Success Factors for Community Health Workers in Implementing an Integrated Group-Based Child Development Intervention in Rural Bangladesh.

Community Health Workers (CHWs) can effectively implement maternal and child health interventions, but there is paucity of evidence on how to integrate child stimulation into these interventions, and their delivery at scale. In rural Bangladesh, CHWs implemented an intervention integrating psychosocial stimulation, nutrition, maternal mental health, water, sanitation, hygiene (WASH) and lead exposure prevention. In each of 16 intervention villages, one CHW worked with 20 households. CHWs bi-weekly held group meetings or alternated group meetings and home visits with pregnant women and lactating mothers. We assessed the intervention through five focus groups, four interviews and one group discussion with CHWs and their supervisors to explore success factors of implementation. CHWs' training, one-on-one supervision and introduction by staff to their own community, and adoption of tablet computers as job aids, enabled successful session delivery to convey behavioral recommendations. CHWs reported difficulties delivering session due to the complexity of behavioral recommendations and struggled with age-specific intervention material. Young children's attendance in group sessions generated distractions that undermined content delivery. We identified ways to minimize the difficulties to strengthen intervention-delivery during implementation, and scale-up. Iterative revisions of similarly integrated interventions based on qualitative evaluation findings could be delivered feasibly by CHWs and allow for implementation at scale.

Exploration of Attendance, Active Participation, and Behavior Change in a Group-Based Responsive Stimulation, Maternal and Child Health, and Nutrition Intervention.

Delivery of interventions through group sessions allows for in-depth discussions and creates opportunities for group members to work together to identify and solve common problems. However, low attendance may limit impact. We explored factors affecting attendance, active participation, and behavior change in an integrated group-based child development and maternal and child health intervention in Bangladesh. Community health workers (CHWs) facilitated two sessions a month including material on child stimulation; water, sanitation, and hygiene; nutrition, maternal depression, and lead exposure prevention. Sessions were conducted with 320 pregnant women and mothers with children younger than 24 months, in 16 villages in Kishoreganj district. After 4 and 9 months of intervention, we conducted focus group discussions and in-depth interviews with mothers (n = 55 and n = 48) to identify determinants of attendance and behavior change, and to examine potential for intervention scale-up. Recruiting family members to assist with childcare resulted in improved attention during sessions. Adopting a storytelling format for presentation of session materials resulted in more engaged participation during courtyard sessions. Session attendance and behavior change, especially purchasing decisions, were difficult for participants without the support of male heads of the household. Selecting a rotating leader from among the group members to remind group members to attend sessions and support CHWs in organizing the sessions was not successful. Facilitating self-appraisals and planning for water and sanitation allowed participants to identify areas for improvement and track their progress. Key determinants of a participant's attendance were identified, and the resulting intervention shows promise for future implementation at scale.

Delayed Diagnosis of X-linked Lymphoproliferative Syndrome Type 2 in a 17-year-old Male With Severe Crohn's Disease and Recurrent Skin Infections.

X-linked lymphoproliferative syndrome type 2 (XLP2) is a rare genetic primary immunodeficiency disease caused by mutations in the XIAP gene that lead to deficiency of the X-linked inhibitor of apoptosis protein. XLP2 is characterized by dysregulated immune responses and can result in an inflammatory bowel disease (IBD)-like phenotype, a form of monogenic IBD. Patients with XLP2 often succumb to fulminant hemophagocytic lymphohistiocytosis or Epstein-Barr virus infections. Hematopoietic stem cell transplantation (HSCT) is currently the only definitive treatment for XLP2. We report an adolescent with a delayed diagnosis of XLP2 in the setting of severe Crohn's disease diagnosed at age 9 years and recurrent skin infections. He is under evaluation for HSCT. Gastroenterologists must recognize monogenic IBD in patients of all ages with severe disease and signs of an underlying primary immunodeficiency disease. Patients with suspected monogenic IBD should undergo immunologic and genetic analysis at diagnosis to initiate potentially life-saving treatment.

Identification of Educational Gaps Among Oncologists Who Manage Patients with Pancreatic Cancer.

INTRODUCTION: Pancreatic ductal adenocarcinoma (PDA) is associated with poor outcomes and presents oncologists with a myriad of clinical challenges. This study was conducted to assess oncologists' practice patterns and to identify the greatest areas of need for future PDA continuing medical education (CME) programs. METHODS: Case vignettes have been validated as an effective tool to assess how physicians approach and treat a wide array of diseases. In order to assess practice patterns for resectable, locally advanced unresectable, and metastatic PDA, an online case vignette survey was distributed to practicing medical oncologists. RESULTS: Responses from 150 US-practicing oncologists were analyzed, and several key opportunities for future CME programs were identified. For case 1 (patient with resectable PDA), 44% of oncologists did not select an evidence-based adjuvant chemotherapy regimen. For case 2 (patient with locally advanced PDA who develops metastases and neuropathy after first-line nab-paclitaxel/gemcitabine followed by chemoradiation), 57% of oncologists did not select an evidence-based second-line chemotherapy regimen, and 35% selected a regimen containing oxaliplatin, a chemotherapeutic known to cause neuropathy. For case 3 (patient with a pancreatic mass and liver metastases), only 34% of oncologists recommended a biopsy, chest imaging, and liver function tests which should be standard of care assessments with this presentation. For all three cases, clinical trial referral was selected by fewer than 5% of respondents. CONCLUSIONS: This study identified appreciable discrepancies between oncologists' recommendations and standard evidence-based guidelines. Well-designed CME programs may help to bridge the educational gaps identified and improve adherence to practice guidelines.

Educational needs in the diagnosis and management of pediatric functional constipation: a US survey of specialist and primary care clinicians.

OBJECTIVES: The goal of this study was to identify opportunities among gastroenterologists and gastroenterology nurse practitioners (NPs)/physician assistants (PAs) for continuing medical education (CME) related to functional constipation. METHODS: An online, case-vignette survey was designed to identify and quantify practice patterns of pediatric gastroenterology clinicians. Case vignettes are a validated method for assessing clinician practice patterns. The survey consisted of three patient cases: a 3-year-old female with a 6-month history of constipation; a 6-year-old male with a 1-year history of constipation refractory to treatment and a sacral dimple with nearby tuft of hair; and a 16-year-old male with a 10-year history of constipation, and a sullen, depressed mood. Survey responses were compared to NASPGHAN guideline recommendations for diagnosis and management to identify areas where additional education may be beneficial. RESULTS: Responses were collected from 197 gastroenterologists, 116 gastroenterology NPs/PAs, and 206 pediatrician/primary care clinicians. Several of the practice patterns observed suggest opportunities for future CME: low use of applicable Rome III diagnostic criteria; approximately 85% recommended testing beyond what is recommended for the 3-year-old patient; over 1/3 did not perform several recommended tests for the 6-year-old patient; and over 25% did not refer the 16-year-old patient for psychological evaluation. Further, there was little consensus in treatment approach among the three clinician groups. Primary care familiarity with NASPGHAN guidelines was low. CONCLUSIONS: CME programs focusing on applying diagnostic criteria, matching diagnostic workup to patient presentation, treatment selection, and identifying patients who may benefit from psychological evaluation may fill knowledge and practice gaps of clinicians who manage pediatric patients with functional constipation.

Fasoracetam in adolescents with ADHD and glutamatergic gene network variants disrupting mGluR neurotransmitter signaling.

The glutamatergic neurotransmitter system may play an important role in attention-deficit hyperactivity disorder (ADHD). This 5-week, open-label, single-blind, placebo-controlled study reports the safety, pharmacokinetics and responsiveness of the metabotropic glutamate receptor (mGluR) activator fasoracetam (NFC-1), in 30 adolescents, age 12-17 years with ADHD, harboring mutations in mGluR network genes. Mutation status was double-blinded. A single-dose pharmacokinetic profiling from 50-800 mg was followed by a single-blind placebo at week 1 and subsequent symptom-driven dose advancement up to 400 mg BID for 4 weeks. NFC-1 treatment resulted in significant improvement. Mean Clinical Global Impressions-Improvement (CGI-I) and Severity (CGI-S) scores were, respectively, 3.79 at baseline vs. 2.33 at week 5 (P < 0.001) and 4.83 at baseline vs. 3.86 at week 5 (P < 0.001). Parental Vanderbilt scores showed significant improvement for subjects with mGluR Tier 1 variants (P < 0.035). There were no differences in the incidence of adverse events between placebo week and weeks on active drug. The trial is registered at https://clinicaltrials.gov/ct2/show/study/NCT02286817 .

Therapeutic Patterns and Barriers to the Treatment of Advanced Prostate Cancer: A Survey of Academic and Community Urologists in the United States.

INTRODUCTION: In this study we assess urologists' decisions about the treatment of patients with metastatic castration resistant prostate cancer, the perceived therapeutic barriers and urologists' educational gaps. METHODS: A clinical case based online survey was distributed to a random sample of practicing urologists in the United States. Questions addressed treatment options and physician confidence in treating cases, and included open-ended questions regarding key educational gaps, attitudes and barriers to patient treatment. RESULTS: Respondents included 96 community urologists and 29 academic urologists. Academic urologists were significantly more likely to withhold therapy and continue observation than community urologists when treating patients with increasing prostate specific antigen after prostatectomy and radiotherapy (41% vs 24%, respectively, p=0.039). The majority of community and academic urologists referred patients with asymptomatic metastatic castration resistant prostate cancer before chemotherapy to an oncologist (64% and 55%, respectively, p=0.500) as well as those who were symptomatic (62%, p=0.678). More community urologists than academic urologists rated patient comorbidities as a barrier to treatment (mean ± SD 3.74 ± 0.92 and 3.14 ± 0.83, respectively, p=0.003). Appropriate therapy sequencing was highly rated by community and academic urologists as a subject for continuing medical education (67% and 66%, respectively, p=0.91). CONCLUSIONS: Similarities and differences were observed between community and academic urologists regarding the treatment of patients with metastatic castration resistant prostate cancer and barriers to treatment. Understanding these comparisons may assist in developing educational activities to improve urologist knowledge and, ultimately, patient care in metastatic castration resistant prostate cancer.

Cost-effectiveness of 13-valent pneumococcal conjugate vaccine: Germany, Greece, and The Netherlands.

BACKGROUND: Seven-valent pneumococcal conjugate vaccine (PCV7) had profound public-health impacts and is considered cost-effective and potentially cost saving. Two new PCVs have been launched, a 10-valent vaccine (PCV10) and a 13-valent vaccine (PCV13). We examined public-health and economic impacts of PCV pediatric national immunization programs (NIPs) in Germany, Greece, and the Netherlands. METHODS: A decision-analytic model was developed to estimate the impact of PCV13, PCV7, and 10-valent pneumococcal conjugate vaccine (PCV10) on invasive pneumococcal disease (IPD), pneumonia (PNE), and acute otitis media (AOM). Using epidemiological data, we calculated the cases of IPD, PNE, and AOM, using country-specific incidence, serotype coverage, disease sequelae, mortality, vaccine effectiveness, indirect effects, costs, and utilities. Direct effects for PCV13- and PCV10-covered serotypes were assumed similar to PCV7. PCV13 was assumed to confer an indirect effect, while PCV10 was not. Assumptions were tested in sensitivity analyses. RESULTS: In a NIP, PCV13 was estimated to eliminate 31.7%, 46.4%, and 33.8% of IPD in Germany, Greece, and the Netherlands, respectively. Compared with PCV7 and PCV10, PCV13 was found to be cost-effective or cost saving in all cases when PCV13 indirect effects were included. CONCLUSIONS: Pediatric NIPs with PCV13 in Europe are expected to have dramatic public-health impacts and be cost-effective or cost saving.

Response to "Outcomes and costs associated with PHiD-CV, a new protein D conjugate pneumococcal vaccine, in four countries".

A recent supplement article by Talbird, Taylor, Knoll, Frostad, and García Martí reported estimates of public health impact and cost-effectiveness of the 10-valent pneumococcal conjugate vaccine compared with the 7-valent vaccine. Although the analysis applies a decision analytic model and modeling methodologies that are scientifically sound, many of the assumptions presented in the paper are inconsistent with the current evidence.

Keratosis pilaris: a common follicular hyperkeratosis.

Keratosis pilaris (KP) is a common inherited disorder of follicular hyperkeratosis It is characterized by small, folliculocentric keratotic papules that may have surrounding erythema. The small papules impart a stippled appearance to the skin resembling gooseflesh. The disorder most commonly affects the extensor aspects of the upper arms, upper legs, and buttocks. Patients with KP usually are asymptomatic, with complaints limited to cosmetic appearance or mild pruritus. When diagnosing KP, the clinician should be aware that a number of diseases are associated with KP such as keratosis pilaris atrophicans, erythromelanosis follicularis faciei et colli, and ichthyosis vulgaris. Treatment options vary, focusing on avoiding skin dryness, using emollients, and adding keratolytic agents or topical steroids when necessary.