Understanding decision-making and educational need in the management of pediatric patients with moderate-to-severe asthma: analysis of a US-based clinician survey.

Background: Asthma creates a substantial burden on the pediatric healthcare system, particularly by those with moderate-to-severe disease. As few studies have been published specific to clinician evaluation and management of this population, this analysis serves to begin to identify educational needs and potential clinical impact.Methods: We conducted a case-based survey of US general pediatric (n = 227), allergy (n = 158), and pediatric pulmonology (n = 70) clinicians to understand the current approach to management of pediatric patients with moderate-to-severe asthma.Results: Results show inconsistencies in guideline adherence, identification of disease severity and control, referral practices, and knowledge of phenotypes, which may impact clinical decision making. While most clinicians refer to guidelines when managing pediatric patients with moderate-to-severe asthma, there is no preferred set, and they find the guidelines to be moderately useful. General pediatricians are more likely than specialists to have difficulty distinguishing control and severity and may not be familiar with the concept of asthma phenotype. Most surveyed pediatricians indicated they refer patients to a specialist, but did not always do so in the cases. Clinicians have little consensus on the best approach to manage patients with uncontrolled symptoms after optimized therapy. Many clinicians may have uncertainty about how elevated eosinophils or FeNO could affect patient management. Further, there may be gaps in incorporating parents and pediatric patients into shared decision-making in their care.Conclusions: Understanding the needs of those managing patients with moderate-to-severe asthma is critical to developing effective continuing education activities to improve patient outcomes.

Assessing the educational needs of physicians in the management of patients with Tourette syndrome: results of a United States survey on practicing clinicians and caregivers.

OBJECTIVE: To better understand current practices of U.S.-based physicians in the management of Tourette syndrome (TS) and identify gaps that may be addressed by future education. METHODS: Two survey instruments were developed to gather data on management of TS and perceptions from physicians and caregivers of children with TS. The clinician survey was developed in consultation with a TS physician expert and utilized clinical vignettes to assess and quantify practice patterns. The caregiver survey was adapted from the clinician survey and other published studies and gathered details on diagnosis, treatment, and perceptions regarding management. RESULTS: Data included responses from 138 neurologists (including 57 pediatric neurologists), 162 psychiatrists (including 42 pediatric psychiatrists), and 67 caregivers. Most (65%) pediatric neurologists rely solely on clinical findings to make a diagnosis, whereas the majority of other specialists utilize additional testing (eg, neuroimaging, lab testing, and genetics). Most psychiatrists (96%) utilize standardized criteria to make a diagnosis, whereas 22% of neurologists do not. Many physicians (44% of psychiatrists and 20% of neurologists) use pharmacotherapy to treat a patient with "slightly bothersome" tics and no functional impairment, whereas caregivers favored behavioral therapy. Most (76%) caregivers preferred to make the final treatment decision, whereas 80% of physicians preferred equal or physician-directed decision-making. CONCLUSIONS: This study provides insight into practice patterns and perceptions of U.S.-based neurologists and psychiatrists in managing TS. Results highlight the potential value of physician education, including diagnostic approach, tic management and monitoring, involvement of caregivers in decision-making, and updates on TS management.

Patient and Caregiver Perspectives on Their Experiences With Crohn's Perianal Fistulas.

Background: Little is known about patients' perception of care and management of Crohn's perianal fistulas (CPF). This study was conducted to understand US patient and caregiver attitudes and challenges to CPF care. Methods: Patients with CPF and caregivers of patients with CPF completed a 36-question survey about their perceptions and challenges regarding the diagnosis, treatment, and overall management of CPF. Patients/caregivers were recruited via online Crohn's and fistula support group websites and forums and via their gastroenterologists (GEs) and surgeons from October 2020 through January 2021. Results: The survey was completed by 96 patients and 54 caregivers. Respondents reported over 60% and 14%-23% of CPF were diagnosed and treated by a GE or surgeon, respectively. Nearly all patients/caregivers wanted to be involved in treatment decision-making with their physicians (81%). While the majority of patients/caregivers were satisfied with their quality of care (65%) and access to care (67%), racial disparities exist and there is room for improvement. A smaller proportion of non-White versus White patients/caregivers reported satisfaction with care quality (39% vs 72%, respectively) and access to care (57% vs 69%, respectively). Half of non-White patient/caregivers (50%) versus 69% of White patient/caregivers knew where to access CPF information. Most patients/caregivers (69%) stated that they would benefit from more information on managing day-to-day CPF symptoms. Significant barriers perceived by patients/caregivers to receiving optimal CPF care included lack of effective treatments (69%) and lack of access to specialist care (68%). Conclusions: Improvements in multidisciplinary CPF care are required to optimize treatment.

Understanding the role of the primary care physician in the management of patients with Crohn's perianal fistulas.

OBJECTIVES: To understand the role of primary care physicians (PCPs) in the recognition, diagnosis, and management of Crohn's perianal fistulas (CPF) and their referral patterns and treatment expectations. METHODS: This survey-based study was conducted between September 2020 and October 2020. US-based PCPs managing at least one patient with Crohn's disease per week were included. Participants were presented with two case vignettes relevant to primary care practice; Case Vignette 1 comprised three parts and focused on initial CPF presentation and progression to partial response; Case Vignette 2 focused on recurrent CPF. Survey questions elicited the physician's clinical approach to each case. Data were presented as descriptive statistics. RESULTS: Overall, 151 PCPs (median 23 years in practice) who saw about three patients per month with new/existing CPF responded. For Case Vignette 1, upon identification of a fistulous tract, 89% of respondents would refer the patient, mostly to a colorectal surgeon or gastroenterologist. Most PCPs (69%) would begin the patient on medication; 46% would conduct a diagnostic/imaging study. Treatment expectations after referral varied: 55% of respondents believed surgeons would place a seton or use one prior to surgery; 23% expected medical management only; 23% were unsure. Case Vignette 2 revealed that 98% of PCPs preferred to be involved in patient care after referral; however, only 49% were. Of these, 76% considered reinforcing patient treatment adherence as their primary role. While 80% of PCPs were at least moderately satisfied with communication and care coordination with multidisciplinary teams, 52% considered lack of access to specialists as at least a moderate barrier to multidisciplinary team management. CONCLUSION: PCPs want more involvement in multidisciplinary management of patients with CPF. Continuing education providing PCPs with up-to-date information on diagnostic modalities, treatment options, early diagnosis, the role of PCPs within a multidisciplinary team, and effective initial CPF care is required.

What were the study's aims?To understand how primary care physicians recognize, treat, and monitor patients with Crohn's disease-related perianal fistulas (small tunnels between the bowel and skin near the anus).How was the study done?US-based primary care physicians, including internists, were included if they had experience in treating patients with Crohn's disease. Descriptions of the history and symptoms of two hypothetical patients were provided: one patient who may have Crohn's perianal fistulas and another patient whose Crohn's perianal fistulas had returned after being treated. After reading these descriptions, the physicians completed a questionnaire designed to show how they would help each patient.What did the study find out?Not all physicians treat patients with Crohn's perianal fistulas in the same way in terms of diagnostic tests and medical treatments, although most said they would refer them to a specialist if a fistula was identified. Many wanted to be involved in patient care after referral to a specialist but only half were. Of those, most thought their main role was to ensure patients followed the treatments given by specialists. More than half of primary care physicians thought a lack of access to specialists could be a barrier to care.How does this impact care?The physicians surveyed want more involvement in multidisciplinary teams who look after patients with Crohn's perianal fistulas. To do this, they need more education about the diagnosis and treatment of Crohn's perianal fistulas, and clarity around their role within multidisciplinary teams who manage these patients.

Management of short-bowel syndrome: A survey of unmet educational needs among healthcare providers.

BACKGROUND: Management of short-bowel syndrome with intestinal failure (SBS-IF) is complex and requires a multidisciplinary approach. Because of the rarity of SBS-IF, healthcare professionals (HCPs) often lack clinical experience with the disease and may benefit from education regarding SBS-IF and its management. This study identified unmet educational needs related to the management of patients with SBS-IF. METHODS: This was a prospective, web-based survey (December 2019-January 2020) in which a series of clinical questions were posed to US HCPs after presenting three standardized SBS-IF cases to assess current practice patterns. HCPs were then asked a series of questions to identify potential knowledge gaps and unmet educational needs relating to SBS-IF management. RESULTS: Overall, 558 HCPs completed the survey, with 12%-38% having a formal SBS-IF multidisciplinary team currently available to make treatment decisions within their institution. Clinicians involved in care included gastroenterologists (93%), registered dietitians (79%), gastroenterology nurse practitioners and physician assistants (37%), registered nurses (43%), social workers (45%), and psychologists/psychiatrists (27%). There was underuse of published guidelines and limited understanding of the course of intestinal adaptation. Responses to the clinical scenarios highlighted disparities in SBS-IF care delivery, including diagnosis, management goals, medications prescribed, and nutrition practices. CONCLUSIONS: Future SBS-IF educational interventions for HCPs should aim to improve awareness and understanding of the disease, facilitate timely diagnosis, and standardize management practices to ensure patients receive optimal interdisciplinary care as widely as possible.

Perceived Burdens and Educational Needs of Caregivers of People with Schizophrenia: Results of a National Survey Study.

PURPOSE: Schizophrenia is a chronic, serious, and disabling mental disorder that affects how an individual thinks, feels, and behaves. With the availability of effective antipsychotic medications, the care of people with schizophrenia has shifted from psychiatric hospitals to outpatient treatment and caregivers, including family members. Caregivers are an often-overlooked target for education but may be a key resource to enhance patient education and foster greater adherence to treatment. This study sought to examine the burdens faced by caregivers and determine their specific educational needs. METHODS: A survey instrument was developed and fielded to 96 caregivers of patients with schizophrenia in the United States (September-October 2019) via online communities and caregiver newsletters. Survey responses were organized into specific topics: symptoms exhibited when diagnosed, current treatment options and use of long-acting injectable (LAI) antipsychotic medications, treatment adherence attitudes, barriers for caregivers and patients, informational resources utilized, and caregiver information and educational topics. RESULTS: Caregivers identified hallucinations, delusions, disorganized behavior, thought disorder, and aggression as the most worrisome symptoms of schizophrenia. Most caregivers felt that they act as a mediator between the medical team and the patient and that they are responsible for the patient's adherence to treatment. Caregivers report that a schizophrenia diagnosis has strained their own emotional health, reduced their ability to have a satisfying personal life, and disrupted their family life. Caregivers generally had fewer barriers caring for patients receiving LAI antipsychotic treatments than caring for patients not receiving such treatments. Caregivers were interested in learning more about new treatments, coping strategies, and understanding specific symptoms. CONCLUSION: Caregivers need help recognizing, understanding, and managing specific and common symptoms of schizophrenia. Information about strategies to handle these symptoms would be beneficial. Caregivers also want information on new and emerging therapies, which may help facilitate discussions with clinicians about different treatment options.

Management of Schizophrenia with Long-Acting Injectable Antipsychotic Medications: An Assessment of the Educational Needs of Clinicians.

PURPOSE: Schizophrenia is a chronic and serious mental disorder characterized by disturbances in thought, perception, and behavior that impair daily functioning and quality of life. Long-acting injectable (LAI) antipsychotic medications may improve long-term outcomes over oral medications; however, LAI antipsychotic medications are often only considered as a last resort late in the disease course. This study sought to assess current clinical practice patterns, clinicians' attitudes, and barriers to the use of LAI antipsychotic medications as well as identify unmet educational needs of psychiatric clinicians in managing patients with schizophrenia. METHODS: A survey was distributed via email to 2330 United States-based clinicians who manage patients with schizophrenia; 379 completed the survey and were included for analysis. The survey included five patient case-based scenarios, with seven decision points. Data were analyzed with qualitative and quantitative methodologies. RESULTS: Clinicians were most confident in determining when to initiate treatment and least confident in transitioning to injectable therapy or administering injectable therapy. Clinicians cited nonadherence, and not wanting to take daily medicine or the "hassle" of frequent treatment, as key factors for which patients were most suitable for an LAI antipsychotic medication. Patient nonadherence was considered the most important barrier to optimal management of patients with schizophrenia. A clinician's perception of relapse was a strong driver of whether or not the clinician would discuss/recommend an LAI antipsychotic medication. CONCLUSION: This study suggests that clinicians may be reluctant to discuss or recommend switching patients to an LAI antipsychotic medication if they are perceived as doing well on current therapy. These results will inform future research and continuing education that aims to improve the confidence, knowledge, and competence of clinicians who provide care for patients with schizophrenia who may benefit from treatment with an LAI antipsychotic medication and clinicians who may be more likely to routinely offer an LAI antipsychotic medication to their patients.

Effectiveness of INROADS into pain management, a nursing educational intervention.

Nurses play a critical role in managing a patient's pain, from initial evaluation to ongoing patient education. However, little information exists on current gaps in nurses' knowledge and their pain-related decision making. To this end, an educational intervention-the INROADS initiative-was designed to improve the knowledge of nurses involved in patient management as well as to guide them toward practices that are consistent with currently available evidence. The results from an evaluation of this intervention show that nurses participating in the INROADS program were 52% more likely to make evidence-based care choices for their patients, compared with a control group of demographically similar nurses. The effect of this program may reinforce it as a model for the design of future interventions for pain management.

How does older age influence oncologists' cancer management?

BACKGROUND: Over half of new cancer cases occur in patients aged > or = 65 years. Many older patients can benefit from intensive cancer therapies, yet evidence suggests that this population is undertreated. METHODS: To assess preferences and influential factors in geriatric cancer management, practicing U.S. medical oncologists completed a survey containing four detailed vignettes exploring colon, breast, lung, and prostate cancer treatment. Participants were randomly assigned one of two surveys with vignettes that were identical except for patient age (<65 years or >70 years). RESULTS: Physicians in each survey group (n = 200) were demographically similar. Intensive therapy was significantly less likely to be recommended for an older than for a younger, but otherwise identical, patient in two of the scenarios. For a woman with metastatic colon cancer (Eastern Cooperative Oncology Group [ECOG] score, 1) for whom chemotherapy was recommended, nearly all oncologists chose an intensive regimen if the patient's age was 63; but if her age was 85, one fourth of the oncologists chose a less intensive treatment. Likewise, for stage IIA breast cancer (ECOG score, 0), 93% recommended intensive adjuvant treatment for a previously healthy patient aged 63; but only 66% said they would do so if the patient's age was 75. Oncologists commonly identified patient age as an influence on treatment choice, but were even more likely to cite performance status as a determining factor. CONCLUSIONS: Advanced age can deter oncologists from choosing intensive cancer therapy, even if patients are highly functional and lack comorbidities. Education on tailoring cancer treatment and a greater use of comprehensive geriatric assessment may reduce cancer undertreatment in the geriatric population.

Evidence-based choices of physicians: a comparative analysis of physicians participating in Internet CME and non-participants.

BACKGROUND: The amount of medical education offered through the Internet continues to increase, providing unprecedented access for physicians nationwide. However, the process of evaluating these activities is ongoing. This study is a continuation of an earlier report that found online continuing medical education (CME) to be highly effective in making evidence-based decisions. METHODS: To determine the effectiveness of 114 Internet CME activities, case vignette-based surveys were administered to U.S.-practicing physicians immediately following participation, and to a representative control group of non-participants. Survey responses were analyzed based on evidence presented in the content of CME activities. An effect size for each activity was calculated using Cohen's d to determine the amount of difference between the two groups in the likelihood of making evidence-based clinical decisions. RESULTS: In a sample of 17,142 U.S. physicians, of the more than 350,000 physicians who participated in 114 activities, the average effect size was 0.82. This indicates an increased likelihood of 48% that physicians participating in online activities were making clinical choices based on evidence. CONCLUSION: Physicians who participated in online CME activities continue to be more likely to make evidence-based clinical choices than non-participants in response to clinical case vignettes.

Regulation of serotonin 1B receptor by glycogen synthase kinase-3.

In response to 5-hydroxytryptamine (5-HT), the type 1 serotonin receptors (5-HT1Rs) preferentially couple to the inhibitory G protein and elicit many physiological and behavioral processes. However, their regulation by intracellular protein kinases has not been fully investigated. In this study, we identified that glycogen synthase kinase-3 (GSK3) differentially regulates 5-HT1Rs. In receptor-expressing cells and brain slices, activation of both 5-HT1AR and 5-HT1BR reduced forskolin-stimulated cAMP production, but only the effect of 5-HT1BR was abolished by selective GSK3 inhibitors, deletion of GSK3beta by RNAi, or overexpression of impaired GSK3beta mutants (R96A and K85,86A). A consensus GSK3 phosphorylation sequence was identified between the serine-154 and threonine-158 in the second intracellular loop of 5-HT1BR. Mutation of either serine-154 or threonine-158 to alanine significantly reduced response of 5-HT1BR to 5-HT. Active GSK3beta interacted with resting 5-HT1BR to form a protein complex. The interaction was enhanced by receptor activation, abolished by GSK3 inhibitors, and dependent on the phosphorylation state of serine-154. In addition, regulation of 5-HT1BR by GSK3 changed the dynamics of agonist-induced cell surface receptor internalization, in which lack of phosphorylation at Ser154 resulted in sustained reduction of 5-HT1BR at the cell surface. Although the physiological consequences of selective regulation of 5-HT1BR by GSK3 remain to be identified, findings in this study reveal a new function of GSK3 as a protein kinase that is able to selectively regulate G protein-coupled receptors.

Improving the physician-patient cardiovascular risk dialogue to improve statin adherence.

BACKGROUND: The purpose of this study was to evaluate the effectiveness of a patient education program developed to facilitate statin adherence. METHODS: A controlled trial was designed to test the effectiveness of a multifaceted patient education program to facilitate statin adherence. The program included a brief, in-office physician counseling kit followed by patient mailings. The primary end point was adherence to filling statin prescriptions during a 120-day period. Patients new to statins enrolled and completed a survey. Data from a national pharmacy claims database were used to track adherence. RESULTS: Patients new to statin therapy exposed to a patient counseling and education program achieved a 12.4 higher average number of statin prescription fill days and were 10% more likely to fill prescriptions for at least 120 days (p = .01). CONCLUSION: Brief in-office counseling on cardiovascular risk followed by patient education mailings can be effective in increasing adherence. Physicians found a one-minute counseling tool and pocket guidelines useful in counseling patients.

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.

Pancreatic Cancer Management and Treatment Landscape Awareness of Gastroenterologists: Results from US Physician Surveys Conducted in 2013 and 2015.

INTRODUCTION: In the US, gastroenterologists (GIs) often inform patients of the initial diagnosis of pancreatic cancer. Thus, GIs are frequently the first physicians to provide vital information regarding treatment strategies and options to patients which can have significant impact on subsequent clinical decision-making. Since treatments for pancreatic cancer are rapidly evolving, it may be challenging for GIs to maintain an adequate knowledge base required to provide accurate cursory information or avoid providing inaccurate data to patients at a very sensitive point in time in their care. However, little to no published data are available on the treatment awareness, knowledge, and comfort of GIs in the United States who diagnose pancreatic cancer. METHODS: This study evaluated the self-reported management of pancreatic cancer, including patient discussion, familiarity with treatments, and use of guidelines. A survey was developed and fielded to US academic and community GIs in 2013. In 2015, the survey was redistributed as a follow-up to determine whether familiarity and practice has shifted; two questions were added, all other items remained identical. For the 2013 sample, 432 GIs were contacted and 113 valid responses were collected (26.2). For the 2015 sample, 712 GIs were contacted and 126 valid responses were collected (17.7%). Analysis compared differences between academic and community gastroenterologists and gastroenterologists performing endoscopic ultrasound (EUS) versus those that do not. RESULTS: Self-reported familiarity with pancreatic cancer therapies has not significantly increased from 2013 to 2015, as gastroenterologists report highest familiarity with 5-fluorouracil and gemcitabine. In the 2015 sample, 68% of academic and 58% of community gastroenterologists entered gemcitabine when identifying therapies FDA-approved for treatment of pancreatic cancer. However, 16% of academic and 24% of community gastroenterologists indicated that they were unaware of which therapies are approved, and some indicated therapies that are not FDA-approved for the treatment of pancreatic cancer, such as capecitabine (10%) and paclitaxel (7%). Gastroenterologists in 2015 are significantly more likely than in 2013 to discuss clinical trial enrollment with their patients with metastatic pancreatic cancer (5.5 on a 10-point scale vs 4.2, P = .013) but were not more confident in their ability to conduct such discussions. When managing patients with pancreatic cancer, academic, and community gastroenterologists responded that they were most likely to refer to guidelines developed by their professional organizations, such as the AGA and ACG. However, these groups have not developed specific guidelines for the management of patients with pancreatic cancer. CONCLUSIONS: As gastroenterologists are frequently the first physicians to disclose a diagnosis of pancreatic cancer, education is needed to improve familiarity with current available treatments, clinical trials, and emerging therapies and resources to advise their patients.

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.

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.

Insulin-like growth factor-1 modulation of CaV1.3 calcium channels depends on Ca2+ release from IP3-sensitive stores and calcium/calmodulin kinase II phosphorylation of the alpha1 subunit EF hand.

In neurons, L-type calcium channels (CaV1.2 and CaV1.3) regulate an extensive range of functions. However, the roles of CaV1.3-containing L channels, which are physiologically and pharmacologically distinct from the better understood CaV1.2 channels, are only beginning to be determined. We find that CaV1.3 channels are modulated by the insulin-like growth factor-1/receptor tyrosine kinase (IGF-1/RTK) through a signaling pathway that involves phospholipase C, calcium release from IP3-sensitive internal stores, and calcium/calmodulin kinase II. In addition, we find that the IGF-1-induced modulation requires phosphorylation of a specific serine residue, S1486, in the EF hand motif of the CaV1.3 subunit. This modulation alters CaV1.3 activity, causing a left shift in the current-voltage relationship and strongly potentiating peak currents at hyperpolarized membrane potentials. We also find that CaV1.3 channels and their RTK-dependent potentiation contribute to the regulation of the survival-promoting transcription factor cAMP response element-binding protein (CREB): in both cortical and hippocampal neurons, depolarization and IGF-1 rapidly increase phospho-CREB levels in a manner that requires CaV1.3 activity and the S1486 phosphorylation site to achieve a full effect. Although the full effects of CaV1.3 channels remain to be determined, their preferential localization to dendritic shafts and spine heads coupled with their ability to activate at relatively hyperpolarized and even subthreshold potentials suggests that CaV1.3 activity may subserve different cellular functions from CaV1.2 and, in particular, may be important in transducing signals initiated by excitatory neurotransmission.

Targeting specific PDZ domains of PSD-95; structural basis for enhanced affinity and enzymatic stability of a cyclic peptide.

A cyclic peptide, Tyr-Lys-c[-Lys-Thr-Glu(betaAla)-]-Val, incorporating a beta-Ala lactam side chain linker and designed to target the PDZ domains of the postsynaptic density protein 95 (PSD-95), has been synthesized and structurally characterized by NMR while free and bound to the PDZ1 domain of PSD-95. While bound, the lactam linker of the peptide makes a number of unique contacts outside the canonical PDZ binding motif, providing a novel target for PDZ-domain specificity as well as producing a 10-fold enhancement in binding affinity. Additionally, the cyclization greatly enhances the enzymatic stability, increasing the duration that the peptide inhibits the association between PSD-95 and glutamate receptors, effectively inhibiting the clustering of kainate receptors for over 14 hr after application. Highly specific regulation of kainate receptor action may provide a novel route for treatment of drug addiction and epilepsy.

Trends in physician preferences for and use of sources of medical information in response to questions arising at the point of care: 2009-2013.

INTRODUCTION: Recent information on the preferences and trends of medical information sources for US practicing physicians in the past several years is lacking. The purpose of this study was to identify current format preferences and attitudes of physicians as well as trends over time to provide timely information for use in educational planning. METHODS: A survey instrument was developed and distributed in 2013 to US practicing physicians in several specialties. Data were aggregated and analyzed to understand trends across these physicians. Differences between and among demographic subsets of physicians, such as practice type and location, were observed by the use of inferential statistics. Additionally, using a similar survey fielded in 2009, these findings were analyzed to observe potential changes in the past 4 years. RESULTS: Peer-reviewed journal articles and continuing medical education (CME) are reported to be the most useful sources of medical information by physicians. Non-CME promotional meetings, pharmaceutical sales representatives, and managed care organizations are least useful or influential. Physicians are receiving more clinical questions from patient encounters in 2013 compared to 2009, and spend more time searching for information online. The use of many formats to receive medical information is increasing, including both technology-derived and traditional formats. DISCUSSION: Increases in clinical questions and time spent online indicate a heightened need for efficiencies in searching for medical information. New uses of technology in medical information delivery may allow educators an avenue to meet the rising needs of physicians.