Abstract Purpose Primary care needs new models to facilitate advance care planning conversations. These conversations focus on preferences regarding serious illness and may involve patients, decision ...makers, and health care providers. We describe the feasibility of the first primary care-based group visit model focused on advance care planning. Methods We conducted a pilot demonstration of an advance care planning group visit in a geriatrics clinic. Patients were aged at least 65 years. Groups of patients met in 2 sessions of 2 hours each facilitated by a geriatrician and a social worker. Activities included considering personal values, discussing advance care planning, choosing surrogate decision-makers, and completing advance directives. We used the RE-AIM framework to evaluate the project. Results Ten of 11 clinicians referred patients for participation. Of 80 patients approached, 32 participated in 5 group visit cohorts (a 40% participation rate) and 27 participated in both sessions (an 84% retention rate). Mean age was 79 years; 59% of participants were female and 72% white. Most evaluated the group visit as better than usual clinic visits for discussing advance care planning. Patients reported increases in detailed advance care planning conversations after participating (19% to 41%, P = .02). Qualitative analysis found that older adults were willing to share personal values and challenges related to advance care planning and that they initiated discussions about a broad range of relevant topics. Conclusion A group visit to facilitate discussions about advance care planning and increase patient engagement is feasible. This model warrants further evaluation for effectiveness in improving advance care planning outcomes for patients, clinicians, and the system.
Background EUS-guided FNA is one of the few techniques that can obtain cells and tissue from the liver and pancreas. However, the technique remains vulnerable to poor specimen quality and sampling ...error. Objective To evaluate the ability of a high-resolution microendoscope (HRME) to visualize the cellular and architectural features of normal and malignant liver and pancreatic tissue ex vivo, to assess the ability of endosonographers to identify normal and neoplastic tissue by using HRME images, and to demonstrate preliminary technical feasibility of in vivo HRME imaging via EUS fine-needle puncture (FNP). Design Ex vivo pilot feasibility study in human tissue; in vivo swine model. Setting Two academic medical centers. Patients Co-registered HRME images and biopsies were obtained from surgically resected hepatic and pancreatic tissues from 44 patients. Intervention Images were divided into training (12 images) and test (80 images) sets containing a range of normal and pathologic conditions for each organ. After viewing the training sets, 9 endosonographers attempted to distinguish malignant tissue from normal or benign lesions in the test sets, each of which contained 40 unique images with individual diagnoses from pathology. Main Outcome Measurements Image acquisition feasibility, ex vivo and in vivo. Ability of endosonographers to recognize features of normal/benign or malignant tissue from the liver and pancreas. Results Overall, the 9 endosonographers achieved median accuracy figures of 85% in the liver and 90% in the pancreas. The endosonographers with prior experience in reading HRME images achieved accuracy rates between 90% and 95%. Technical feasibility of HRME imaging through a 19-gauge EUS-FNP needle was demonstrated in an in vivo swine model. Limitations Ex vivo study. Conclusion High-resolution microendoscopy allows real-time imaging of cellular-level morphology and tissue architecture in the liver and pancreas. The technique appears to have a short learning curve, after which endosonographers achieved high accuracy rates in distinguishing malignant tissue from normal and benign pathology in both organs. Translating this imaging platform to the in vivo setting appears technically feasible.
Background Multidetector computed tomography (MDCT) scanning technology has increased the ease with which pulmonary emboli (PE) are evaluated. Our aim was to determine whether the incidence and ...severity of postoperative PE have changed since adoption of Multidetector computed tomography. Study Design A prospective postoperative morbidity and mortality database from a single institution was used to identify all cancer patients who experienced a PE within 30 days of thoracic, abdominal, or pelvic operations. The incidence, type (central, segmental, and subsegmental), and severity of PE were examined. Results A total of 295 PE were documented among 47,601 postoperative cancer patients. The incidence of PE increased yearly from 2.3 per 1,000 patients in 2000 to 9.3 per 1,000 patients in 2005 (p < 0.0001). This corresponded to an increasing number of CT scans of the chest performed (6.6 CT scans per 1,000 postoperative patients in 2000 versus 45 in 2005; p < 0.0001). The increased incidence was because of a 7.8% (CI, 4.0 to 11.7) and 5.4% (CI, 4.1 to 6.7) average annual increase in segmental and subsegmental PE, respectively. There was no change in the number of central (0.1%; CI, –1.0 to 1.12) PE. Overall incidence of fatal PE was 0.4 and did not change during the time period (p = 0.3). A central PE was more commonly associated with hypoxia, ICU admission, and 30-day mortality (33% versus 5% for peripheral; p = 0.02). Conclusions Chest CT scans are being performed more frequently on postoperative cancer patients and have resulted in an increased diagnosis of peripheral PE. The clinical significance of, and optimal treatment for, diagnosed subsegmental PE are incompletely defined.
DNA Methylation and Childhood Asthma in the Inner-City Yang, Ivana, PhD; Liu, Andrew H., MD, FAAAAI; Pedersen, Brent, PhD ...
Journal of allergy and clinical immunology,
02/2015, Letnik:
135, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Methods We compared DNA methylation patterns and gene expression in African American inner city children with persistent atopic asthma versus healthy controls, using DNA and RNA from peripheral blood ...mononuclear cells (PBMCs).
Although perceived risk is central to most theories of health behavior, there is little consensus on its measurement with regard to item wording, response set, or the number of items to include. In a ...methodological assessment of perceived risk, we assessed the impact of changing the order of three commonly used perceived risk items: quantitative personal risk, quantitative population risk, and comparative risk. Participants were 432 men and women enrolled in an ancillary study of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Three groups of consecutively enrolled participants responded to the three items in one of three question orders. Results indicated that item order was related to the perceived risk ratings of both ovarian (P < 0.05) and colorectal (P < 0.05) cancers. Perceptions of risk were significantly lower when the comparative rating was made first. The findings suggest that compelling participants to consider their own risk relative to the risk of others results in lower ratings of perceived risk. Although the use of multiple items may provide more information than when only a single method is used, different conclusions may be reached depending on the context in which an item is assessed.
The nasal methylome and childhood atopic asthma Yang, Ivana V., PhD; Pedersen, Brent S., PhD; Liu, Andrew H., MD ...
Journal of allergy and clinical immunology,
05/2017, Letnik:
139, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Background Given the strong environmental influence on both epigenetic marks and allergic asthma in children, the epigenetic alterations in respiratory epithelia might provide insight into allergic ...asthma. Objective We sought to identify DNA methylation and gene expression changes associated with childhood allergic persistent asthma. Methods We compared genomic DNA methylation patterns and gene expression in African American children with persistent atopic asthma (n = 36) versus healthy control subjects (n = 36). Results were validated in an independent population of asthmatic children (n = 30) by using a shared healthy control population (n = 36) and in an independent population of white adult atopic asthmatic patients (n = 12) and control subjects (n = 12). Results We identified 186 genes with significant methylation changes, differentially methylated regions or differentially methylated probes, after adjustment for age, sex, race/ethnicity, batch effects, inflation, and multiple comparisons. Genes differentially methylated included those with established roles in asthma and atopy and genes related to extracellular matrix, immunity, cell adhesion, epigenetic regulation, and airflow obstruction. The methylation changes were substantial (median, 9.5%; range, 2.6% to 29.5%). Hypomethylated and hypermethylated genes were associated with increased and decreased gene expression, respectively ( P < 2.8 × 10−6 for differentially methylated regions and P < 7.8 × 10−10 for differentially methylated probes). Quantitative analysis in 53 differentially expressed genes demonstrated that 32 (60%) have significant methylation-expression relationships within 5 kb of the gene. Ten loci selected based on the relevance to asthma, magnitude of methylation change, and methylation-expression relationships were validated in an independent cohort of children with atopic asthma. Sixty-seven of 186 genes also have significant asthma-associated methylation changes in nasal epithelia of adult white asthmatic patients. Conclusions Epigenetic marks in respiratory epithelia are associated with allergic asthma and gene expression changes in inner-city children.
Summary Background In the post-intervention period of the Women's Health Initiative (WHI) trial, women assigned to treatment with oestrogen plus progestin had a higher risk of cancer than did those ...assigned to placebo. Results also suggested that the combined hormone therapy might increase mortality from lung cancer. To assess whether such an association exists, we undertook a post-hoc analysis of lung cancers diagnosed in the trial over the entire follow-up period. Methods The WHI study was a randomised, double-blind, placebo-controlled trial undertaken in 40 centres in the USA. 16 608 postmenopausal women aged 50–79 years with an intact uterus were randomly assigned by a computerised, stratified, permuted block algorithm to receive a once-daily tablet of 0·625 mg conjugated equine oestrogen plus 2·5 mg medroxyprogesterone acetate (n=8506) or matching placebo (n=8102). We assessed incidence and mortality rates for all lung cancer, small-cell lung cancer, and non-small-cell lung cancer by use of data from treatment and post-intervention follow-up periods. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov , number NCT00000611. Findings After a mean of 5·6 years (SD 1·3) of treatment and 2·4 years (0·4) of additional follow-up, 109 women in the combined hormone therapy group had been diagnosed with lung cancer compared with 85 in the placebo group (incidence per year 0·16% vs 0·13%; hazard ratio HR 1·23, 95% CI 0·92–1·63, p=0·16). 96 women assigned to combined therapy had non-small-cell lung cancer compared with 72 assigned to placebo (0·14% vs 0·11%; HR 1·28, 0·94–1·73, p=0·12). More women died from lung cancer in the combined hormone therapy group than in the placebo group (73 vs 40 deaths; 0·11% vs 0·06%; HR 1·71, 1·16–2·52, p=0·01), mainly as a result of a higher number of deaths from non-small-cell lung cancer in the combined therapy group (62 vs 31 deaths; 0·09% vs 0·05%; HR 1·87, 1·22–2·88, p=0·004). Incidence and mortality rates of small-cell lung cancer were similar between groups. Interpretation Although treatment with oestrogen plus progestin in postmenopausal women did not increase incidence of lung cancer, it increased the number of deaths from lung cancer, in particular deaths from non-small-cell lung cancer. These findings should be incorporated into risk–benefit discussions with women considering combined hormone therapy, especially those with a high risk of lung cancer. Funding National Heart, Lung and Blood Institute, National Institutes of Health.
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