Women with atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS) have a significantly increased risk of breast cancer, which can be substantially reduced with antiestrogen therapy for ...chemoprevention. However, antiestrogen therapy for breast cancer risk reduction remains underutilized. Improving knowledge about breast cancer risk and chemoprevention among high-risk patients and their healthcare providers may enhance informed decision-making about this critical breast cancer risk reduction strategy.
We are conducting a cluster randomized controlled trial to evaluate the effectiveness and implementation of patient and provider decision support tools to improve informed choice about chemoprevention among women with AH or LCIS. We have cluster randomized 26 sites across the U.S. through the SWOG Cancer Research Network. A total of 415 patients and 200 healthcare providers are being recruited. They are assigned to standard educational materials alone or combined with the web-based decision support tools. Patient-reported and clinical outcomes are assessed at baseline, after a follow-up visit at 6 months, and yearly for 5 years. The primary outcome is chemoprevention informed choice after the follow-up visit. Secondary endpoints include other patient-reported outcomes, such as chemoprevention knowledge, decision conflict and regret, and self-reported chemoprevention usage. Barriers and facilitators to implementing decision support into clinic workflow are assessed through patient and provider interviews at baseline and mid-implementation.
With this hybrid effectiveness/implementation study, we seek to evaluate if a multi-level intervention effectively promotes informed decision-making about chemoprevention and provide valuable insights on how the intervention is implemented in U.S. clinical settings.
NCT04496739
HYPOTHESIS The incidence of postoperative intra-abdominal abscess is higher after laparoscopic compared with open appendectomy for perforated appendicitis. METHODS A historical cohort study of ...pediatric patients operated on for suspected appendicitis by open appendectomy or laparoscopic appendectomy compares the incidence of postoperative intra-abdominal abscess for each procedure. SETTING A tertiary care center. PATIENTS Five hundred thirty-eight pediatric patients were operated on for suspected appendicitis at our institution between 1974 and 1999. Of these, 453 were included in the study. Of the excluded patients, 9 had incomplete medical records, 69 had normal or interval appendectomies, and 7 had appendixes removed by methods other than laparoscopy or right lower quadrant incision. INTERVENTIONS Open appendectomy performed through a right lower quadrant incision or laparoscopic appendectomy performed through a 3-trocar approach by 1 of 3 pediatric surgeons at our institution. MAIN OUTCOME MEASURE The incidence of postoperative intra-abdominal abscess after laparoscopic vs open appendectomy. RESULTS In perforated appendicitis (170 patients), the incidence of postoperative abscess after laparoscopic appendectomy was 24% vs 4.2% after open appendectomy. The relative risk ratio of developing a postoperative abscess after perforated appendicitis was 5.6 (confidence interval, 2.1-16.0) after laparoscopic vs open appendectomy. The results remained significant when controlled for age, sex, intraoperative irrigation, and preoperative antibiotics. Postoperative abscess in all acute, gangrenous, and perforated appendicitis after laparoscopic appendectomy was 6.4% vs 3.0% after open appendectomy. This was not statistically significant. CONCLUSION There is a significant increase in the incidence of postoperative intra-abdominal abscess with perforated appendicitis after laparoscopic compared with open appendectomy in pediatric patients.Arch Surg. 2001;136:438-441-->
Background Data from an immunocompromised subpopulation in which both vaccine recipients and nonrecipients have frequent opportunities for vaccination can help determine the associations between ...vaccination against seasonal influenza and pneumococcal disease and all-cause mortality. Study Design We surveyed dialysis centers and performed a retrospective analysis of health status at dialysis therapy initiation, vaccination for influenza and pneumococcal disease, laboratory results, and mortality associated with the 2005-2006 influenza season for patients in 3 End-Stage Renal Disease Networks across the United States. Setting & Participants Of 1,033 dialysis facilities considered, 903 centers with a total patient population of 54,734 reported vaccination data. Analysis was limited to 36,966 patients on dialysis treatment for at least 1 year as of December 31, 2005. Predictor Vaccination status. Outcomes OR for all-cause mortality (vaccinated vs unvaccinated patients). Results The estimated adjusted OR for mortality was significantly less than 1.0 for patient who received either vaccination and was lower for patients who had received both vaccinations than for those who had received either. Survival analysis confirmed these findings. Limitations Possible misclassification due to self-report of vaccination for some patients. Lack of vaccination date. Conclusions Vaccination against influenza and pneumococcal disease is associated with improved survival in dialysis patients. The 2 vaccinations have independent effects on mortality.
Background Patients with end-stage renal disease (ESRD) are at high risk of complications from influenza, but many dialysis centers report <50% influenza immunization coverage. Study Design A ...group-randomized evaluation of a multicomponent intervention to increase influenza vaccination rates in poorly performing dialysis centers in ESRD Networks 6, 11, and 15. Setting & Participants Facilities with the lowest immunization percentages in 2006-2007 were selected from each network and randomly assigned to a standard (n = 39) or intensive intervention (n = 38). Intervention Standard intervention included a feedback report with comparison to other centers in their network and educational materials for staff and patients. Intensive-intervention centers also received 3 educational seminars, assistance with and review of center-specific action plans, and monthly monitoring of vaccination plan and rates. Outcomes Change in vaccination rate in following year. Measurements Dialysis center records of patient vaccination status. Results There was an 8.9% ( P = 0.04) adjusted mean absolute difference in improvement between intensive- and standard-intervention centers. Limitations Some vaccinations were self-reported by patients. The vaccination data form does not have an option for patient data unavailable, which may have caused patients without data to be coded as unvaccinated. Conclusions Multicomponent interventions may serve as a successful strategy to increase influenza vaccination rates at poorly performing centers, with a benefit beyond that provided by usual oversight and support.
Background Patients with end-stage renal disease are at increased risk of morbidity and mortality because of infection. Quality improvement efforts for this patient population include assessment of ...institutional policies and practices that may increase vaccination rates for influenza, hepatitis B, and pneumococcal disease. Study Design A survey of vaccination practices, beliefs, and attitudes was sent to all dialysis centers in End-Stage Renal Disease Networks 6, 11, and 15. Setting & Participants Of 1,052 dialysis facilities considered, 683 returned the survey, reported vaccination rates for 2005 to 2006, and had 20 or more patients. Predictor or Factor Standing-order policy of the dialysis facility, categorized as facility-wide orders, preprinted admission orders for each patient (chart orders), physician-specific orders, and individual orders. Outcomes Vaccination rates for influenza, hepatitis B (full or partial series), hepatitis B, and pneumococcal vaccine. Measurements Patient vaccination, given at or outside the center. Results Overall vaccination rates were 76% ± 18% (SD) for influenza, 73% ± 22% for hepatitis B full or partial series, 62% ± 25% for hepatitis B full series, and 44% ± 34% for pneumococcal vaccine. Compared with individual orders, facility-wide standing orders and chart orders were not associated with greater vaccination rates for influenza (0.4%; confidence interval, −4 to 5; and 1.27%; confidence interval, −3 to 5, respectively), but were associated with greater vaccination rates for hepatitis B full or partial series (9%; confidence interval, 3 to 15; and 11%; confidence interval, 5 to 17, respectively), hepatitis B full series (11%; confidence interval, 4 to 17; and 13%; confidence interval, 7 to 19, respectively), and pneumococcal disease (21%; confidence interval, 14 to 29; and 20%; confidence interval, 13 to 27, respectively). Limitations Data are cross-sectional, and vaccinations outside the center were self-reported. Conclusions Existing facility-wide or chart-based order programs may be effective in promoting vaccination against hepatitis B and pneumococcal disease.
Activities intended to improve the detection, treatment, and control of chronic kidney disease (CKD) should be incorporated into existing health care systems and targeted to high-risk populations to ...avoid redundancy and waste of resources. One high-risk population consists of first- or second-degree family members of patients with end-stage renal disease (ESRD), who are 2 to 3 times as likely to have incident ESRD, have high rates of impaired kidney function and undetected and uncontrolled high blood pressure, and are more likely to be obese. These individuals usually are unaware of their underlying CKD and may discount their own risk of ESRD. The ESRD Network 6 Family History Project shows that the ESRD Networks, which constitute a national CKD surveillance system for patients with stage 5 CKD, may be an existing resource that can be used to identify relatives of incident patients with ESRD and provide these families with information about CKD. Nationally available resources have been developed by the National Kidney Disease Education Program for use with these at-risk families. Individuals interested in population-based CKD control activities should be aware of and use these resources.
In vitro oocyte maturation is an assisted reproductive technology in which a meiotically immature oocyte (prophase I or germinal vesicle stage) is recovered from an antral follicle and matured in ...vitro prior to fertilization. This technology, although in widespread use in domestic livestock, is not typically implemented during human in vitro fertilization cycles. This review examines how in vitro oocyte maturation is currently used in the clinical setting, including the various ways in vitro oocyte maturation is defined in practice. The role of in vitro oocyte maturation in patient care and the major challenges for implementation are described. Efficiency and safety are critically explored. The role of in vitro oocyte maturation in oncofertility will also be discussed. Finally, the outlook for the future of clinical in vitro oocyte maturation is considered. Summary Sentence This review summarizes the current state of the art of in vitro oocyte maturation as used in the treatment of human infertility and fertility preservation, its advantages, and shortcomings, and examines what is next for this technology.
Objective To determine the composition of commercially available culture media and test whether differences in composition are biologically relevant in a murine model. Design Experimental laboratory ...study. Setting University-based laboratory. Animal(s) Cryopreserved hybrid mouse one-cell embryos were used in experiments. Intervention(s) Amino acid, organic acid, ions, and metal content were determined for two different lots of media from Cook, In Vitro Care, Origio, Sage, Vitrolife, Irvine CSC, and Global. To determine whether differences in the composition of these media are biologically relevant, mouse one-cell embryos were thawed and cultured for 120 hours in each culture media at 5% and 20% oxygen in the presence or absence of protein in an EmbryoScope time-lapse incubator. Main Outcome Measure(s) The compositions of seven culture media were analyzed for concentrations of 39 individual amino acids, organic acids, ions, and elements. Blastocyst rates and cell cycle timings were calculated at 96 hours of culture, and the experiments were repeated in triplicate. Result(s) Of the 39 analytes, concentrations of glucose, lactate, pyruvate, amino acids, phosphate, calcium, and magnesium were present in variable concentrations, likely reflecting differences in the interpretation of animal studies. Essential trace elements, such as copper and zinc, were not detected. Mouse embryos failed to develop in one culture medium and were differentially affected by oxygen in two other media. Conclusion(s) Culture media composition varies widely, with differences in pyruvate, lactate, and amino acids especially notable. Blastocyst development was culture media dependent and showed an interaction with oxygen concentration and presence of protein.
PDF
