Evaluating the impact of thrombopoietin receptor agonist medications on patient outcomes and quality of life in paediatric immune thrombocytopenia through semi-structured interviews.

Over the last decade, treatment of immune thrombocytopenia (ITP) in children has advanced to include thrombopoietin receptor agonist (TPO-RA) medications. Concurrently, there has been an increased emphasis on patient-reported outcomes-especially quality of life-to guide treatment. Assessing the impact of TPO-RAs on quality of life in paediatric ITP is therefore a priority. In this single-centre integrative mixed-methods study, a cohort of children with ITP prescribed a TPO-RA was identified. These children and/or their caregivers were invited to participate in semi-structured interviews focussed on quality-of-life measures. Independently, a retrospective chart review collected ITP-related data (platelet count, bleeding events) and TPO-RA data (dosing, side effects). Among the 23 eligible patients, 20 were represented in interviews. On chart review, 11/20 patients responded to TPO-RA by meeting platelet count criteria of ≥50 × 109 /L for six or more weeks in the absence of rescue therapy. In interviews with these children and/or their parents, 19/20 expressed the TPO-RA had 'worked', with 11/20 reporting benefit to mood and 11/20 reporting increased participation in activities/sports. Concerns were raised in interviews about TPO-RA medication cost (17/20), medication administration (10/20) and potential side effects (10/20). In conclusion, this study suggests that TPO-RA use in children with ITP improves quality of life.

Return to valued activities: Survivors' experiences of adaptation and growth after treatment for head and neck cancer.

OBJECTIVE: The objective of this study was to explore the experiences of head and neck cancer (HNC) survivors who returned to valued activities to understand how they reconstruct their lives following HNC diagnosis and treatment. METHODS: A qualitative research approach based on social constructionist theory was used. A total of 21 in-depth semi-structured interviews were conducted with adults diagnosed with any type of HNC in the previous 6 years. Reflexive thematic analysis was used to identify themes. RESULTS: HNC presents a unique trauma following which some survivors navigate paths back to meaningful activities. The experiences of HNC survivors who adapted to life after treatment described internal and external change and development, identified by three themes; Mindfulness; Gratitude; and Adaptation. CONCLUSION: People diagnosed with HNC frequently experience lasting effects and other survivorship issues, however some survivors were able to return to valued activities and recreate a meaningful lifestyle reflecting the possibility of post traumatic growth. This study provides insight into the experiences of head and neck cancer survivors who were able to make meaning and find internal and external growth following treatment. These findings can be used to inform advanced communication skills training for oncology health professionals and psychoeducational courses for people diagnosed with head and neck cancer in the future.

The Role of Temperature in Modifying the Risk of Ozone-Attributable Mortality under Future Changes in Climate: A Proof-of-Concept Analysis.

Air pollution risk assessments typically estimate ozone-attributable mortality counts using concentration-response (C-R) parameters from epidemiologic studies that treat temperature as a potential confounder. However, some recent epidemiologic studies have indicated that temperature can modify the relationship between short-term ozone exposure and mortality, which has potentially important implications when considering the impacts of climate change on public health. This proof-of-concept analysis quantifies counts of temperature-modified ozone-attributable mortality using temperature-stratified C-R parameters from a multicity study in which the pooled ozone-mortality effect coefficients change in concert with daily temperature. Meteorology downscaled from two global climate models is used with a photochemical transport model to simulate ozone concentrations over the 21st century using two emission inventories: one holding air pollutant emissions constant at 2011 levels and another accounting for reduced emissions through the year 2040. The late century climate models project increased summer season temperatures, which in turn yields larger total counts of ozone-attributable deaths in analyses using temperature-stratified C-R parameters compared to the traditional temperature confounder approach. This analysis reveals substantial heterogeneity in the magnitude and distribution of the temperature-stratified ozone-attributable mortality results, which is a function of regional variability in both the C-R relationship and the model-predicted temperature and ozone.

"My life's not my own": A qualitative study into the expectations of head and neck cancer carers.

INTRODUCTION: Cancers that originate from the upper aerodigestive tract are collectively known as head and neck cancer. The most common are squamous cell carcinomas of the oropharynx, larynx, and oral cavity. Head and neck cancer patients experience significant physical and psychological changes because of the disease and treatment. There is a substantial strain on family carers who have extensive responsibilities over most aspects of the patient's life. The aim of the study was to understand the perspectives of being an HNC carer and their perceived expectations of the role. METHODS: The study adopted a qualitative research design with a social constructionist epistemology. Interviews were conducted with 20 carers who were currently caring for someone diagnosed with head and neck cancer. RESULTS: Three overarching themes were identified: taking responsibility for the patient's nutrition, navigating a new and different relationship, and "my life's not my own." Participants felt responsible for ensuring the patient was eating and became increasingly frustrated when the patient was unable to intake food. Carers prioritised the patients' needs at the expense of their own, and several came to resent the role. CONCLUSION: Carers' expectations of their role informed how they approached giving care. Carers need to be supported from diagnosis and encouraged to prioritise their own wellbeing.

From the carer's mouth: A phenomenological exploration of carer experiences with head and neck cancer patients.

OBJECTIVE: Receiving a diagnosis of head and neck cancer is devastating for patients and family carers and causes high levels of distress. Previous studies report that carer distress levels exceed that of patients, but go largely unnoticed by health professionals. To date, there is a paucity of studies that have described carers' perspectives of the lived experience of caring for a loved one diagnosed with head and neck cancer. The aim of this study was to explore the lived experiences of carers of patients diagnosed with head and neck cancer. METHODS: This qualitative study was informed by descriptive phenomenology. Carers of patients who had been diagnosed with head and neck cancer within the last 6 years were recruited from participating hospitals in Perth, Western Australia. Semi-structured interviews were conducted with 20 carers of patients diagnosed with head and neck cancer. Thematic analysis was conducted to gain an understanding of participants lived experiences. RESULTS: Key themes identified were: Silent Suffering, Gamut of Emotions, Causal Attribution, Changing Priorities, Gaining Support, and Coping. The changing priorities themes highlights that carers prioritised (a) being available for their loved one and (b) taking an active role in managing head and neck cancer symptoms and side effects. CONCLUSIONS: Carers of patients diagnosed with head and neck cancer experience distress. Instead of seeking support, carers often elected to suffer in silence. Implications for practice include screening for carer distress and providing specific interventions focused on caring for someone diagnosed with head and neck cancer.

Birthing outside the system: the motivation behind the choice to freebirth or have a homebirth with risk factors in Australia.

BACKGROUND: Childbirth in Australia occurs predominantly in a biomedical context, with 97% of births occurring in hospital. A small percentage of women choose to birth outside the system - that is, to have a midwife attended homebirth with risk factors, or a freebirth, where the birth at home is intentionally unattended by any health professional. METHOD: This study used a Grounded Theory methodology. Data from 13 women choosing homebirth and 15 choosing freebirth were collected between 2010 and 2014 and analysed over this time. RESULTS: The core category was 'wanting the best and safest,' which describes what motivated the women to birth outside the system. The basic social process, which explains the journey women took as they pursued the best and safest, was 'finding a better way'. Women who gave birth outside the system in Australia had the countercultural belief that their knowledge about what was best and safest had greater authority than the socially accepted experts in maternity care. The women did not believe the rhetoric about the safety of hospitals and considered a biomedical approach towards birth to be the riskier birth option compared to giving birth outside the system. Previous birth experiences taught the women that hospital care was emotionally unsafe and that there was a possibility of further trauma if they returned to hospital. Giving birth outside the system presented the women with what they believed to be the opportunity to experience the best and safest circumstances for themselves and their babies. CONCLUSION: Shortfalls in the Australian maternity care system is the major contributing factor to women's choice to give birth outside the system. Systematic improvements should prioritise humanising maternity care and the expansion of birth options which prioritise midwifery-led care for women of all risk.

Chesapeake Bay's "forgotten" Anacostia River: eutrophication and nutrient reduction measures.

The Anacostia River, a Chesapeake Bay tributary running through Washington, D.C., is small but highly polluted with nutrients and contaminants. There is currently a multi-billion dollar tunnel project underway, being built in several phases, aimed at diverting effluent to sewage treatment, especially during high flow periods, and improving water quality of the Anacostia and the river into which it flows, the Potomac. Here, 4 years of biweekly to monthly nutrient and phytoplankton data are analyzed to assess pre-tunnel eutrophication status and relationships to flow conditions. Under all flow conditions, nutrients prior to tunnel implementation were well in excess of values normally taken to be limiting for growth, and hypoxia was apparent during summer. Chlorophyll a was higher in summer (averaging 26.9 µg L-1) than in spring (averaging 14.8 µg L-1), and based on pigment composition, summer communities had proportionately more cyanobacteria (> 2-fold higher zeaxanthin to chlorophyll a ratios) compared to spring, which had proportionately more diatoms (> 2-fold higher fucoxanthin to chlorophyll a ratios). When all data from all years and sites were considered, there was a decrease in diatoms and increase in cyanobacteria with decreasing NO3- and increasing NH4+ concentrations, increasing ratios of NH4+ to NO3-, and increasing temperature. Tunnel implementation and associated nutrient reductions may reduce the severity of summer blooms but reductions of spring assemblages may be even greater because river flows are typically higher at that time of year.

Glioblastoma stem-like cells: at the root of tumor recurrence and a therapeutic target.

Glioblastoma is the most common and most aggressive primary brain malignancy. The current initial standard of care consists of maximal safe surgical resection followed by radical radiotherapy and adjuvant temozolomide. Despite optimal therapy, median survival is ~15 months from diagnosis in molecularly unselected patients, and <6 months for patients with recurrent disease. Therefore, clinical treatments are currently palliative, not curative. Collectively, current knowledge suggests that the continued tumor growth and recurrence is in part due to the presence of glioma stem-like cells, which display self-renewal and tumorigenic potential. They differ from their more differentiated progeny, as they are more resistant to current treatments. Recurrent disease may be a consequence of the enhancement and/or gain of stem cell-like characteristics during disease progression, together with preferential death of more differentiated tumor cells during treatment, signifying that the cancer stem cell phenotype is a crucial therapeutic target. The limited knowledge of the characteristics of these cells and their response to current clinical treatments warrants intensive investigation with the aim to improve patient survival and/or develop a cure for this disease.

Worry and bother: factors in rural women's health decision making.

This exploratory study examined older rural women's health decision making. Thirty-three rural women were recruited to participate in semistructured qualitative interviews. Major themes emerged that focused on rural women's comments regarding their concerns about not worrying or bothering their children with personal health matters. Themes were discussed in the context of an ethic of care. Results suggest that it is important for mental health professionals, family physicians, social workers, and other practitioners to be aware of the sense of worry and concern for others that older rural women bring to bear in decision making about personal health issues.

Midwives' experiences with PPE during the COVID-19 pandemic: The Birth in the Time of COVID (BITTOC) study.

BACKGROUND: The COVID-19 pandemic resulted in rapid changes aimed at reducing disease transmission in maternity services in Australia. An increase in personal protective equipment (PPE) in the clinical and community setting was a key strategy. There was variation in the type of PPE and when it was to be worn in clincial practice. AIM: This paper reports on Australian midwives' experiences of PPE during the pandemic. METHODS: This sequential mixed methods study was part of the Birth in the Time of COVID-19 (BITTOC 2020) study. Data were obtained from in-depth semi-structured interviews with midwives in 2020 followed by a national survey undertaken at two time points (2020 and 2021). Qualitative open-text survey responses and interview data were analysed using content analysis. FINDINGS: 16 midwives were interviewed and 687 midwives provided survey responses (2020 n = 477, 2021 n = 210). Whilst midwives largley understood the need for increased PPE, and were mainly happy with this, as it was protective, they reported a number of concerns. These included: inconsistency with PPE type, use, availability, quality, fit and policy; the impact of PPE on the physical and psychological comfort of midwives; and the barriers PPE use placed on communication and woman centred care. This at times resulted in midwives working outside of policy. CONCLUSION: These findings highlight the need for future comprehensive pandemic preparedness that ensures policy and procedure recommendations are consistent and PPE is available, of approriate quality, and individually fitted in order to ensure that Australian maternity services are well placed to manage future pandemics.

Telehealth use in maternity care during a pandemic: A lot of bad, some good and possibility.

BACKGROUND: To reduce transmission risk during the COVID-19 pandemic, 'telehealth' (health care delivered via telephone/video-conferencing) was implemented into Australian maternity services. Whilst some reports on telehealth implementation ensued, there was scant evidence on women and midwives' perspectives regarding telehealth use. METHODS: A qualitative study was conducted in Australia during 2020-2021 using two data sources from the Birth in the Time of COVID-19 (BITTOC) study: i) interviews and ii) surveys (open-text responses). Content analysis was utilised to analyse the data and explore telehealth from the perspective of midwives and women accessing maternity care services. In-depth interviews were conducted with 20 women and 16 midwives. Survey responses were provided from 687 midwives and 2525 women who were pregnant or gave birth in 2021, generating 212 and 812 comments respectively. FINDINGS: Telehealth delivery was variable nationally and undertaken primarily by telephone/videoconferencing. Perceived benefits included: reduced COVID-19 transmission risk, increased flexibility, convenience and cost efficiency. However, women described inadequate assessment, and negative impacts on communication and rapport development. Midwives had similar concerns and also reported technological challenges. CONCLUSION: During the COVID-19 pandemic, telehealth offered flexibility, convenience and cost efficiency whilst reducing COVID-19 transmission, yet benefits came at a cost. Telehealth may particularly suit women in rural and remote areas, however, it also has the potential to further reduce equitable, and appropriate care delivery for those at greatest risk of poor outcomes. Telehealth may play an adjunct role in post-pandemic maternity services, but is not a suitable replacement to traditional face-to-face maternity care.

Quantifying Multipollutant Health Impacts Using the Environmental Benefits Mapping and Analysis Program-Community Edition (BenMAP-CE): A Case Study in Atlanta, Georgia.

BACKGROUND: Air pollution risk assessments do not generally quantify health impacts using multipollutant risk estimates, but instead use results from single-pollutant or copollutant models. Multipollutant epidemiological models account for pollutant interactions and joint effects but can be computationally complex and data intensive. Risk estimates from multipollutant studies are therefore challenging to implement in the quantification of health impacts. OBJECTIVES: Our objective was to conduct a case study using a developmental multipollutant version of the Environmental Benefits Mapping and Analysis Program-Community Edition (BenMAP-CE) to estimate the health impact associated with changes in multiple air pollutants using both a single and multipollutant approach. METHODS: BenMAP-CE was used to estimate the change in the number of pediatric asthma emergency department (ED) visits attributable to simulated changes in air pollution between 2011 and 2025 in Atlanta, Georgia, applying risk estimates from an epidemiological study that examined short-term single-pollutant and multipollutant (with and without first-order interactions) exposures. Analyses examined individual pollutants (i.e., ozone, fine particulate matter, carbon monoxide, nitrogen dioxide (NO2), sulfur dioxide, and particulate matter components) and combinations of these pollutants meant to represent shared properties or predefined sources (i.e., oxidant gases, secondary pollutants, traffic, power plant, and criteria pollutants). Comparisons were made between multipollutant health impact functions (HIF) and the sum of single-pollutant HIFs for the individual pollutants that constitute the respective pollutant groups. RESULTS: Photochemical modeling predicted large decreases in most of the examined pollutant concentrations between 2011 and 2025 based on sector specific (i.e., source-based) estimates of growth and anticipated controls. Estimated number of avoided asthma ED visits attributable to any given multipollutant group were generally higher when using results from models that included interaction terms in comparison with those that did not. We estimated the greatest number of avoided pediatric asthma ED visits for pollutant groups that include NO2 (i. e., criteria pollutants, oxidants, and traffic pollutants). In models that accounted for interaction, year-round estimates for pollutant groups that included NO2 ranged from 27.1 [95% confidence interval (CI): 1.6, 52.7; traffic pollutants] to 55.4 (95% CI: 41.8, 69.0; oxidants) avoided pediatric asthma ED visits. Year-round results using multipollutant risk estimates with interaction were comparable to the sum of the single-pollutant results corresponding to most multipollutant groups [e.g., 52.9 (95% CI: 43.6, 62.2) for oxidants] but were notably lower than the sum of the single-pollutant results for some pollutant groups [e.g., 77.5 (95% CI: 66.0, 89.0) for traffic pollutants]. DISCUSSION: Performing a multipollutant health impact assessment is technically feasible but computationally complex. It requires time, resources, and detailed input parameters not commonly reported in air pollution epidemiological studies. Results estimated using the sum of single-pollutant models are comparable to those quantified using a multipollutant model. Although limited to a single study and location, assessing the trade-offs between a multipollutant and single-pollutant approach is warranted. https://doi.org/10.1289/EHP12969.

The Social Cost of Ozone-Related Mortality Impacts From Methane Emissions.

Atmospheric methane directly affects surface temperatures and indirectly affects ozone, impacting human welfare, the economy, and environment. The social cost of methane (SC-CH4) metric estimates the costs associated with an additional marginal metric ton of emissions. Current SC-CH4 estimates do not consider the indirect impacts associated with ozone production from changes in methane. We use global model simulations and a new BenMAP webtool to estimate respiratory-related deaths associated with increases in ozone from a pulse of methane emissions in 2020. By using an approach consistent with the current SC-CH4 framework, we monetize and discount annual damages back to present day values. We estimate that the methane-ozone mechanism is attributable to 760 (95% CI: 330-1200) respiratory-related deaths per million metric tons of methane globally, for a global net present damage of $1800/mT (95% CI: $760-$2800/Mt CH4; 2% Ramsey discount rate); this would double the current SC-CH4 if included. These physical impacts are consistent with recent studies, but comparing direct costs is challenging. Economic damages are sensitive to uncertainties in the exposure and health risks associated with tropospheric ozone, assumptions about future projections of NOx emissions, socioeconomic conditions, and mortality rates, monetization parameters, and other factors. Our estimates are highly sensitive to uncertainties in ozone health risks. We also develop a reduced form model to test sensitivities to other parameters. The reduced form tool runs with a user-supplied emissions pulse, as well as socioeconomic and precursor projections, enabling future integration of the methane-ozone mechanism into the SC-CH4 modeling framework.

The influence of testosterone suppression and recovery on sexual function in men with prostate cancer: observations from a prospective study in men undergoing intermittent androgen suppression.

PURPOSE: We investigated the effects of testosterone change on the sexual function of men with prostate cancer undergoing intermittent maximal androgen deprivation therapy. MATERIALS AND METHODS: We conducted a phase II cohort study of 250 patients with prostate cancer undergoing intermittent maximal androgen deprivation therapy. Flutamide (Eulexin®) 250 mg 3 times daily and leuprolide (Lucrin®) 22.5 mg were given during a 9-month treatment phase (ONPhase). Therapy was ceased provided that prostate specific antigen was 4 ng/ml or less. Monitoring continued every 3 months for a further 2 years (OFFPhase) unless re-treatment occurred. Sexual function was assessed with the QLQ-PR25 version 3.0 prostate module in conjunction with the QLQ-C30 questionnaire at baseline and every 3 months thereafter. RESULTS: At baseline 46% of patients reported sexual activity with almost half (43%) reporting mild or no erectile problems. Of the men 63% reported an interest in sex (libido), with 28% reporting moderate to high libido. In addition, 26% felt less masculine as a result of illness or treatment. By 3 months of ONPhase all parameters deteriorated, worsening to a low at 9 months. Only 13% of the men reported sexual activity and 10% reported moderate to high libido. The proportion of men feeling less masculine increased to 50%. During the OFFPhase recovery was observed. Of those previously sexually active men 52% resumed sexual activity. Of these patients all reported erectile function returning to baseline. Levels of libido, masculinity and sexual activity recovered but not to baseline levels. CONCLUSIONS: Libido, sexual activity and perceptions of masculinity deteriorate during ONPhase. Of the sexually active men at baseline half will resume sexual activity despite 9 months of androgen deprivation therapy.

Stable liquid glucagon formulations for rescue treatment and bi-hormonal closed-loop pancreas.

Small doses of glucagon given subcutaneously in the research setting by an automated system prevent most cases of hypoglycemia in persons with diabetes. However, glucagon is very unstable and cannot be kept in a portable pump. Glucagon rapidly forms amyloid fibrils, even within the first day after reconstitution. Aggregation eventually leads to insoluble gels, which occlude pump catheters. Fibrillation occurs rapidly at acid pH, but is absent or minimal at alkaline pH values of ~10. Glucagon also degrades over time; this problem is greater at alkaline pH. Several studies suggest that its primary degradative pathway is deamidation, which results in a conversion of asparagine to aspartic acid. A cell-based assay for glucagon bioactivity that assesses glucagon receptor (GluR) activation can screen promising glucagon formulations. However, mammalian hepatocytes are usually problematic as they can lose GluR expression during culture. Assays for cyclic AMP (cAMP) or its downstream effector, protein kinase A (PKA), in engineered cell systems, are more reliable and suitable for inexpensive, high-throughput assessment of bioactivity.

Silenced: Patients' experiences of voicelessness in head and neck cancer.

OBJECTIVES: The objective of this qualitative study was to explore patients' experiences of communicating with health professionals following a diagnosis of head and neck cancer (HNC). METHODS: A qualitative research approach based on social constructionist theory was used. A total of 21 in-depth semi-structured interviews were conducted with people diagnosed with HNC. Thematic analysis was used to identify themes. RESULTS: The experience of losing the capacity for speech was experienced by survivors of HNC as distressing and traumatic. Voicelessness was not just a loss of physical speech, but a holistic experience of silencing. A number of tensions emerged including patients' experiences of losing their voice and then finding different ways to verbally express themselves; in interactions with health professionals there was a tension between abrupt, hurried communication and a slower, more mindful communication style. Sub-themes around communication style emerged where disparities between levels of health literacy were unaddressed, and patients' experienced a lack of empathy. Another tension experienced was between an old style medical model and the ideal of person-centred care and the biopsychosocial model of health. CONCLUSION: Whether HNC patients lose their voice temporarily, have periods of voicelessness, or are able to speak, but feel unheard, the treatment experience is too often one of disempowerment and silencing of their perspectives. PRACTICE IMPLICATIONS: Health professionals are challenged to find creative communication methods, to practice mindful listening, source speech pathology and adaptive technologies, and to facilitate communication that supports patients in expressing their values, preferences and needs.

Type 2 Diabetes and the Use of Real-Time Continuous Glucose Monitoring.

The role of continuous glucose monitoring (CGM) in type 1 diabetes (T1D) is well established in improving glycemic control and reducing hypoglycemia. Type 2 diabetes (T2D) is more prevalent than T1D and management of T2D is more heterogeneous, requiring treatment ranging from lifestyle modification to oral medications to intensive insulin therapy. Recent randomized controlled trials in intensively insulin-treated T2D demonstrated the efficacy and safety of real-time CGM (rtCGM) in reducing glycated hemoglobin without increasing hypoglycemia. Although evidence is limited, early studies have indicated a role for rtCGM in selected patients with non-insulin requiring T2D to improve glycemic control and/or reduce hypoglycemia. Based on literature review, we summarized current data on the use of rtCGM in T2D management and provided future research direction to generate more evidence on the utility of CGM in this population.