Could Education Be the Best Galactagogue? Development and Content Validation of Provider and Patient Checklists to Promote Lactation Among Black Parents.

One of the factors contributing to the disparities still present by race in the United States may be inequitable access to lactation education. In order to ensure that all parents receive the education they deserve to make informed infant feeding decisions, two checklists were created for patient and healthcare professional use, respectively. This paper describes the process of creating and validating the healthcare professional and patient checklists. The authors completed a review of the most recent literature surrounding barriers to lactation initiation and retention in the Black community to create the initial version of the checklists. Expert consultation was then utilized to assess their content validity. Local healthcare providers unanimously agreed that pregnant and postpartum parents need more education and support than currently provided. The consulted experts described the two checklists as useful and comprehensive and offered feedback for their revision and optimization. Implementing these checklists offer the possibility of increasing provider accountability in delivering adequate lactation education and enhancing client lactation knowledge and self-efficacy. Further research is needed to assess the effect of implementation of the checklists in a healthcare setting.

Post-Pemphigus Acanthomata Presenting as an Isolated, Hyperkeratotic Plaque.

Post-pemphigus acanthomas have been rarely discussed in the literature. A prior case series identified 47 cases of pemphigus vulgaris and 5 cases of pemphigus foliaceus, out of which 13 developed acanthomata as a part of the healing process. Additionally, a case report by Ohashi et al. reported similar recalcitrant lesions on the trunk of a patient with pemphigus foliaceus being treated with prednisolone, IVIG, plasma exchange, and cyclosporine. Some view post-pemphigus acanthomas as variants of hypertrophic pemphigus vulgaris, being difficult to diagnose when they present as only single lesions, with a clinical differential of an inflamed seborrheic keratosis or squamous cell carcinoma. Here, we present a case of a 52-year-old female with a history of pemphigus vulgaris and four months of only topical therapy (fluocinonide 0.05%) who presented with a painful, hyperkeratotic plaque on the right mid-back that was found to be a post-pemphigus acanthoma.

Cutaneous T-cell lymphoma following dupilumab use: a systematic review.

In recent years, studies have associated dupilumab with unmasking or progression of cutaneous T-cell lymphoma (CTCL). The objective of this study was to synthesize reported cases of CTCL in the setting of dupilumab use. Two independent reviewers conducted a systematic review using PubMed and Embase databases. Twelve studies, of 27 total patients, were included. Dupilumab-associated CTCL was diagnosed on average 7.8 months following dupilumab initiation. Of reports that included body surface area (BSA), 100% had a BSA >50% prior to diagnosis, and the majority of patients were diagnosed at later stages of disease: stage III (4/18) or IV (6/18). Post-dupilumab biopsies revealed a greater density of cells and a predominant lichenoid pattern, compared to various histologic patterns and less cell density in pre-dupilumab biopsies. The majority of TCR gene rearrangement studies were equivocal (20%) or negative (60%), posing a potential diagnostic pitfall. Limitations included lack of standardized data collection and reporting and a small number of studies. We suggest that earlier biopsies, three to four months after initiation of dupilumab, may be helpful for earlier recognition of CTCL in patients who are not improving, progressing, or have morphologic changes on dupilumab.

Dupilumab-Associated Mycosis Fungoides with a CD8+ Immunophenotype.

Dupilumab is a humanized IgG4 monoclonal-antibody that is approved by the United States Food and Drug Administration (FDA) for the treatment of moderate-to-severe atopic dermatitis (AD) in patients aged 12 years and older. In recent years, several case studies have associated the unmasking or progression of cutaneous T-cell lymphomas (CTCL) with dupilumab treatment. To date, all reported cases of dupilumab-associated CTCL have shown a CD4+ T-helper-cell-predominant immunophenotype. Here, we report a case of a 72-year-old man who presented with a 2-year history of a diffuse, pruritic eruption, who was started on dupilumab for 9 weeks. He subsequently developed mycosis fungoides (MF) with a CD8+-predominant immunophenotype. Overall, cases of CD8+ mycosis fungoides are less common and relatively less understood than their CD4+ counterparts, with varied presentations and courses. We present a case of dupilumab-associated CD8+ MF to highlight this presentation for pathologists and providers.

Effects of Season, Location, Species, and Sex on Hematologic and Plasma Biochemical Values and Body Mass in Free-ranging Grebes (Aechmophorus species).

The effects of season, location, species, and sex on body weight and a comprehensive array of blood chemistry and hematology analytes were compared for free-ranging western (Aechmophorus occidentalis) and Clark's (Aechmophorus clarkii) grebes. Birds (n = 56) were collected from Puget Sound, WA, and Monterey Bay and San Francisco Bay, CA, from February 2007 to March 2011. The data supported generalization of observed ranges for most analytes across Aechmophorus grebe metapopulations wintering on the Pacific coast. Notable seasonal and location effects were observed for packed cell volume (winter 6% greater than fall; winter California [CA] 5% greater than Washington [WA]), total white blood cell count (CA 3.57 × 103 cells/µL greater than WA), heterophils (WA 10% greater than CA), lymphocytes (winter 19% greater than fall), heterophil to lymphocyte ratio (fall 5.7 greater than winter), basophils (CA greater than WA), plasma protein (WA about 10 g/L [1.0 g/dL] greater than CA), plasma protein to fibrinogen ratio (winter about 15 greater than fall), potassium (CA 2 mmol/L greater than WA), and liver enzymes (alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase: WA greater than CA). Within California, season had a greater effect on body mass than sex (mean winter weights about 200 g greater than fall), whereas within a season, males weighed only about 80 g more than females, on average. These data give biologists and veterinarians quantitative reference values to better assess health at the individual and metapopulation level.

An international randomized phase III trial of pulse actinomycin-D versus multi-day methotrexate for the treatment of low risk gestational trophoblastic neoplasia; NRG/GOG 275.

OBJECTIVES: Methotrexate and actinomycin-D are both effective first-line drugs for low-risk (WHO score 0-6) Gestational Trophoblastic Neoplasia (GTN) with considerable debate about which is more effective, less toxic, and better tolerated. The primary trial objective was to test if treatment with multi-day methotrexate (MTX) was inferior to pulse actinomycin-D (ACT-D). Secondary objectives included evaluation of severity and frequency of adverse events, and impact on quality of life (QOL). METHODS: This was a prospective international cooperative group randomized phase III two arm non-inferiority study (Clinical Trials Identifier: (NCT01535053). The control arm was ACT-D; the experimental arm was multi-day MTX regimen (institutional preference of 5 or 8 day). Outcome measures included complete response rate, recurrence rate, toxicity, and QOL as measured by FACT-G and FACIT supplemental items. RESULTS: The complete response rates for multi-day methotrexate and pulse actinomycin-D were 88% (23/26 patients) and 79% (22/28 patients) (p = NS) respectively, there were two recurrences in each arm, and 100% of patients survived. Significant toxicity was minimal, but mouth sores (mucositis), and eye pain were significantly more common in the MTX arm (p = 0.001 and 0.01 respectively). Quality of life showed no significant difference in overall quality of life, body image, sexual function, or treatment related side effects. The study was closed for low accrual rate (target 384, actual accrual 57), precluding statistical analysis of the primary objective. CONCLUSIONS: The complete response rate for multi-day methotrexate was higher than actinomycin-D, but did not reach statistical significance. The multi-day MTX regimens were associated with significantly more mucositis and were significantly less convenient.

Newborn Adipokines and Birth Outcomes.

BACKGROUND: Adipokines can serve as a measure of adipose tissue activity. Although birthweight correlates with neonatal adiposity, findings for cord blood levels of adipokines and birth outcomes have been conflicted. Therefore, we determined the cross-sectional associations between adipokines measured in newborn dried blood spots (DBS) and birth outcomes. METHODS: The Upstate KIDS study enrolled mothers and infants from 2008 to 2010. Among infants whose parents consented to the use of residual DBS from newborn screening, 2397 singletons and 1240 twins had adipokine measurements from the Human Obesity Panel (R&D Systems) by Luminex. Odds ratios were estimated by multivariable logistic regression for risk of birth outcomes of preterm delivery (<37 weeks for singletons, <32 for twins) and small-for-gestational age (SGA <10th for singletons and <3rd for twins age- and sex-specific percentiles) by adipokine quintiles. Generalised estimating equations were applied to account for correlations between twins. RESULTS: Singletons in the lowest compared with the highest quintile of adiponectin were more likely preterm (adjusted odds ratio 3.26; 95% confidence interval [CI] 1.99, 5.34) and SGA (1.81; [95% CI 1.18, 2.77]). Similar associations were observed among twins. Resistin was associated with preterm birth (Q1 vs. Q5: 2.08; [95% CI 1.20, 3.62]) only among singletons. Adipsin had inconsistent associations after adjustment. CONCLUSIONS: This large population-based study demonstrates that newborn DBS-measured adipokines are associated with birth outcomes, particularly preterm birth and SGA among those with lower adiponectin levels regardless of plurality.

Mindful movement program for older breast cancer survivors: a pilot study.

BACKGROUND: Older breast cancer survivors (BCSs) are at risk for late and long-term treatment effects on quality of life (QOL), including lower physical functioning and fear of recurrence. Two promising approaches to address this include dance/movement therapy and mindfulness. OBJECTIVE: The purpose of this 2-group randomized controlled pilot feasibility study was to test short-term effects of a 12-week Mindful Movement Program (MMP) intervention combining mindfulness with self-directed movement on QOL and mindfulness in female BCSs 50 years or older and at 12 months or more following treatment. METHODS: Consented participants were randomized to an experimental group (EG) (12 weekly MMP sessions) or a control group (no sessions). All completed questionnaires 3 times. The EG participants kept home practice diaries. Analysis was conducted after intervention for immediate effects on outcome variables and 6 weeks later for maintenance of effects. RESULTS: Participants (n = 49) ranged in age from 50 to 90 years (average, 65.6 years) and were at 9.8 years since diagnosis (range, 1-32 years), and the majority were white, unpartnered, and retired. After intervention, EG participants showed improved QOL via decreased fear of recurrence and increased mindfulness attitude. At 6 weeks, initial effects were retained. CONCLUSIONS: The MMP appears to benefit older BCSs by reducing fear of recurrence and improving mindfulness attitude. Although these findings are promising, a larger study is needed to determine more specifically what short- and long-term effects are possible. IMPLICATIONS FOR PRACTICE: The combination of self-directed movement and mindfulness, as tested here, may be a valuable tool for promoting health and well-being in older long-term survivors of breast cancer.

Silencing of insulin receptor substrate-1 increases cell death in retinal Müller cells.

PURPOSE: To determine whether ß-adrenergic receptors require insulin receptor substrate (IRS)-1 activity to regulate apoptosis in retinal Müller cells. METHODS: Müller cells were cultured in Dulbecco's Modified Eagle Medium (DMEM) medium grown in normal (5 mm) or high glucose (25 mM) conditions. The medium was supplemented with 10% fetal bovine serum and antibiotics. Cells were allowed to reach 80%-90% confluence. After becoming appropriately confluent, cells were placed in medium with reduced serum (2%) for 18-24 h to eliminate any effects of fetal bovine serum. Cells were then transfected with 10 ug of IRS-1 small hairpin RNA (shRNA). Forty-eight hours following transfection, cells were lysed and harvested for protein analysis using western blotting. In additional experiments, some cells were treated with 10 uM salmeterol for 24 h following transfection with IRS-1 shRNA. To determine whether IRS-1 directly regulates apoptotic events in the insulin-signaling pathway in retinal Müller cells, a cell death assay kit was used. In tumor necrosis factor (TNF)α inhibitory studies, cells were treated with 5 ng/ml of TNFα alone for 30 min or 30 min pretreatment with TNFα followed by salmeterol for 4 h. RESULTS: Müller cells treated with 5 ng/ml TNFα in 25 mM glucose significantly increased phosphorylation of IRS-1(Ser307). Treatment with the selective beta-2-adrenergic receptor agonist, salmeterol, significantly decreased phosphorylation of IRS-1(Ser307). Following IRS-1 shRNA transfection+salmeterol treatment, Bcl-2-associated X protein (Bax) and cytochrome c levels were significantly decreased. Salmeterol+IRS-1 shRNA also decreased cell death and increased protein levels of B-cell lymphoma-extra large (Bcl-xL), an anti-apoptotic factor. CONCLUSIONS: In these studies, we show for the first time that salmeterol, a beta-2-adrenergic receptor agonist, can reduce retinal Müller cell death through IRS-1 actions. These findings also suggest the importance of IRS-1 in beta-adrenergic receptor signaling in the prevention of cell death in retinal Müller cells.

Participant perceptions of a mindful movement program for older women with breast cancer: focus group results.

BACKGROUND: Little attention has been directed to the longer-term survivorship phase for older breast cancer survivors (BCSs) who often continue to struggle with late and long-term adverse effects of treatment including lower physical functioning, fear of recurrence, stress and anxiety, neuropathies, and pain. Creative and accessible strategies are needed that offer support to this population of cancer survivors. OBJECTIVE: The purpose of this study was to examine participant perceptions of the effects of a Mindful Movement Program intervention on quality of life and mindfulness through focus groups. This was part of a pilot feasibility study testing the intervention with older women at more than 1 year after treatment for breast cancer. METHODS: Eight to 9 weeks after completion of 12 weekly, 2-hour mindful movement sessions, focus groups were held with 3 experimental group cohorts of participants who had attended on average 10.4 classes. Focus group interviews were recorded, transcribed verbatim, and analyzed using qualitative techniques for recurrent themes. RESULTS: Four themes emerged from the direct quotes of the participants: freedom, rediscovering, body sense in moving, and in the moment. Participants also contributed opinions about program delivery. CONCLUSIONS: Participants described how the Mindful Movement Program experience affected their lives. Their feedback indicated that the intervention yielded positive results and was feasible for a variety of older BCSs. IMPLICATIONS FOR PRACTICE: Research with a wider group of participants is needed. Preliminary indications are that mindful movement may offer an acceptable strategy for increasing activity and decreasing stress among older BCSs.

Role of ß-adrenergic receptor regulation of TNF-α and insulin signaling in retinal Muller cells.

PURPOSE: The goal of this study was to determine the relationship of TNF-α and the downregulation of insulin receptor signaling in retinal Müller cells cultured under hyperglycemic conditions and the role of ß-adrenergic receptors in regulating these responses. METHODS: Retinal Müller cells were cultured in normal (5 mM) or high (25 mM) glucose until 80% confluent and then were reduced to 2% serum for 18 to 24 hours. The cells were then treated with 10 µM salmeterol followed by Western blot analysis or ELISA. For TNF-α inhibitory studies, the cells were treated with 5 ng/mL of TNF-α for 30 minutes or by a 30-minute pretreatment with TNF-α followed by salmeterol for 6 hours. In the TNF-α short hairpin (sh)RNA experiments, the cells were cultured until 90% confluent, followed by transfection with TNF-α shRNA for 18 hours. RESULTS: TNF-α-only treatments of Müller cells resulted in significant decreases of tyrosine phosphorylation of the insulin receptor and Akt in high-glucose conditions. Salmeterol (10 µM), a ß-2-adrenergic receptor agonist, significantly increased phosphorylation of both insulin receptor and Akt. TNF-α shRNA significantly decreased phosphorylation of IRS-1(Ser307), which was further decreased after salmeterol+TNF-α shRNA. Both TNF-α shRNA and salmeterol significantly reduced death of the retinal Müller cells. CONCLUSIONS: These studies demonstrate that ß-adrenergic receptor agonists in vitro can restore the loss of insulin receptor activity noted in diabetes. By decreasing the levels of TNF-α and decreasing the phosphorylation of IRS-1(Ser307) while increasing tyrosine phosphorylation of insulin receptor, these results suggest a possible mechanism by which restoration of ß-adrenergic receptor signaling may protect the retina against diabetes-induced damage.

A grounded theory of the process of adherence to oral chemotherapy in Hispanic and caucasian children and adolescents with acute lymphoblastic leukemia.

Children and adolescents with acute lymphoblastic leukemia (ALL) receive treatment that relies on daily self- or parent/caregiver-administered oral chemotherapy for approximately 2 years. Despite the fact that pediatric ALL is uniformly fatal without adequate treatment, nonadherence to oral chemotherapy has been observed in up to one third of patients. Little is known about the reasons for nonadherence in these patients. This study used Straussian grounded theory methodology to develop and validate a model to explain the process of adherence to oral chemotherapy in children and adolescents with ALL. Thirty-eight semistructured interviews (with 17 patients and 21 parents/caregivers) and 4 focused group discussions were conducted. Three stages were identified in the process of adherence: (a) Recognizing the Threat, (b) Taking Control, and (c) Managing for the Duration. Doing Our Part was identified as the core theme explaining the process of adherence and involves the parent (or patient) taking responsibility for assuring that medications are taken as prescribed. Understanding the association between taking oral chemotherapy and control/cure of leukemia (Making the Connection) appeared to mediate adherence behaviors.

Discontinuation of radiation treatment among medicaid-enrolled women with local and regional stage breast cancer.

For women with nonmetastatic breast cancer, radiation therapy is recommended as a necessary component of the breast conserving surgery (BCS) treatment option. The degree to which Medicaid-enrolled women complete recommended radiation therapy protocols is not known. We evaluate radiation treatment completion rates for Medicaid enrollees aged 18-64 diagnosed with breast cancer. We determine clinical and socio-demographic factors associated with not starting treatment, and with interruptions or not completing radiation treatment. Using data from the Washington State Cancer Registry linked to Medicaid enrollment and claims records, we identified Medicaid enrollees diagnosed with breast cancer from 1997 to 2003 who received BCS. Among the 402 women who met inclusion criteria, 105 (26%) did not receive any radiation. Factors significantly associated with not receiving radiation included in situ disease and non-English as a primary language. Among those who received at least one radiation treatment, 65 (22%) failed to complete therapy and 71 (24%) patients had at least one 5 to 30 day gap in treatment. We found no significant predictors of interruptions in treatment or early discontinuation. A substantial proportion of Medicaid-insured women who are eligible for radiation therapy following BCS either fail to receive any treatment, experience significant interruptions during therapy, or do not complete a minimum course of treatment. More effort is needed to ensure this vulnerable population receives adequate radiation following BCS.

A case of tuberculosis in a patient on Efalizumab and Etanercept for treatment of refractory palmopustular psoriasis and psoriatic arthritis.

We discuss a patient with a history of a positive tuberculin skin test, who presented with severe, recalcitrant palmoplantar pustular psoriasis with psoriatic arthritis whose symptoms did not resolve with monotherapy of etanercept (Enbrel) or efalizumab (Raptiva) alone, but did respond to a combination of both biologics. However, our patient was later found to have re-activation tuberculosis after long-term treatment. This case highlights many key points for treatment of psoriasis and psoriatic arthritis with biologics. Namely, that recalcitrant psoriatic skin lesions may have good clearing on one biologic, such as efalizumab, and arthritic symptoms can be well-controlled with etanercept, leading patients to be on two different biologics concurrently to control symptoms. However, it also highlights the importance of determining a patient's tuberculosis status, initiating prophylactic anti-tuberculosis therapy prior to starting treatment with etanercept, and setting up an adequate treatment regime if the patient develops active tuberculosis during therapy with etanercept.

Factors influencing adolescents' decision not to smoke.

OBJECTIVE: Although adolescents ultimately make their own decisions to smoke or not to smoke, social, economic, and environmental circumstances shape their choices. Most research on prevention of youth tobacco use focuses on predictors of smoking initiation. In this study, we explored nonsmoking attitudes, beliefs, and norms from the perspective of 16-17-year-old nonsmokers. DESIGN: This qualitative study targeted nonsmoking youths because most social policy in the arena of tobacco prevention aims to support adolescents who are tobacco free. SAMPLE: Participants were 39 nonsmokers recruited from youth organizations in an urban community and included 22 African Americans (12 females; 10 males) and 17 Caucasian Americans (10 females; 7 males). METHODS: A health behavior framework guided the development of semistructured questions on attitudes, beliefs, and norms associated with nonsmoking, used in eight in-depth group interviews. RESULTS: Concerns for health and addiction, a positive self-image, and perceived confidence, emerged as factors affecting participants' decisions not to smoke. The approval of parents and friends, and personal beliefs further reinforced adolescents' nonsmoking decisions. CONCLUSIONS: There were more commonalities than differences in nonsmoking attitudes across gender and race. Future studies of youth tobacco prevention should employ multifaceted approaches targeting adolescents' attitudes, families, and peer networks.

Fatigue in women receiving intraperitoneal chemotherapy for ovarian cancer: a review of contributing factors.

Women diagnosed with stage III or IV ovarian cancer typically are treated with surgery followed by chemotherapy. Intraperitoneal (IP) chemotherapy, the direct administration of chemotherapy into the IP cavity, has been explored as a viable treatment option for some women with advanced ovarian cancer. Fatigue may occur as a result of the disease process, treatment, or a wide variety of physical, psychological, or situational factors. Fatigue is one of the most common and distressing side effects associated with chemotherapy and it may be intensified in women receiving IP chemotherapy. The purpose of this article is to examine fatigue in women receiving IP chemotherapy for advanced ovarian cancer and to examine what aspects of IP chemotherapy may contribute to fatigue development. Factors reviewed include surgery for debulking the tumor and placement of the IP catheter, administration of IV chemotherapy in addition to IP chemotherapy, pain, anemia, sleep disturbances, gastrointestinal disturbances, and emotional distress. Oncology nurses who are knowledgeable about the factors that contribute to fatigue in women receiving IP chemotherapy will be better prepared to conduct a comprehensive assessment and develop effective treatment strategies.

Disenrollment from Medicaid after recent cancer diagnosis.

OBJECTIVES: We examine the frequency with which newly diagnosed cancer patients are covered by Medicaid in Washington State and the duration of coverage. METHODS: Medicaid enrollment and claims files were linked to the Washington State Cancer Registry to identify all Medicaid enrollees with breast, cervical, lung, colorectal, and prostate cancer between 1997 and 2002. RESULTS: We identified 5009 newly diagnosed cancer patients covered by Medicaid, approximately 13% of the total cases diagnosed in subjects less than 65 years of age in Washington State. The majority, 2866 (57%), enrolled in Medicaid around the time of diagnosis; the remainder had been enrolled at least 3 months before diagnosis. Persons enrolled at diagnosis had later-stage cancer; those enrolled before diagnosis had more noncancer comorbidities. Overall, 18% had disenrolled by 6 months after diagnosis; 34% by 1 year; and 54% by 2 years. CONCLUSIONS: Medicaid patients with cancer in Washington State experience a high rate of disenrollment within 1 year after diagnosis. Further research is needed to determine whether disenrollment compromises initial therapy or follow-up care.

Bilateral facial pigmentation.

A 38-year-old man presented with a chief complaint of blue-speckled secretions on his cheeks, brought on by exertion. Based on the clinical features, a diagnosis of apocrine chromhidrosis was made. Histopathologic exam further supported this diagnosis. Possible treatment options for apocrine chromhidrosis are discussed.

Aphthous ulcers associated with imiquimod and the treatment of actinic cheilitis.

Our case series report is the first documented depiction of the appearance of aphthous ulcers secondary to imiquimod application. This case series presentation discusses the underlying pathophysiology of aphthous ulcer development and imiquimod therapy in terms of the stimulation of proinflammatory cytokines, such as tumor necrosis factor alpha (TNF-alpha). The literature review suggests more than just a mere coincidence for the development of aphthous ulcers subsequent to the treatment of actinic cheilitis with imiquimod application.