Treating Patients As People: What Do Hospital Patients Want Clinicians to Know About Them As a Person?

BACKGROUND: There is little understanding or focus on the patient's personal communicative perspective during their experience of clinical treatment. An exploratory study and a follow-up study were conducted at a large safety net hospital to determine whether and what patients wanted clinicians to know more about them as a person. STUDY DESIGN: A convenience sample of 230 patients was selected from 9 different clinical units within the hospital for exploratory interviews to determine whether patients wanted their clinical team to know about them as a person. Based on these findings, additional personal preference data of patients were collected from a census sample of 387 patients selected from 2 intensive care unit units and 2 medical-surgical units. FINDINGS: The majority of patients in the exploratory study reported they wanted to tell their doctors/nurses some personal information about themselves, thought doctors/nurses could provide better care to them if they knew more about them as a person, and that communication between themselves and their doctors/nurses would improve if they knew more about them as a person. The follow-up study found that a majority of patients preferred that their clinicians call them by their first name and identified specific personal information they wanted to share with the clinical care team. The data also showed a meaningful number of patients who did not want to share this information with others. This split in patient preferences is an important reminder that being aware of personal preferences of patients does not necessarily mean an invitation to increase intimacy in all clinician-patient communications.

Health literacy and abdominal aortic aneurysms.

OBJECTIVE: Little is known about the public's knowledge of abdominal aortic aneurysms (AAA). Although preventive screening is available, millions of Americans remain unaware of their risk. Improved health literacy has been associated with increased screening and improvement in health outcomes. This study assessed the level of AAA literacy among respondents who participated in a free AAA screening event. METHODS: Thirteen key words used by vascular surgeons to describe the risk, diagnosis, and treatment options for AAA were extracted from the screening tool used by the nation's largest provider of free AAA diagnostic services, AAAneurysm Outreach. The National Institutes of Health recommends readability of patient education materials to be at the sixth-grade level, but a readability analysis of these words placed them at a grade level of 14.6. A self-administrated questionnaire was developed that allowed respondents to compare each of the extracted words with a definitionally correct or incorrect word that reflected a sixth-grade readability score. These scores were then compared with the available demographics. RESULTS: There were 570 completed questionnaires. Of the participants, 57.6% were female, 61.4% were 60 and above, and 32.6% were veterans. The average number of correct answers was 9.31 out of 13 (72% correct). Only 4.7% answered all questions correctly, with 29.1% missing five or more answers. The most frequently missed words were asymptomatic, screening, and cholesterol (56.5%, 44%, and 41.4% incorrect, respectively). The most frequently known terms were abdominal, diagnosis, and genetic (96%, 95.3%, and 91.9% correct, respectively). The remaining words fell between these extremes. Those aged 60 and above scored significantly lower than younger respondents (P < .0001). A post hoc power analysis indicated that the power to detect the obtained effects of age at the .05 level was greater than 0.95. Gender and veteran status did not produce any significant differences. CONCLUSIONS: These data suggest an important communication gap between the words used by clinicians to describe the risks, diagnostic results, and treatment options of AAA and the targeted at-risk population, especially those 60 years and older.

CENTRAL DIABETES INSIPIDUS AND CHEMOTHERAPY: USE OF A CONTINUOUS ARGININE VASOPRESSIN INFUSION FOR FLUID AND SODIUM BALANCE.

OBJECTIVE: Central diabetes insipidus can occur in the setting of primary or metastatic tumors that disrupt the hypothalamic-pituitary axis. Usual treatment consists of water intake to replace ongoing fluid losses and desmopressin administration aimed at decreasing the urine output to enable maintenance of eunatremia without polyuria. Marked derangement in plasma sodium concentration can occur when high-volume intravenous fluid administration is required during chemotherapy to prevent nephrotoxicity, particularly if obligate fluid intake exceeds the total daily fluid intake necessary to maintain eunatremia. METHODS: We developed a protocol for a rapidly titratable low-dose continuous intravenous arginine vasopressin infusion to maintain eunatremia in patients with central diabetes insipidus during periods of obligate fluid intake. RESULTS: We successfully maintained eunatremia in 2 patients with central nervous system lymphoma who underwent several cycles of obligate intravenous fluid administration with 5% dextrose in 0.45% sodium chloride for chemotherapy. CONCLUSION: Obligate fluid administration can result in dangerous and severe fluctuations in plasma sodium concentration in patients with central diabetes insipidus receiving conventional desmopressin therapy. The use of a rapidly titratable low-dose continuous vasopressin infusion successfully maintained eunatremia in this setting. This protocol can be replicated to prevent the wide and potentially dangerous fluctuations in plasma sodium concentration that can occur in patients with central diabetes insipidus who require high-volume intravenous fluid administration. This protocol has not been assessed among patients with impaired renal function and, thus, may not be generalizable to this population. (AACE Clinical Case Rep. 2018;4:e487-e492).

Extensive miRNA expression analysis in craniopharyngiomas.

PURPOSE: Craniopharyngiomas are benign tumors of the sellar or parasellar regions. They arise from the remnants of Rathke's pouch and are considered a "developmental disease." microRNAs are short non-coding RNAs that play a key regulatory role in the control of expression of entire gene networks. We performed an extensive analysis of miRNAs in craniopharyngiomas aiming to identify a miRNA expression signature that might aid in the prognosis of disease progression and outcome. METHODS: Thirty-seven craniopharyngioma samples from twenty-three patients, ten age-matched controls from autopsy, and ten infant controls from the developing pituitary from autopsy were evaluated for the expression of 754 miRNAs using TaqMan® Low Density Arrays (TLDAs) v2.0 (Applied Biosystems, Foster City, CA). RESULTS: Among the most differentially expressed miRNAs, downregulation of miR-132 appears to be a marker of aggressiveness and also plays a role in epithelial-mesenchymal transition. CONCLUSIONS: This is the first time that an extensive study of miRNA expression has been performed in craniopharyngiomas. Further research needs to be performed to investigate the potential role of miR-132 in the development and progression of craniopharyngiomas, and its value as a prognostic marker of aggressiveness.

Diabetes insipidus in infants and children.

Diabetes insipidus, the inability to concentrate urine resulting in polyuria and polydipsia, can have different manifestations and management considerations in infants and children compared to adults. Central diabetes insipidus, secondary to lack of vasopressin production, is more common in children than is nephrogenic diabetes insipidus, the inability to respond appropriately to vasopressin. The goal of treatment in both forms of diabetes insipidus is to decrease urine output and thirst while allowing for appropriate fluid balance, normonatremia and ensuring an acceptable quality of life for each patient. An infant's obligate need to consume calories as liquid and the need for readjustment of medication dosing in growing children both present unique challenges for diabetes insipidus management in the pediatric population. Treatment modalities typically include vasopressin or thiazide diuretics. Special consideration must be given when managing diabetes insipidus in the adipsic patient, post-surgical patient, and in those undergoing chemotherapy or receiving medications that alter free water clearance.

Recognizing Endocrinopathies Associated With Tyrosine Kinase Inhibitor Therapy in Children With Chronic Myelogenous Leukemia.

Side effects of tyrosine kinase inhibitor (TKI) treatment vary in children and adults with chronic myelogenous leukemia (CML). As children have a much longer life expectancy than adults, TKI therapy may continue for decades and with long-term consequences that differ from adults. Children may develop endocrinopathies related to "off-target" effects of TKIs, such as delayed growth, changes in bone metabolism, thyroid abnormalities, and effects on puberty and fertility. These endocrinopathies present additional challenges for pediatric patients with CML. This review critically evaluates the literature on long-term endocrine side effects of TKIs in the pediatric CML population and provides suggested recommendations.

The Use of 123I in Diagnostic Radioactive Iodine Scans in Children with Differentiated Thyroid Carcinoma.

BACKGROUND: Adult studies have shown that iodine-123 ((123)I) is as effective as (131)I in detecting metastatic disease in patients with differentiated thyroid carcinoma. However, the type and administered activity of radioiodine used for diagnostic imaging of metastatic thyroid cancer has not been well studied in children. Here we describe our institution's experience with using (123)I in diagnostic radioiodine scans in children with differentiated thyroid carcinoma. METHODS: Every patient with differentiated thyroid carcinoma who completed diagnostic scanning followed by radioiodine therapy at our institution over the past 8 years was included in this retrospective chart review. Patient age, sex, presentation of thyroid disease, past medical history, thyrotropin, thyroglobulin, and antithyroglobulin antibodies were recorded. A single nuclear medicine radiologist evaluated all scans. RESULTS: Thirty-three subjects completed 37 pairs of scans at a mean age of 13.4 years (range 6-17 years). The majority of subjects were female (81%) and had papillary thyroid cancer (91%). For diagnostic scanning, 5 received 2 mCi of (131)I, 21 received 2 mCi of (123)I, and 11 received 3 mCi of (123)I. There was no statistically significant difference in rate of discordant scan pairs when comparing (131)I and (123)I (20% and 23% respectively, p=0.9). The detection of metastatic pulmonary disease on diagnostic scanning was not improved by increasing the dose of (123)I from 2 mCi to 3 mCi (10% rate of missed lung detection with 2 mCi (123)I vs. 20% with 3 mCi (123)I). CONCLUSIONS: (123)I is effective for use in diagnostic radioactive iodine scans in children with differentiated thyroid cancer. The primary advantages of using (123)I include decreased radiation exposure and avoidance of stunning. However, in children there is a possibility of missed detection of metastatic pulmonary disease.

Pediatric thyroid nodules and malignancy.

Proper management of pediatric thyroid nodules is crucial to achieving good outcomes. It is important to obtain a thorough history, including prior radiation exposure and family history of thyroid cancer and any symptoms of hypothyroidism or hyperthyroidism. A complete physical examination with special attention to the thyroid gland and any cervical lymphadenopathy is important. Nodules between 5 and 10 mm with risk factors (clinical or sonographic) and all nodules greater than 10 mm should undergo a fine-needle aspiration biopsy. A comprehensive center of pediatric specialists is the best environment for treatment of these patients.

Do static and dynamic insulin resistance indices perform similarly in predicting pre-diabetes and type 2 diabetes?

AIMS: We designed a study to compare the predictive power of static and dynamic insulin resistance indices for categorized pre-diabetes (PDM)/type 2 diabetes (DM). METHODS: Participants included 1134 adults aged 18-60 years old with normal glucose at baseline who completed both baseline and 6-years later follow-up surveys. Insulin resistance indices from baseline data were used to predict risk of PDM or DM at follow-up. Two static indices and two dynamic indices were calculated from oral glucose tolerance test results (OGTT) at baseline. Area under the receiver operating characteristic curve (AROC) analysis was used to estimate the predictive ability of candidate indices to predict PDM/DM. A general estimation equation (GEE) model was applied to assess the magnitude of association of each index at baseline with the risk of PDM/DM at follow-up. RESULTS: The dynamic indices displayed the largest and statistically predictive AROC for PDM/DM diagnosed either by fasting glucose or by postprandial glucose. The bottom quartiles of the dynamic indices were associated with an elevated risk of PDM/DM vs. the top three quartiles. However, the static indices only performed significantly to PDM/DM diagnosed by fasting glucose. CONCLUSIONS: Dynamic insulin resistance indices are stronger predictors of future PDM/DM than static indices. This may be because dynamic indices better reflect the full range of physiologic disturbances in PDM/DM.

Consequences of choosing samples in hypothesis testing to ensure homogeneity of variance.

The two-sample Student t test of location was performed on random samples of scores and on rank-transformed scores from normal and non-normal population distributions with unequal variances. The same test also was performed on scores that had been explicitly selected to have nearly equal sample variances. The desired homogeneity of variance was brought about by repeatedly rejecting pairs of samples having a ratio of standard deviations that exceeded a predetermined cut-off value of 1.1, 1.2, or 1.3, while retaining pairs with ratios less than the cut-off value. Despite this forced conformity with the assumption of equal variances, the tests on the selected samples were no more robust than tests on unselected samples, and in most cases substantially less robust. Under conditions where sample sizes were unequal, so that Type I error rates were inflated and power curves were atypical, the selection procedure produced still greater inflation and distortion of the power curves.

Randomized trial of a smartphone mobile application compared to text messaging to support smoking cessation.

BACKGROUND: Text messaging has successfully supported smoking cessation. This study compares a mobile application with text messaging to support smoking cessation. MATERIALS AND METHODS: Young adult smokers 18-30 years old (n = 102) participated in a randomized pretest-posttest trial. Smokers received a smartphone application (REQ-Mobile) with short messages and interactive tools or a text messaging system (onQ), managed by an expert system. Self-reported usability of REQ-Mobile and quitting behavior (quit attempts, point-prevalence, 30-day point-prevalence, and continued abstinence) were assessed in posttests. RESULTS: Overall, 60% of smokers used mobile services (REQ-Mobile, 61%, mean of 128.5 messages received; onQ, 59%, mean of 107.8 messages), and 75% evaluated REQ-Mobile as user-friendly. A majority of smokers reported being abstinent at posttest (6 weeks, 53% of completers; 12 weeks, 66% of completers [44% of all cases]). Also, 37% (25%of all cases) reported 30-day point-prevalence abstinence, and 32% (22% of all cases) reported continuous abstinence at 12 weeks. OnQ produced more abstinence (p<0.05) than REQ-Mobile. Use of both services predicted increased 30-day abstinence at 12 weeks (used, 47%; not used, 20%; p = 0.03). CONCLUSIONS: REQ-Mobile was feasible for delivering cessation support but appeared to not move smokers to quit as quickly as text messaging. Text messaging may work better because it is simple, well known, and delivered to a primary inbox. These advantages may disappear as smokers become more experienced with new handsets. Mobile phones may be promising delivery platforms for cessation services using either smartphone applications or text messaging.

Thyroid carcinoma in children and adolescents: diagnostic implications of analysis of the tumor genome.

PURPOSE OF REVIEW: To update information about pediatric thyroid cancer. RECENT FINDINGS: This review of thyroid nodules in children indicates that the incidence of thyroid cancer has been steadily increasing over the last 30 years. Knowledge of factors which predispose to the development of thyroid cancer--radiation exposure and family history of thyroid cancer or personal or family history of familial syndromes associated with thyroid cancer--can help determine the aggressiveness with which the diagnostic studies of thyroid nodules should be pursued. Presence of thyroid nodules should prompt measurement of circulating thyroid-stimulating hormone. Thyroid nodules should generally be studied with thyroid ultrasonography; those greater than 0.5-1 cm in diameter which are not simple cysts should be studied with fine-needle aspiration (FNA). When cytologic analysis is indeterminate, a number of molecular techniques may assist in determining which patients should undergo thyroid surgery. SUMMARY: The relative frequency of indeterminate cytology on FNA could necessitate surgery in a large number of patients who will be found to have benign lesions. A number of molecular techniques are available to identify patients with indeterminate cytology who can confidently be followed without surgery as the probability of malignancy is low.

Association of adiposity trajectories with insulin sensitivity and glycemic deterioration: a longitudinal study of rural Chinese twin adults.

OBJECTIVE: To evaluate associations between adiposity trajectories over time and insulin sensitivity and glucose deterioration in a Chinese twin cohort. RESEARCH DESIGN AND METHODS: This study focused on 341 males and 292 females aged 20-50 years at baseline who had physical clinical examinations and oral glucose tolerance test at two time points with an average of 6 years apart. BMI, waist circumference, percent body fat (PBF), and percent trunk fat (PTF) trajectories were classified into five track groups based on age- and sex-specific tertiles at each visit. We calculated the odds of the insulin sensitivity index((0,120)) [ISI((0,120))] or glycemic deterioration at follow-up among five defined trajectories (tertile(baseline) → tertile(follow-up)) using generalized estimate equation models. Additionally, we applied structural equation models to examine genetic and environmental influences on adiposity, adiposity change over time (ACO), ISI((0,120)), and the interrelationships among them. RESULTS: Participants with stable adiposity (BMI, waist circumference, PBF, and PTF) in the highest tertile or shifting to the highest tertile tended to have the lowest ISI((0,120)) at follow-up or experience glycemic deterioration. Genetic factors exerted the major influence on adiposity, but environmental factors unique to each twin contributed more strongly to ISI and ACO. Correlations between adiposity/ACO and insulin sensitivity were mainly due to environmental influences. CONCLUSIONS: When adiposity stays or becomes high, insulin sensitivity falls and risk of glycemic deterioration rises. Additionally, we found that genetic factors exerted the major influence on adiposity, while environmental factors played the principal role for ACO and insulin sensitivity.

A note on consistency of non-parametric rank tests and related rank transformations.

The extent to which rank transformations result in the same statistical decisions as their non-parametric counterparts is investigated. Simulations are presented using the Wilcoxon-Mann-Whitney test, the Wilcoxon signed-rank test and the Kruskal-Wallis test, together with the rank transformations and t and F tests corresponding to each of those non-parametric methods. In addition to Type I errors and power over all simulations, the study examines the consistency of the outcomes of the two methods on each individual sample. The results show how acceptance or rejection of the null hypothesis and differences in p-values of the test statistics depend in a regular and predictable way on sample size, significance level, and differences between means, for normal and various non-normal distributions.

Correcting two-sample z and t tests for correlation: an alternative to one-sample tests on difference scores

In order to circumvent the influence of correlation in paired-samples and repeated measures experimental designs, researchers typically perform a one-sample Student t test on difference scores. That procedure entails some loss of power, because it employs N - 1 degrees of freedom instead of the 2N - 2 degrees of freedom of the independent-samples t test. In the case of non-normal distributions, researchers typically substitute the Wilcoxon signed-ranks test for the one-sample t test. The present study explored an alternate strategy, using a modified two-sample t test with a correction for correlation, analogous to the "z test for correlated samples" used at one time for paired observations. For non-normal distributions, the same modified t test was performed on rank-transformed data. Simulations disclosed that this procedure protects the Type I error rate for moderate and large sample sizes, maintains power for normal distributions and several symmetric non-normal distributions, and substantially increases power for various skewed nonnormal distributions(AU)

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A simple and effective decision rule for choosing a significance test to protect against non-normality.

There is no formal and generally accepted procedure for choosing an appropriate significance test for sample data when the assumption of normality is doubtful. Various tests of normality that have been proposed over the years have been found to have limited usefulness, and sometimes a preliminary test makes the situation worse. The present paper investigates a specific and easily applied rule for choosing between a parametric and non-parametric test, the Student t test and the Wilcoxon-Mann-Whitney test, that does not require a preliminary significance test of normality. Simulations reveal that the rule, which can be applied to sample data automatically by computer software, protects the Type I error rate and increases power for various sample sizes, significance levels, and non-normal distribution shapes. Limitations of the procedure in the case of heterogeneity of variance are discussed.

Short sleep duration is associated with insulin resistance independent of adiposity in Chinese adult twins.

OBJECTIVE: To investigate the association between sleep duration and insulin resistance in rural Chinese adults and examine whether any such associations are independent of adiposity. METHODS: This is a cross-sectional analysis of 854 men and 640 women aged 20 to 70 years from the Anqing Twin Cohort. The following measures were obtained for each subject: Body mass index (BMI) and percentage of trunk fat (%TF), fasting plasma glucose, homeostatic model assessment of insulin resistance index (HOMA-IR), self-reported sleep duration and measures of snoring and sleep disturbance from the Pittsburgh Sleep Quality Indices (PSQI) questionnaire were modified for a Chinese population. Multivariate linear regressions were applied to examine the association of sleep duration with HOMA-IR, with and without adjustment for adiposity variables, along with other relevant covariates. RESULTS: In this sample of relatively lean rural Chinese adults, short sleep duration was associated with HOMA-IR in women but not in men. In women, short (≤ 7 h/night) sleep duration was associated with a higher HOMA-IR (p=0.003) compared with normal sleep duration (>7 to ≤ 8 h/night) after adjustment for all the covariates except adiposity. Further adjustment for BMI or %TF attenuated the sleep-HOMA-IR association, but the association remained significant upon adjustment for BMI (p=0.013); and upon adjustment for %TF (p=0.026). Long sleep duration (> 8 h/night) was not significantly associated with HOMA-IR. CONCLUSION: In this rural Chinese cohort, short sleep duration is independently associated with increased insulin resistance among women only, even after adjusting for adiposity and other potential confounders.