting boys and girls as either gender-conforming (GC) or GV. Multiple measures gauged children's appraisals in various domains (i.e., friendship/social preference, popularity, happiness, imitation, and moral judgment). Children's bias against GV peers was modest. Children preferred peers who presented as the same gender and/or with same-gender-typed behaviors/interests. Compared with GC peers, GV peers were rated as less happy, and older children rated a GV boy as less popular. When juxtaposed with a previous study of Hong Kong children that used the same study design, there were several parallels in the patterns observed, but Canadian children had a weaker and less consistent pattern of bias against GV peers than children from Hong Kong. In addition, children from these two cultures showed discrepant patterns for certain aspects of appraisals (e.g., happiness, moral judgment). Overall, these findings inform age-, gender-, and cultural-related influences on children's appraisals of GV peers.

Children's Appraisals of Gender Nonconformity: Developmental Pattern and Intervention.

Gender-nonconforming (GN) children are often perceived less positively, which may harm their well-being. We examined the development of such perceptions and an intervention to modify them. Chinese children's appraisals were assessed using multiple measures (verbal responses, sharing, and rank order task) after viewing vignettes of gender-conforming (GC) and GN hypothetical peers. In Study 1, children (N = 210; 4-, 5-, 8-, and 9-year-olds) were less positive toward GN than GC peers, especially if they were older or if the peers were boys. In Study 2 (N = 211, 8- and 9-year-olds), showing children exemplars of GN peers who displayed positive and GC characteristics subsequently reduced bias against gender nonconformity. These findings inform strategies aimed at reducing bias against gender nonconformity.

Persistent vasomotor symptoms and breast cancer in the Women's Health Initiative.

OBJECTIVE: Vasomotor symptoms (VMS) including hot flashes and night sweats are common during the menopausal transition and may persist. Although VMS pathophysiology is complex, estrogen's efficiency as VMS therapy suggests hormonal environment change may influence this process. As studies of VMS and breast cancer are inconsistent, we examined associations between persistent VMS and breast cancer incidence and mortality. METHODS: The analytic sample included 25,499 postmenopausal women aged 50 to 79 in the Women's Health Initiative (WHI) without current/former menopausal hormone therapy use with information on VMS status (never vs persistent). Breast cancers were verified by medical record review. Cause of death attribution was enhanced by serial National Death Index queries. Associations between VMS status and breast cancer incidence and mortality was determined using time dependent Cox regression analyses adjusted for breast cancer risk factors. RESULTS: Through 17.9 years (median) follow-up, 1,399 incident breast cancers were seen. Women with persistent VMS (VMS median duration 10+ years) (n = 9,715), compared to women with never VMS (n = 15,784), had a higher breast cancer incidence (hazard ratio [HR] 1.13 95% confidence interval [CI] 1.02-1.27). While breast cancer-specific mortality was higher in women with persistent VMS (HR 1.33 95% CI 0.88-2.02), the difference was not statistically significant. Persistent VMS status had no influence on breast cancer overall survival (HR 1.02 95% CI 0.81-1.29). CONCLUSION: Women with persistent VMS are more likely to be diagnosed with breast cancer than women who never experienced VMS, but not more likely to die from breast cancer.

Radiologic discrepancies in children with special healthcare needs in a pediatric emergency department.

BACKGROUND: After-hours radiologic interpretation by nonradiology attendings or resident radiologists introduces the risk of discrepancies. Clinical outcomes following radiologic discrepancies among pediatric emergency department (ED) patients are poorly described. In particular, children with special healthcare needs (CSHCN), have more opportunities for discrepancies and potential consequences than non- CSHCN. Our objective was to determine the rates and types of radiologic discrepancies, and to compare CSHCN to non-CSHCN. METHODS: From July 2014 to February 2015, all children who underwent a diagnostic imaging study at a free-standing children's ED were included. Data collected included radiologic studies - type and location - and clinical details - chief complaint and CSHCN type. Differences between preliminary reads and final pediatric radiology attending reads were defined as discrepancies, and categorized by clinical significance. Descriptive statistics, z-tests, and chi-square were used. RESULTS: Over 8months, 8310 visits (7462 unique patients) had radiologic studies (2620 CSHCN, 5690 non-CSHCN). A total of 198 (2.4%) radiologic discrepancies [56 (28.3%) CSHCN, 142 (71.7%) non-CSHCN] were found. Chief complaints for CSCHN were more often within the cardiac, pulmonary and neurologic systems (p<0.001 for each), whereas non-CSHCN presented with more trauma (p<0.001). The rates of discrepancies (CSHCN 2.1%, non- CSHCN 2.5%, p=0.3) and severity of clinical consequences (p=0.6) were not significantly different between CSHCN and non-CSHCN. CONCLUSION: Though the frequency and type of radiologic studies performed between CSHCN and non-CSHCN were different, we found no significant difference in the rate of radiologic discrepancies or the rate of clinically significant radiologic discrepancies.

An Unlikely Rapid Transformation of Myelodysplastic Syndrome to Acute Leukemia: A Case Report.

INTRODUCTION: Myelodysplastic syndrome is characterized by stem-cell-derived clonal myelopoiesis with an alteration in proliferation and differentiation. This condition carries a potential for transformation to acute leukemia, primarily in cases that are accompanied by high-risk features at diagnosis. CASE PRESENTATION: A 68-year-old man with recently diagnosed myelodysplastic syndrome and Sweet syndrome (acute febrile neutrophilic dermatosis) presented to our Emergency Department with shortness of breath. During his hospital course, he developed signs and symptoms, predominantly consisting of respiratory difficulties, that were not typically characteristic of transformation to acute leukemia. Several days into his hospitalization, it was determined that the patient's underlying hematologic process seemed to have rapidly evolved into an acute myeloid leukemia, which accounted for the progression of symptoms. This patient ultimately opted for comfort measures only and died shortly thereafter. DISCUSSION: Two important factors stood out as representing an atypical presentation. First, this patient lacked any of the high-risk features of myelodysplastic syndrome that typically portend transformation. In addition, his progression to acute leukemia in 28 days from the time of diagnosis was far more rapid than the 274-day median previously described in the literature. We theorize that the presence of Sweet syndrome may have served as a predisposing factor to transformation. This finding may offer benefit to physicians to potentially better predict this outcome and pursue more aggressive treatment measures earlier in the course of the disease in such a setting.

Introducing Teamwork Challenges in Simulation Using Game Cards.

STATEMENT: Poor teamwork and communication during resuscitations are linked to patient safety problems and poorer outcomes. We present a novel simulation-based educational intervention using game cards to introduce challenges in teamwork. This intervention uses sets of game cards that designate roles, limitations, or communication challenges designed to introduce common communication or teamwork problems. Game cards are designed to be applicable for any simulation-based scenario and are independent from patient physiology. In our example, participants were pediatric emergency medicine fellows undergoing simulation training for orientation. We describe the use of card sets in different scenarios with increasing teamwork challenge and difficulty. Both postscenario and summative debriefings were facilitated to allow participants to reflect on their performance and discover ways to apply their strategies to real resuscitations. In this article, we present our experience with the novel use of game cards to modify simulation scenarios to improve communication and teamwork skills.

Pediatric emergency medicine asynchronous e-learning: a multicenter randomized controlled Solomon four-group study.

OBJECTIVES: Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e-learning curriculum has not been studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e-learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers. METHODS: Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four-group design. The experimental arms received an asynchronous e-learning curriculum consisting of nine Web-based, interactive, peer-reviewed Flash/HTML5 modules. Postrotation testing and in-training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearson's correlation tested associations between module usage, scores, and ITE scores. RESULTS: A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e-learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e-learning modules was associated with an improvement in posttest scores (p < 0.001), from a mean score of 18.45 (95% confidence interval [CI] = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η(2) = 0.19). Posttest scores correlated with ITE scores (r(2) = 0.14, p < 0.001) among pediatric residents. CONCLUSIONS: Asynchronous e-learning is an effective educational tool to improve knowledge in a clinical rotation. Web-based asynchronous e-learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in-hospital learning.

Walking speed, physical activity, and breast cancer in postmenopausal women.

Higher self-reported physical activity is associated with lower breast cancer incidence and mortality. Objectively measured timed walking speed, predictive of longevity in older adults, has been associated with ambulatory physical activity in small studies but definitive assessment of the association is lacking. Participants were a subset of 14 719 postmenopausal women in the Women's Health Initiative study who, at entry, had 10 m, timed walking speed determined. After 12.4 years [mean (SD) (3.5)] follow-up, 762 invasive breast cancers were diagnosed in this group. In addition, 8162 of these women self-reported physical activity. Simple linear regression was used to examine the relationship between timed walking speed and self-reported physical activity. A Cox proportional hazard model was used to estimate age-adjusted hazard ratios and 95% confidence intervals for the association between timed walking speed and invasive breast cancer incidence. Although a linear regression model for self-reported physical activity [log metabolic equivalent task (MET) h/week] versus 10 m, timed walking speed had a statistically significant slope (coefficient=0.03, P<0.0001, correlation=0.20), the magnitude of the relationship was not clinically useful. Timed walking speed quintile was not associated with breast cancer incidence in age-adjusted or multivariant analyses (P for trend=0.60). Timed walking speed was not associated with self-reported physical activity in a clinically useful manner or with breast cancer incidence. Our findings do not support use of timed walking speed as an objective surrogate for self-reported physical activity.

Silver nanoparticles alter proteoglycan expression in the promotion of tendon repair.

This study demonstrates a novel method of using silver nanoparticles for Achilles tendon injury healing. In vitro results indicated a stimulatory effect on cell proliferation and collagen synthesis with silver nanoparticles. Biomechanical test on the 42-day post operation Achilles tendon sample exhibited a significant improvement in tensile modulus when compared to the untreated group. Histology suggested that silver nanoparticles promoted cell alignment and proteoglycan synthesis. The collagen deposition was also improved. An alleviation of tumor necrosis factor α, and an increase in fibromodulin and proliferating cell nuclear antigen expression were seen in silver nanoparticles group by immunohistochemistry. This study further corroborates the finding of our previous study that silver nanoparticles help to restore the functionality of injured connective tissues. We believe that the anti-inflammatory nature of silver nanoparticles has an important role in accelerating the healing process and reducing scarring, leading to better functional outcome. From the clinical editor: Tendon healing after surgeries remains a slow and tedious process, typically requiring several weeks of recovery time and gradual introduction of physical therapy. There are no currently utilized methods that could promote tendon healing. In this study, silver nanoparticles are reported to facilitate Achilles tendon repair in a model system, through increased proteoglycan and collagen synthesis, paving the way to potential clinical applications in the future.

Modulation of collagen alignment by silver nanoparticles results in better mechanical properties in wound healing.

Our previous study has revealed that silver nanoparticles (AgNPs) have potential to promote wound healing by accelerated re-epithelization and enhanced differentiation of fibroblasts. However, the effect of AgNPs on the functionality of repaired skin is unknown. The aim of this study was to explore the tensile properties of healed skin after treatment with AgNPs. Immunohistochemical staining, quantitative assay and scanning electron microscopy (SEM) were used to detect and compare collagen deposition, and the morphology and distribution of collagen fibers. Our results showed that AgNPs improved tensile properties and led to better fibril alignments in repaired skin, with a close resemblance to normal skin. Based on our findings, we concluded that AgNPs were predominantly responsible for regulating deposition of collagen and their use resulted in excellent alignment in the wound healing process. The exact signaling pathway by which AgNPs affect collagen regeneration is yet to be investigated. FROM THE CLINICAL EDITOR: The aim of this study was to explore the tensile properties of healed skin after treatment with AgNPs. These nanoparticles improved tensile properties and led to better fibril alignments in repaired skin, with a close resemblance to normal skin. The exact signaling pathway by which AgNPs affect collagen regeneration is yet to be investigated.

Diagnosing pediatric appendicitis: usefulness of laboratory markers.

OBJECTIVE: This study aimed to evaluate the utility of C-reactive protein (CRP), procalcitonin (PCT), D-lactate, and white blood cell (WBC) count as an aid to distinguish appendicitis from other diagnoses. METHODS: This prospective, observational study was conducted at an urban tertiary academic pediatric emergency department (ED). Subjects aged 1 to 18 years presenting with abdominal pain suspicious for acute appendicitis were enrolled. Data included history, physical examination, laboratory data (complete blood count, CRP, D-lactate, PCT [semiquantitative]), laboratory results, x-rays, surgical consultation notes, histopathology, and admission data. Stepwise logistic regression analysis was performed to identify independent risk factors. RESULTS: Two hundred nine subjects (59% male, 41% female) were enrolled over 6 months. One hundred fifteen subjects were histologically diagnosed with appendicitis; 94 subjects did not have appendicitis and were used as controls. Mean values of WBC, CRP, PCT, and absolute neutrophil count in subjects with definitive appendicitis were significantly higher than in subjects with no definitive appendicitis. D-Lactate levels were noncorrelative. Significant independent risk factors identified for definitive appendicitis included WBC count more than 12 cells × 1000/mm(3) (adjusted odds ratio [AOR], 6.54), CRP level greater than 3 mg/dL (AOR, 3.44), presence of hopping pain (AOR, 2.69), and presence of pain with walking (AOR, 2.56). Odds ratio for definitive appendicitis and its 95% confidence interval was found to be 7.75 for subjects with both WBC more than 12 cells × 1000/mm(3) and CRP greater than 3 mg/dL. CONCLUSIONS: C-reactive protein with WBC is useful in distinguishing appendicitis from other diagnoses in pediatric subjects presenting to the ED. White blood cell count greater than >12 cells × 1000/mm(3) and CRP greater than 3 mg/dL increases the likelihood of appendicitis. D-Lactate is not a useful laboratory adjunct.

Sexual dysfunction and aromatase inhibitor use in survivors of breast cancer.

Aromatase inhibitors (AIs) are now an integral component in the management of postmenopausal adjuvant therapy for breast cancer in women with hormone receptor-positive disease; however, the AI-associated reduction in estrogen levels can increase vaginal/vulvar symptoms and adversely influence sexual function. Although non-hormone-containing local agents with demonstrated efficacy are available, optimal therapy for estrogen deprivation-associated vaginal/vulvar symptoms might require local or systemic estrogen use. However, the safety of systemic estrogen use in the breast cancer setting, especially for women on AIs, has been challenged by recent randomized clinical trial evidence. In addition, maintenance of estrogen levels in the postmenopausal range cannot be assured with local estrogen use. Thus, for postmenopausal women with limiting vaginal/vulvar symptoms on adjuvant AIs that are not manageable with non-hormone-containing agents, a switch to tamoxifen might be preferred rather than adding local or systemic estrogens to the AI regimen.