Clinical prognostic models in children with sepsis in low- and middle-income countries: a systematic review and meta-analysis.

Introduction: Sepsis is the leading cause of child death worldwide, with the majority of these deaths occurring in low- and middle-income countries (LMICs). The aim of this systematic review and meta-analysis was to describe clinical prognostic scores and models for pediatric sepsis outcomes and assess the performance of these scores for predicting mortality in LMICs. Methods: Ovid Medline, CINAHL, Cochrane Library, EBSCO Global Health, and Web of Science, were searched through September 2022 for citations related to the development or validation of a clinical prognostic score or model among children with sepsis, conducted in LMIC. Titles, abstracts, and full texts were screened by two independent reviewers and data extracted included population characteristics, variables included, outcomes, and model performance. Risk of bias was assessed with the Prediction Model Risk of Bias Assessment Tool (PROBAST). Results: 4,251 titles/abstracts and 315 full-text studies were screened, with 12 studies meeting inclusion criteria. Study countries included India, China, Egypt, Indonesia, Tanzania, and a multi-site study in Latin America. Prognostic scores/models included existing scores such as PELOD-2, pSOFA, PRISM, P-MODS, refractory shock criteria. There was high risk of bias in all studies. Meta-analysis was possible for pSOFA, PELOD-2, PRISM, and P-MODS, with pooled area under the receiver-operator characteristic curve of 0.86 (95%CI 0.78-0.94), 0.83 (95% CI 0.76-0.91), respectively. Conclusion: Relatively few clinical scores and models have been externally validated for prognostication and risk-stratification among children with sepsis in diverse LMIC settings. Notably there were no studies from low-income countries. Some potentially relevant studies were excluded due to lack of clarity regarding the presence of sepsis in the study populations. More widespread and standardized use of sepsis criteria may aid in better understanding the burden of sepsis and prognostic model performance at the bedside among children in LMICs. Further research to externally validate, implement and adapt these models is needed to account for challenges in use of these scores in resource-limited settings. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022340126, PROSPERO [CRD42022340126].

Physician Perceptions of Dose Escalation for Type 2 Diabetes Medications in the United States.

INTRODUCTION: Medications used to treat type 2 diabetes (T2D) often require dose escalation to optimize effectiveness. Physician and patient perceptions of treatment characteristics of T2D medications have previously been examined, but little is known about perceptions of escalation to the optimal dose for each patient. This study examined physicians' perceptions of dose escalation for medications used to treat T2D. METHODS: Data on dose escalation and other factors influencing decision-making for treatment of T2D were collected via an online survey of endocrinologists and primary care physicians in the USA. RESULTS: The sample included 501 physicians (348 primary care physicians and 153 endocrinologists). Dose escalation was not frequently considered by physicians as a primary factor keeping patients' from reaching treatment goals (mentioned as a factor by only 7.6% of the sample) or a barrier to prescribing T2D medication (16.2%). Factors more likely to keep patients from reaching treatment goals included an unhealthy diet (86.6%) and medication adherence (77.4%). The most common reasons that physicians reported for escalating dose levels were the need for better glycemic control (reported by 89.8% of the sample), ability to decrease the total number of medications by increasing the dose of one medication (39.9%), and the need for the patient to lose weight (39.3%). Data reported by primary care physicians and endocrinologists followed similar patterns. CONCLUSIONS: Although common with T2D treatments, escalating the dose of T2D medication was not perceived by physicians to be a significant barrier to attaining treatment goals or prescribing medication. Multiple factors contribute to the decision to escalate the dose of T2D medication.

In early phases of initiating medication treatment for a patient with type 2 diabetes (T2D), it is common for physicians to increase from a lower initial dose to a higher end dose to maximize treatment benefit. This process is known as dose escalation. The purpose of this study was to examine physicians' perceptions of dose escalation for medications used to treat T2D. An online survey was designed to identify reasons why physicians in the US may choose to escalate or not escalate a dose of medication for T2D. In addition, physicians were asked about factors that keep patients from reaching treatment goals to identify whether the requirement for dose escalation is perceived to be a common barrier to successful treatment. The sample included 501 physicians (348 primary care, 153 endocrinologists). Dose escalation was not frequently considered to be a primary factor keeping patients' from reaching treatment goals or a barrier to prescribing medication for T2D. Dose escalation decisions are complex, driven by a range of factors such as glycemic control medication tolerability, the patient's body mass index, treatment guidelines, comorbidities, characteristics of the patient's entire treatment regimen, and potential cardiovascular benefits.

Inability to move one's face dampens facial expression perception.

Humans rely heavily on facial expressions for social communication to convey their thoughts and emotions and to understand them in others. One prominent but controversial view is that humans learn to recognize the significance of facial expressions by mimicking the expressions of others. This view predicts that an inability to make facial expressions (e.g., facial paralysis) would result in reduced perceptual sensitivity to others' facial expressions. To test this hypothesis, we developed a diverse battery of sensitive emotion recognition tasks to characterize expression perception in individuals with Moebius Syndrome (MBS), a congenital neurological disorder that causes facial palsy. Using computer-based detection tasks we systematically assessed expression perception thresholds for static and dynamic face and body expressions. We found that while MBS individuals were able to perform challenging perceptual control tasks and body expression tasks, they were less efficient at extracting emotion from facial expressions, compared to matched controls. Exploratory analyses of fMRI data from a small group of MBS participants suggested potentially reduced engagement of the amygdala in MBS participants during expression processing relative to matched controls. Collectively, these results suggest a role for facial mimicry and consequent facial feedback and motor experience in the perception of others' facial expressions.

Repression of TRIM13 by chromatin assembly factor CHAF1B is critical for AML development.

Acute myeloid leukemia (AML) is an aggressive blood cancer that stems from the rapid expansion of immature leukemic blasts in the bone marrow. Mutations in epigenetic factors represent the largest category of genetic drivers of AML. The chromatin assembly factor CHAF1B is a master epigenetic regulator of transcription associated with self-renewal and the undifferentiated state of AML blasts. Upregulation of CHAF1B, as observed in almost all AML samples, promotes leukemic progression by repressing the transcription of differentiation factors and tumor suppressors. However, the specific factors regulated by CHAF1B and their contributions to leukemogenesis are unstudied. We analyzed RNA sequencing data from mouse MLL-AF9 leukemic cells and bone marrow aspirates, representing a diverse collection of pediatric AML samples and identified the E3 ubiquitin ligase TRIM13 as a target of CHAF1B-mediated transcriptional repression associated with leukemogenesis. We found that CHAF1B binds the promoter of TRIM13, resulting in its transcriptional repression. In turn, TRIM13 suppresses self-renewal of leukemic cells by promoting pernicious entry into the cell cycle through its nuclear localization and catalytic ubiquitination of cell cycle-promoting protein, CCNA1. Overexpression of TRIM13 initially prompted a proliferative burst in AML cells, which was followed by exhaustion, whereas loss of total TRIM13 or deletion of its catalytic domain enhanced leukemogenesis in AML cell lines and patient-derived xenografts. These data suggest that CHAF1B promotes leukemic development, in part, by repressing TRIM13 expression and that this relationship is necessary for leukemic progression.

When looking 'hot' means not feeling cold: Evidence that self-objectification inhibits feelings of being cold.

Self-objectification, the internalization of an observer's appearance-based perspective of one's body, has been theorized and demonstrated to reduce body awareness among women. In this field study, we propose self-objectification as the mechanism to explain the oft-observed phenomenon where women wearing little clothing appear unbothered by cold weather, positing that self-objectification obstructs women's feelings of cold. We surveyed women outside nightclubs on cold nights, assessed self-objectification, and asked participants to report how cold they felt. Anonymous photos were taken and coded for amount of skin exposure. We hypothesized that self-objectification would moderate the relationship between clothing coverage and reports of feeling cold. Our hypothesis was supported: women low in self-objectification showed a positive, intuitive, relationship between skin exposure and perceptions of coldness, but women more highly focused on their appearance did not feel colder when wearing less clothing. These findings offer support for the relationship between self-objectification and awareness of bodily sensations in the context of a naturalistic setting. We discuss implications of these findings, and also consider limitations, an alternative explanation, and directions for future research.

Patient Perceptions of and Preferences Between Characteristics of Injectable Diabetes Treatments.

INTRODUCTION: The administration of medications targeting type 2 diabetes mellitus (T2D) has evolved over time. As injection delivery systems continue to evolve, it is necessary to understand patients' perceptions of currently available treatments. The objective of this study was to examine the patient perspective of injectable treatment for T2D and identify characteristics of these treatments that are most important to patients. METHODS: Data were collected via an online survey study with a sample of individuals in the UK and US who were treated for T2D with injectable medication. The survey was designed to elicit perceptions of the treatment process for injectable glucagon-like peptide 1 (GLP-1) receptor agonists and insulin. RESULTS: The sample included 504 participants (251 UK, 253 US). Approximately half (50.4%) were treated with a GLP-1 receptor agonist and half (49.6%) were treated with insulin. Respondents were presented with a list of 17 characteristics of injectable medication and asked to indicate which were most important to them. Respondents most frequently selected confidence in administering the correct dose (n = 300, 59.5%); ease of selecting the correct dose (n = 268, 53.2%); overall ease of using the injection device (n = 239, 47.4%); frequency of injections (n = 223, 44.2%); and ease of carrying the device when necessary to inject away from home (n = 190, 37.7%). Characteristics least frequently cited as important included dose escalation (n = 79, 15.7%); handling the needle (n = 74, 14.7%); connectivity to an electronic device (n = 70, 13.9%); and the time required to prepare and inject each dose (n = 62, 12.3%). CONCLUSION: Results of this survey suggest that patients prioritize some attributes of injectable treatments over others. These findings may have implications for clinical practice and development of injection devices.

Patient-Reported Outcomes and Impact of Type 2 Diabetes: A Cross-Sectional Study in the Kingdom of Saudi Arabia.

BACKGROUND: The Kingdom of Saudi Arabia (KSA) has the second highest prevalence of type 2 diabetes mellitus (T2DM) in the Middle East. There is a paucity of research on the experiences and treatment preferences of patients with T2DM in KSA. This study explored Saudi patients' health-related quality of life, eating habits, experiences during Ramadan, and preference between two glucagon-like peptide-1 receptor agonist (GLP-1 RA) treatment devices. METHODS: A cross-sectional, observational study was conducted in three cities in KSA. Participants completed sociodemographic and clinical forms, EQ-5D-5L, Impact of Weight on Self-Perceptions, and a diabetes treatment survey. Participants also viewed instructional videos on GLP-1 RA injection devices and indicated their device preference. RESULTS: Of the 310 participants, 53% were male. The mean age was 43 years (range: 30.0-75.0), duration since diabetes diagnosis was 6.3 years (range: 0.2-27.1), the most commonly reported last HbA1c level was between ≥7.1% and 8% (45%). The mean EQ-5D-5L index score was 0.90, with some participants reporting problems with pain/discomfort (34.5%) and usual activities (33.2%). Patients reported a low-to-moderate impact of weight on self-perception. In preparation for Ramadan, participants sought physician advice on diabetes management (37%) and/or increased checks of their blood glucose (37%). After watching the videos, 89% (n=277) of participants indicated a device preference, with significantly more preferring the dulaglutide device (n=186, 67%) over the semaglutide device (n=91, 33%) (p<0.0001). CONCLUSION: This study indicates that T2DM has a significant social, emotional, and behavioral impact on the lives of patients in KSA.

Assessing patient PREFERence between the dulaglutide pen and the semaglutide pen: A crossover study (PREFER).

AIM: When selecting treatments for type 2 diabetes (T2D), it is important to consider not only efficacy and safety, but also other treatment attributes that have an impact on patient preference. The objective of this study was to examine preference between injection devices used for two weekly GLP-1 receptor agonists. MATERIALS AND METHODS: The PREFER study was an open-label, multicentre, randomized, crossover study assessing patient preference for dulaglutide and semaglutide injection devices among injection-naïve patients receiving oral medication for type 2 diabetes. After being trained to use each device, participants performed all steps of injection preparation and administered mock injections into an injection pad. Time-to-train (TTT) for each device was assessed in a subset. RESULTS: There were 310 evaluable participants (48.4% female; mean age, 60.0 years; 78 participants in the TTT subgroup). More participants preferred the dulaglutide device than the semaglutide device (84.2% vs. 12.3%; P < 0.0001). More participants perceived the dulaglutide device to have greater ease of use (86.8% vs. 6.8%; P < 0.0001). After preparing and using the devices, more participants were willing to use the dulaglutide device (93.5%) than the semaglutide device (45.8%). Training participants to use the dulaglutide device required less time than the semaglutide device (3.38 vs. 8.14 minutes; P < 0.0001). CONCLUSIONS: Participants with type 2 diabetes preferred the dulaglutide injection device to the semaglutide injection device. If patients prefer a device, they may be more willing to use the medication, which could result in better health outcomes. Furthermore, a shorter training time for injection devices may be helpful in busy clinical practice settings.

Patient Preferences and Health State Utilities Associated with Mealtime Insulin Concentrations Among Patients with Diabetes in Italy.

INTRODUCTION: Standard concentration (100 units/mL) mealtime insulin is frequently used to treat patients with type 1 (T1D) and type 2 diabetes (T2D). A more concentrated version of the medication (200 units/mL) has been available in Italy since 2016. This concentrated version is bioequivalent to the standard version and delivers the same amount of medication but in half the volume of liquid. The purpose of this study was to examine patient preferences and estimate health state utilities associated with standard and concentrated rapid-acting mealtime analog insulin. METHODS: Participants with T1D and T2D in Italy valued two health states in time trade-off interviews. The descriptions of diabetes and treatment in the two health states were identical, differing only in terms of insulin concentration (e.g., half as much liquid for the same dose, less effort needed to press the injection button, and fewer injection pens required with concentrated insulin). To ensure participants understood the health states, they were shown a short video illustrating the differences between concentrations. RESULTS: A total of 217 participants completed the interviews (49.8% male; mean age 56.1 years; 109 from Milan; 108 from Rome; 12.0% T1D; 88.0% T2D). When asked which health state they preferred, 98.2% responded the concentrated version, 0.9% said the standard version, and 0.9% had no preference. Mean [standard deviation (SD)] utilities rounded to three decimals were 0.892 (0.099) for the concentrated version and 0.884 (0.101) for the standard version. The mean (SD; p value) utility difference between the standard and concentrated rapid-acting insulin was 0.007 (0.019; p < 0.0001). CONCLUSIONS: Findings from this study provide insight into patient preferences associated with concentration of rapid-acting insulin. Although the difference in utility is small, patients consistently preferred the concentrated formulation over the standard insulin, and for some patients this difference had an impact on utility valuations. These results suggest that the concentration of rapid-acting insulin should be considered because it could affect treatment preference and quality of life. FUNDING: Eli Lilly and Company.

Developing a preference-based utility scoring algorithm for the Psoriasis Area Severity Index (PASI).

Introduction: It is challenging to identify health state utilities associated with psoriasis because generic preference-based measures may not capture the impact of dermatological symptoms. The Psoriasis Area Severity Index (PASI) is one of the most commonly used psoriasis rating scales in clinical trials. The purpose of this study was to develop a utility scoring algorithm for the PASI. Methods: Forty health states were developed based on PASI scores of 40 clinical trial patients. Health states were valued in time trade-off interviews with UK general population participants. Regression models were conducted to crosswalk from PASI scores to utilities (e.g. OLS linear, random effects, mean, robust, spline, quadratic). Results: A total of 245 participants completed utility interviews (51.4% female; mean age = 45.3 years). Models predicting utility based on the four PASI location scores (head, upper limbs, trunk, lower limbs) had better fit/accuracy (e.g. R2, mean absolute error [MAE]) than models using the PASI total score. Head/upper limb scores were more strongly associated with utility than trunk/lower limb. The recommended model is the OLS linear model based on the four PASI location scores (R2 = 0.13; MAE = 0.03). An alternative is recommended for situations when it is necessary to estimate utility based on the PASI total score. Conclusions: The derived scoring algorithm may be used to estimate utilities based on PASI scores of any treatment group with psoriasis. Because the PASI is commonly used in psoriasis clinical trials, this scoring algorithm greatly expands options for quantifying treatment outcomes in cost-effectiveness analyses of psoriasis therapies. Results indicate that psoriasis of the head/upper limbs could be more important than trunk/lower limbs, suggesting reconsideration of the standard PASI scoring approach.

Timing of GLP-1 Receptor Agonist Initiation for Treatment of Type 2 Diabetes in the UK.

INTRODUCTION: Patients with type 2 diabetes mellitus (T2DM) who fail to meet glycaemic control are at increased risk of diabetes complications. For patients who cannot maintain glycaemic control with oral medication, one recommended option is to add an injectable glucagon-like peptide-1 receptor agonist (GLP-1 RA) to their treatment regimen. The purpose of this study was to examine time to treatment intensification with GLP-1 RAs, including the duration of time that patients did not maintain glycaemic control with oral medication. METHODS: This was a medical record review conducted in the UK via a physician survey. Patients eligible to have their records reviewed were required to be ≥ 18 years of age, have a confirmed T2DM diagnosis, and have initiated GLP-1 RA treatment for T2DM in the past 6 months. All glycated haemoglobin (HbA1c) values within 5 years prior to GLP-1 RA initiation were collected. RESULTS: A total of 113 physicians contributed data for 1096 patients (mean age at the time of GLP-1 RA initiation was 54.9 years, 55.4% were male, and 71.4% were White). Median time from T2DM diagnosis to GLP-1 RA initiation was 6.1 years. Median consecutive time patients taking oral regimens were not under glycaemic control (HbA1c > 7.0%) prior to GLP-1 RA initiation was 13.5 months. Patients treated by general practitioners (GPs) had a significantly longer duration of time with insufficient glycaemic control prior to GLP-1 RA initiation compared with patients treated by diabetes specialists (median time for specialists was 11.0 months vs. 17.0 months for GPs; p = 0.038). CONCLUSIONS: Results suggest that treatment intensification is often delayed despite consistently poor glycaemic control for more than 12 months, contrary to treatment guideline recommendations. Findings from this study highlight that some T2DM patients may benefit from more rapid treatment intensification, which could improve glycaemic control and reduce the risk for many short- and long-term health complications.

Patient preferences and health state utilities associated with dulaglutide and semaglutide injection devices among patients with type 2 diabetes in Italy.

Aims: Several glucagon like peptide-1 (GLP-1) receptor agonists are available as weekly injections for treatment of type 2 diabetes. These medications vary in their injection devices, and these differences could impact quality-of-life and patient preference. The purpose of this study was to examine patient preferences and estimate health state utilities associated with injection devices for two weekly GLP-1 therapies. Materials and methods: Participants with type 2 diabetes in Italy (Milan, Rome) valued three health state vignettes in time trade-off interviews. The health states had identical descriptions of type 2 diabetes, but differed in description of the treatment process: (1) oral treatment regimen, (2) oral plus weekly dulaglutide injection, and (3) oral plus weekly semaglutide injection. Results: A total of 216 participants completed interviews (57.9% male; mean age = 60.5). Almost all patients (99.5%) preferred the oral health state over either injection health state. Comparing between the two injections, 88.4% preferred the dulaglutide health state, while 11.6% preferred the semaglutide state. Mean (SD) utilities were 0.907 (0.076) for oral, 0.894 (0.085) for dulaglutide, and 0.887 (0.087) for semaglutide. The mean (SD) utility difference between the injection device health states was 0.007 (0.019). Limitations: Although the health states were designed to match the injection device instructions for use as closely as possible, vignette-based methods are inherently limited because results are based on perceptions of the health states rather than actual patient experience with the devices. Conclusions: Results provide insight into patient preferences associated with injection devices for weekly GLP-1 receptor agonists. The majority of patients preferred the dulaglutide device over the semaglutide device, and for some patients, this difference had an impact on utility valuations. Patient preferences for injection devices could be an important factor to consider when selecting treatments for type 2 diabetes.

Effects of incidental positive emotion and cognitive reappraisal on affective responses to negative stimuli.

Previous studies have identified two powerful ways to regulate emotional responses to a stressor: experiencing incidental positive emotions and using cognitive reappraisal to reframe the stressor. Several cognitive and motivational theories of positive emotion support the formulation that incidental positive emotions may facilitate cognitive reappraisal. To test the separate and interacting effects of positive emotions and cognitive reappraisal, we first adapted an established picture-based reappraisal paradigm by interspersing blocks of positive emotion inducing and neutral pictures. Across two pre-registered studies (Studies 1, 2), reappraisal effectively decreased self-reported negative emotions and increased self-reported positive emotions; however, experiencing incidental positive emotions did not facilitate reappraisal success. In another preregistered study (Study 3), we employed a more powerful positive emotion induction via virtual reality (VR), used a social stress anticipation task, and instructed participants to reappraise the anticipated stressor positively. Although there was a robust effect of the positive emotion induction (relative to the neutral induction) on feeling more positive emotions throughout stress anticipation, the results again indicated that incidental positive emotions did not facilitate cognitive reappraisal. We propose that incidental positive emotions and cognitive reappraisal may constitute separate pathways of influence when regulating one's responses to negative events.

Outcomes of children with congenital heart disease implanted with ventricular assist devices: An analysis of the Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs).

BACKGROUND: The reported ventricular assist device (VAD) experience in the pediatric congenital heart disease (CHD) population is limited. We sought to describe contemporary use and outcomes of VADs in children with CHD and compare these outcomes to those of non-CHD children. METHODS: Patients enrolled in the Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) between September 19, 2012 through June 30, 2017 were included. CHD was classified as biventricular vs single ventricle (Stages 1, 2, or 3). Outcomes were compared between groups and multivariable analysis was used to identify factors associated with mortality on the device. RESULTS: Among the 471 patients enrolled, 108 (24%) had CHD (45 biventricular and 63 single ventricle). CHD patients were younger (5.7 ± 5.7 years vs 9.8 ± 6.5 years; p < 0.0001) and smaller (0.8 ± 0.5 m2 vs 1.2 ± 0.7 m2; p < 0.0001) compared with non-CHD patients. CHD patients were more likely to receive a paracorporeal continuous-flow VAD (36.1% vs 12.9%; p < 0.0001) and less likely to receive an implantable continuous-flow VAD (27.8% vs 55.0%; p < 0.0001) compared with non-CHD patients. After 6 months on a VAD, CHD patients had higher mortality (36.4% vs 12.1%) and a lower transplantation rate (29.1% vs 59.9%) than non-CHD patients (p < 0.0001). In the multivariable analysis, CHD was the factor most strongly associated with mortality on VAD (hazard ratio [HR] = 2.9; p < 0.0001), whereas the factors implantable continuous-flow device and high-volume center were protective (HR = 0.3, p < 0.0001, and HR = 0.6, respectively; p = 0.02). CONCLUSIONS: VAD use in children with CHD is associated with increased mortality and decreased transplant rates compared to children without CHD. For the subgroup of children with CHD who received implantable continuous-flow VADs, survival rates were higher and comparable to those of children without CHD. Increased experience correlated with better survival in pediatric VADs.

Development of the Diabetes Injection Device Experience Questionnaire (DID-EQ) and Diabetes Injection Device Preference Questionnaire (DID-PQ).

BACKGROUND: Previous research has examined patient perceptions of insulin injection devices. However, injectable medications other than insulin are increasingly used to treat type 2 diabetes, including GLP-1 receptor agonists. No patient-reported outcome (PRO) instruments have been developed taking into account the experiences of patients using newer injection devices, which are often different from devices used for insulin. Therefore, the purpose of this qualitative study was to develop two draft PRO instruments focusing on patients' experiences with these newer injection devices (one instrument assessing perceptions of a single injection device, and another assessing preferences between two devices). METHODS: Questionnaire development proceeded in six steps: literature review, interviews with six device experts, concept elicitation interviews with patients (N = 32), preliminary translatability assessment, cognitive interviews with patients (N = 20), and final translatability assessment. RESULTS: Literature review and expert interviews were conducted to inform a concept elicitation interview guide. In concept elicitation in the US, UK, and Germany, patients with type 2 diabetes reported a range of injection features that influenced their perceptions of non-insulin injection devices (e.g., requirements for preparation of the medication/device, issues related to the needle, ease-of-use, portability). Two draft "item pools" were developed based on the literature review, expert interviews, and concept elicitation results. In cognitive interviews, patients recommended minor revisions and indicated that the draft instruments were generally clear, comprehensible, and relevant to their experience with non-insulin injectable medication. The instruments were refined based on the cognitive interviews and translatability assessment, resulting in two questionnaires. CONCLUSIONS: The various steps of qualitative research support the content validity of these new PRO instruments, which are the first developed specifically to assess perceptions of non-insulin injection delivery systems. Despite some overlap with insulin-focused questionnaires, the new instruments are distinct from previous instruments (omitting content that would not be relevant to patients receiving non-insulin injectable treatment, while including content that is not included in the insulin focused instruments). This qualitative research yielded two draft questionnaires that are grounded in patient perceptions and ready for psychometric validation studies with larger samples of patients with type 2 diabetes.

Patient preferences in Italy: health state utilities associated with attributes of weekly injection devices for treatment of type 2 diabetes.

OBJECTIVES: Several glucagon-like peptide-1 receptor agonists are administered as weekly injections for treatment of type 2 diabetes (T2D). These medications vary in their injection processes, and a recent study in the UK found that these differences had an impact on patient preference and health state utilities. The purpose of this study was to replicate the UK study in Italy to examine preferences of an Italian patient sample, while allowing for comparison between utilities in the UK and Italy. MATERIALS AND METHODS: Participants with T2D in Italy valued health states in time trade-off interviews. All health states had the same description of T2D, but differed in description of the treatment process. As in the original UK study, the first health state described an oral treatment regimen, while additional health states added a weekly injection. The injection health states differed in three injection-related attributes: requirements for reconstituting the medication, waiting during medication preparation, and needle handling. RESULTS: Interviews were completed by 238 patients (58.8% male; mean age = 60.2 years; 118 from Milan, 120 from Rome). The oral treatment health state had a mean (SD) utility of 0.90 (0.10). The injection health states had significantly (p < 0.0001) lower utilities, which ranged from 0.87 (requirements for reconstitution, waiting, and handling) to 0.89 (weekly injection with none of these requirements). Differences in health state utility scores suggest that each administration requirement was associated with a disutility (ie, negative utility difference): -0.006 (reconstitution), -0.006 (needle handling), -0.011 (reconstitution, needle handling), and -0.022 (reconstitution, waiting, needle handling). CONCLUSION: Disutilities associated with the injection device characteristics were similar to those reported with the UK sample. Results suggest that injection device attributes may be important to some patients with T2D, and it may be useful for clinicians to consider these attributes when choosing medication for patients initiating these weekly treatments.

Patient perceptions of injection devices used with dulaglutide and liraglutide for treatment of type 2 diabetes.

OBJECTIVE: Liraglutide and dulaglutide have demonstrated similar glycemic efficacy and safety. However, they differ in treatment administration and injection devices. The purpose of this study was to examine and compare patient perceptions of the injection devices used with liraglutide and dulaglutide. METHODS: Patients with type 2 diabetes treated with liraglutide or dulaglutide were recruited from across the US. Patients completed the Diabetes Injection Device Experience Questionnaire (DID-EQ) to rate their current injection device. Patients who had experience with both treatments also completed the Diabetes Injection Device Preference Questionnaire (DID-PQ) to report preferences between the two devices. ANCOVAs were conducted to compare DID-EQ scores between dulaglutide and liraglutide patients, while controlling for covariates. Descriptive statistics are presented for preferences reported on the DID-PQ. RESULTS: A total of 404 patients were recruited from 49 states (mean age = 60.7 years; 54.0% female; 204 liraglutide; 200 dulaglutide). Mean DID-EQ item scores for both treatments were high, ranging from 3.48 to 3.90 on a 4 point scale. ANCOVAs found significantly higher scores for dulaglutide than liraglutide on DID-EQ global items assessing ease of use (3.82 vs. 3.73, p = .040) and convenience (3.79 vs. 3.66, p = .004). Among the 58 patients who had used both devices, more patients reported a preference for the dulaglutide device than the liraglutide device on every item of the DID-PQ. CONCLUSIONS: High DID-EQ scores indicate positive perceptions of both the liraglutide and dulaglutide injection devices. The dulaglutide device was associated with slightly higher scores for ease of use and convenience than the liraglutide device.

Psychosocial functioning in pediatric heart transplant recipients and their families.

Across pediatric organ transplant populations, patient and family psychosocial functioning is associated with important health-related outcomes. Research has suggested that pediatric heart transplant recipients and their families are at increased risk for adverse psychosocial outcomes; however, recent investigation of psychosocial functioning in this population is lacking. This study aimed to provide a contemporary characterization of psychosocial functioning in pediatric heart transplant recipients and their families. Associations between psychosocial function, demographic variables, and transplant-related variables were investigated. Fifty-six parents/guardians of pediatric heart transplant recipients completed a comprehensive psychosocial screening measure during transplant follow-up clinic visits. Descriptive statistics, correlational analyses, and independent samples t tests were performed. Forty percent of pediatric heart transplant recipients and their families endorsed clinically meaningful levels of total psychosocial risk. One-third of patients presented with clinically significant psychological problems per parent report. Psychosocial risk was unassociated with demographic or transplant-related factors. Despite notable improvements in the survival of pediatric heart transplant recipients over the past decade, patients and families present with sustained psychosocial risks well beyond the immediate post-transplant period, necessitating mental health intervention to mitigate adverse impact on health-related outcomes.

Optimizing the Use of Discharge Medication Lists in Nursing Facilities.

OBJECTIVE: To highlight the need to optimize the use of discharge medication lists in nursing facilities. SETTING: In January 2014, the care transitions (CT) pharmacists at Frederick Memorial Hospital, Frederick, Maryland, began a pilot project in which they identified and followed high-risk patients transitioning from hospital to nursing facility and from nursing facility to home. PRACTICE DESCRIPTION: This pilot project served as a needs assessment to identify opportunities to improve patients' transition from nursing facility to home with the goal of reducing hospital readmissions. PRACTICE INNOVATION: One of the enormous opportunities that were immediately recognized was the nursing facility discharge medication list. MAIN OUTCOME MEASUREMENTS: The CT pharmacists found that patients had difficulty deciphering and understanding the medication lists. RESULTS: By reviewing the elements of existing medication lists, the CT pharmacists identified 11 components of a nursing facility discharge medication list that would increase patient safety and potentially reduce medication-related hospital readmissions. These elements include the capability of electronically generating a medication list that includes both brand and generic medication names with accurate indications in layperson terms. The ideal discharge medication list would also be patient-specific and remove irrelevant information and take into consideration patients' age, vision, and health literacy. CONCLUSION: With the upcoming implementation of the nursing facility value-based purchasing program, nursing facilities may soon receive incentives to improve their medication management systems at discharge.

A prospective evaluation of short-term dysphagia after transoral robotic surgery for squamous cell carcinoma of the oropharynx.

BACKGROUND: Transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) has been associated with improved long-term dysphagia symptomatology compared with chemoradiation. Dysphagia in the perioperative period has been inadequately characterized. The objective of this study was to characterize short-term swallowing outcomes after TORS for OPSCC. METHODS: Patients undergoing TORS for OPSCC were enrolled prospectively. The Eating Assessment Tool 10 (EAT-10) was used as a measure of swallowing dysfunction (score >2) and was administered on postoperative day (POD) 1, 7, and 30. Patient demographics, weight, pain level, and clinical outcomes were recorded prospectively and focused on time to oral diet, feeding tube placement, and dysphagia-related readmissions. RESULTS: A total of 51 patients were included with pathologic T stages of T1 (n = 24), T2 (n = 20), T3 (n = 3), and Tx (n = 4). Self-reported preoperative dysphagia was unusual (13.7%). The mean EAT-10 score on POD 1 was lower than on POD 7 (21.5 vs 26.6; P = .005) but decreased by POD 30 (26.1 to 12.2; P < .001). Forty-seven (92.1%) patients were discharged on an oral diet, but 57.4% required compensatory strategies or modification of liquid consistency. Ninety-eight percent of patients were taking an oral diet by POD 30. There were no dysphagia-related readmissions. CONCLUSION: This prospective study shows that most patients who undergo TORS experience dysphagia for at least the first month postoperatively, but nearly all can be started on an oral diet. The dysphagia-associated complication profile is acceptable after TORS with a minority of patients requiring temporary feeding tube placement. Aggressive evaluation and management of postoperative dysphagia in TORS patients may help prevent dysphagia-associated readmissions. Cancer 2017;123:3132-40. © 2017 American Cancer Society.