Inpatient pain assessment and decision-making in internal medicine and general surgery residents: A qualitative analysis.

Background: Understanding physician approaches to pain treatment is a critical component of opioid and analgesic stewardship. Practice patterns learned in residency often persist longitudinally into practice. Objective: This study sought to identify salient factors and themes in how resident physicians assess and manage pain. Methods: Video-recorded focus groups of internal medicine and general surgery residents were conducted via videoconferencing software. Data were analyzed using a ground theory approach and constant comparative method to identify themes and subthemes. Focus groups occurred in September and October 2020. Results: 10 focus groups including 35 subjects were conducted. Four general themes emerged: (1) Assessment considerations; (2) Education & Expectations; (3) Systems Factors; and (4) Management considerations. Participants indicated that while it is important to treat pain, its inherently subjective nature makes it difficult to objectively quantify it. The 0-10 numeric rating scale was problematic and infrequently utilized. Patient expectations of no pain following procedures was viewed as particularly challenging. The absence of formal best practices to guide pain assessment and management was noted in every group. Management approaches overall very highly variable, often relying on word-of-mouth relay of the preferences of specific attending physicians. Conclusions: Pain is highly nuanced and resident physicians struggle to balance pain's subjectivity with a desire to quantify and appropriately treat it. The 0-10 numeric rating pain scale, though ubiquitous, is problematic. Priority areas of improvement identified include education for both patients and physicians, functional pain scales, and expansion of existing effective resources like the nursing pain team.

The Influence of Health Mindset on Perceptions of Illness and Behaviors Among Adolescents.

BACKGROUND: Health mindsets can be viewed on a continuum of malleability from fixed (health cannot be altered) to growth (health can be affected by behavior). We propose that mindsets may influence the health perceptions of healthy adolescents as well as the health behaviors of adolescents with a chronic illness. METHODS: In Study 1, we surveyed healthy adolescents about their health mindsets and their judgments of illness in response to vignettes of fictional others. In Study 2, we measured the health mindsets and health behaviors of adolescents with type 1 diabetes RESULTS: In Study 1, healthy adolescents with a fixed health mindset were more likely to rate fictional others as being less healthy, less likely to recover, and more vulnerable to additional diseases. In Study 2, a growth mindset was associated with a greater frequency of glucose monitoring among younger, but not older, adolescents with type 1 diabetes. Further, growth mindset was associated with lower HbA1c levels for younger adolescents. CONCLUSIONS: Health mindsets may shape views of the implications of illness or injury for overall health and, in adolescents with a chronic condition, may interact with age to influence health behaviors and outcomes.

A new approach to capturing pain disclosure in daily life in-person and online.

This feasibility study employed a new approach to capturing pain disclosure in face-to-face and online interactions, using a newly developed tool. In Study 1, 13 rheumatoid arthritis and 52 breast cancer patients wore the Electronically Activated Recorder to acoustically sample participants' natural conversations. Study 2 obtained data from two publicly available online social networks: fibromyalgia (343,439 posts) and rheumatoid arthritis (12,430 posts). Pain disclosure, versus non-pain disclosure, posts had a greater number of replies, and greater engagement indexed by language style matching. These studies yielded novel, multimethod evidence of how pain disclosure unfolds in naturally occurring social contexts in everyday life.

Mindset correlates with health-related quality of life assessment in patients with adolescent idiopathic scoliosis.

PURPOSE: Mindset theory describes two different belief systems regarding ability: "fixed", in which a particular personal characteristic is seen as unchangeable, and "growth", in which the characteristic is viewed as malleable and subject to improvement. The purpose of this study is to evaluate how that mindset toward one's health correlates with health-related quality of life assessments (HRQoL) in patients with adolescent idiopathic scoliosis (AIS). METHODS: Patients undergoing brace treatment for AIS were prospectively recruited for this study and completed both an SRS-30 and Health Mindset Scale questionnaire. Inclusion criteria for patients are based on Scoliosis Research Society standardized criteria for bracing studies: diagnosis of AIS, a prescribed TLSO brace for full-time wear, skeletal immaturity at brace initiation (Risser 0-2), Cobb angles 25-50 degrees, no prior treatment, and, if female, no more than 1 year post-menarchal at the time of brace initiation. Statistical analysis was performed utilizing Mann-Whitney U tests for skewed data and two-sample t tests for normally distributed data. Multivariable models were also used to evaluate the relationships of SRS-30 subscores with health mindset, adjusting for age, gender, and pre-treatment curve magnitudes. RESULTS: Among the 110 enrolled patients, a stronger growth mindset was associated with significantly higher SRS-30 scores overall (p = 0.001), as well as in the appearance (p = 0.003), and mental (p = 0.001) subscores. CONCLUSION: We demonstrate that health mindset affects an AIS patients' HRQoL. Prior studies have demonstrated that mindset is malleable and can be altered. Further studies are required to determine whether changing health mindset from a fixed to a growth mindset can also improve HRQoL in patients with scoliosis.

Review of Clinically Relevant Drug Interactions with Next Generation Hepatitis C Direct-acting Antiviral Agents.

In this review, we examine the pharmacokinetics and clinically relevant drug interactions of the newer generation direct-acting antivirals (DAAs) for the treatment of chronic hepatitis C, specifically sofosbuvir/velpatasvir (Epclusa®), sofosbuvir/velpatasvir/voxilaprevir (Vosevi®), glecaprevir/pibrentasvir (Maviret®), and elbasvir/grazoprevir (Zepatier®). We searched MEDLINE (1948-January 2020), Embase (1964-January 2020), Google, and GoogleScholar using the terms pharmacokinetics, drug interaction, drug metabolism, sofosbuvir, velpatasvir, Epclusa, voxilaprevir, Vosevi, glecaprevir, pibrentasvir, Maviret, elbasvir, grazoprevir, and Zepatier, from inception to January 13, 2020. The search was limited to randomized controlled trials, in vitro studies, prospective and retrospective human studies, drug monographs, abstracts, and conference proceedings. All relevant published literature on pharmacokinetic and pharmacodynamic interactions involving DAAs were reviewed and the data extracted. Numerous clinically relevant drug-drug interactions (DDIs) were identified with the newer generation DAAs and commonly prescribed drugs. NS3/4A protease inhibitors are more likely to be involved in DDIs, followed by NS5A inhibitors and NS5B polymerase inhibitor. The majority of clinically relevant DDIs are predictable, according to known pharmacokinetic, pharmacodynamics, and physicochemical properties of DAAs; however, in select cases, unpredictable DDIs do occur. As expected, many drug interactions exist between newer generation DAAs and commonly prescribed medications. While the majority of clinically relevant interactions are predictable, many require therapeutic dose adjustment or careful selection of non-interacting drugs. In select cases, severe and unpredictable drug interactions can occur. Clinicians should consult hepatitis C virus pharmacotherapy experts and tertiary drug interaction resources when initiating DAA therapy in patients taking other medications.

Parental Understanding of Surgical Care in the Neonatal Intensive Care Unit.

BACKGROUND: Pediatric surgeons are routinely required to discuss complex diagnoses and treatment plans with the parents of their patients. Yet, how well this information is understood by its target audience is unknown. To explore this issue, we asked parents of postoperative neonatal intensive care unit patients to describe their children's care in a variety of domains. Our goal was to assess the degree of parental understanding and to identify factors that influenced comprehension. MATERIALS AND METHODS: Parents of neonatal intensive care unit patients who underwent a general surgical procedure were asked to complete a survey of their children's care in six domains of comprehension: name of the primary diagnosis, description of the primary diagnosis, description of the purpose of surgery, identification of surgical risks, identification of surgical benefits, and identification of concerning signs or symptoms to look for after discharge. Parental demographic factors such as age, level of education, and socioeconomic status were recorded, as was the presence of a prenatal diagnosis. RESULTS: Overall, 66% of participants described their child's primary surgical condition. Even fewer were able to describe a benefit or risk of the procedure. Parental use of outside resources to gain information was found to significantly relate to parental understanding in all domains. Parental level of education also improved comprehension. CONCLUSIONS: Parental understanding of surgical procedures, including the events leading up to and after an operation, is an important component of overall patient care. However, we were able to demonstrate that this understanding may be limited in spite of the best efforts of medical professionals. Further investigations should focus on ways in which information can be delivered more effectively to parents.

Interpersonal positive reframing in the daily lives of couples coping with breast cancer.

OBJECTIVES: This study examined word use as an indicator of interpersonal positive reframing in daily conversations of couples coping with breast cancer and as a predictor of stress. DESIGN: The Electronically Activated Recorder (EAR) and Linguistic Inquiry and Word Count (LIWC) were used to examine naturally occurring word use conceptually linked to positive reframing (positive emotion, negative emotion, and cognitive processing words). SAMPLE: Fifty-two couples coping with breast cancer. METHODS: Couples wore the EAR, a device participants wear, that audio-recorded over one weekend (>16,000 sound files), and completed self-reports of positive reframing (COPE) and stress (Perceived Stress Scale). LIWC, a software program, measured word use. FINDINGS: Both partners' word use (i.e., positive emotion and cognitive processing words) was associated with their own reported positive reframing, and spouses' word use was also indicative of patients' positive reframing. Results also revealed that, in general, words indicating positive reframing predicted lower levels of stress. CONCLUSIONS: Findings supported the hypothesis that partners-and particularly spouses of breast cancer patients-may assist each other's coping by positively reframing the cancer experience and other negative experiences in conversation.

Social Belonging as a Predictor of Surgical Resident Well-being and Attrition.

OBJECTIVE: In light of the predicted shortage of surgeons, attrition from surgical residency is a significant problem. Prior data have shown that those who are happier are more productive, and those who are less well have higher rates of absenteeism. This study sought to identify the role of social belonging and its relationship to well-being and risk of attrition. DESIGN: Surgical residents were invited to participate in an online survey containing measures of social belonging (a 10-item scale adapted from previous studies), well-being (the Dupuy Psychological General Well-Being Scale, Beck Depression Inventory Short Form, and Maslach Burnout Inventory), and risk of attrition (indicated by frequency of thoughts of leaving the program). SETTING: We surveyed residents at 2 tertiary care centers, Stanford Health Care (2010, 2011, and 2015) and Washington University in St. Louis (2017). PARTICIPANTS: Categorical general surgery residents, designated preliminary residents going into 7 surgical subspecialties, and nondesignated preliminary residents were included. RESULTS: One hundred sixty-nine residents responded to the survey for a response rate of 66%. Belonging was positively correlated with general psychological well-being (r = 0.56, p < 0.0001) and negatively correlated with depression (r = -0.57, p < 0.0001), emotional exhaustion (r = -0.58, p < 0.0001), and depersonalization (r = -0.36, p < 0.0001). Further, belonging was negatively correlated with frequency of thoughts of leaving residency (r = -0.45, p < 0.0001). In regression analysis controlling for demographic variables, belonging was a significant positive predictor of psychological well-being (B = 0.95, t = 8.18, p < 0.0001) and a significant negative predictor of thoughts of leaving (B = -1.04, t = -5.44, p < 0.0001). CONCLUSIONS: Social belonging has a significant positive correlation with well-being and negative correlation with thoughts of leaving surgical training. Lack of social belonging appears to be a significant predictor of risk of attrition in surgical residency. Efforts to enhance social belonging may protect against resident attrition.

Isocitrate-to-SENP1 signaling amplifies insulin secretion and rescues dysfunctional ß cells.

Insulin secretion from ß cells of the pancreatic islets of Langerhans controls metabolic homeostasis and is impaired in individuals with type 2 diabetes (T2D). Increases in blood glucose trigger insulin release by closing ATP-sensitive K+ channels, depolarizing ß cells, and opening voltage-dependent Ca2+ channels to elicit insulin exocytosis. However, one or more additional pathway(s) amplify the secretory response, likely at the distal exocytotic site. The mitochondrial export of isocitrate and engagement with cytosolic isocitrate dehydrogenase (ICDc) may be one key pathway, but the mechanism linking this to insulin secretion and its role in T2D have not been defined. Here, we show that the ICDc-dependent generation of NADPH and subsequent glutathione (GSH) reduction contribute to the amplification of insulin exocytosis via sentrin/SUMO-specific protease-1 (SENP1). In human T2D and an in vitro model of human islet dysfunction, the glucose-dependent amplification of exocytosis was impaired and could be rescued by introduction of signaling intermediates from this pathway. Moreover, islet-specific Senp1 deletion in mice caused impaired glucose tolerance by reducing the amplification of insulin exocytosis. Together, our results identify a pathway that links glucose metabolism to the amplification of insulin secretion and demonstrate that restoration of this axis rescues ß cell function in T2D.

Human islet function following 20 years of cryogenic biobanking.

AIMS/HYPOTHESIS: There are potential advantages to the low-temperature (-196 °C) banking of isolated islets, including the maintenance of viable islets for future research. We therefore assessed the in vitro and in vivo function of islets cryopreserved for nearly 20 years. METHODS: Human islets were cryopreserved from 1991 to 2001 and thawed between 2012 and 2014. These were characterised by immunostaining, patch-clamp electrophysiology, insulin secretion, transcriptome analysis and transplantation into a streptozotocin (STZ)-induced mouse model of diabetes. RESULTS: The cryopreservation time was 17.6 ± 0.4 years (n = 43). The thawed islets stained positive with dithizone, contained insulin-positive and glucagon-positive cells, and displayed levels of apoptosis and transcriptome profiles similar to those of freshly isolated islets, although their insulin content was lower. The cryopreserved beta cells possessed ion channels and exocytotic responses identical to those of freshly isolated beta cells. Cells from a subset of five donors demonstrated similar perifusion insulin secretion profiles pre- and post-cryopreservation. The transplantation of cryopreserved islets into the diabetic mice improved their glucose tolerance but did not completely normalise their blood glucose levels. Circulating human insulin and insulin-positive grafts were detectable at 10 weeks post-transplantation. CONCLUSIONS/INTERPRETATION: We have demonstrated the potential for long-term banking of human islets for research, which could enable the use of tissue from a large number of donors with future technologies to gain new insight into diabetes.

Highly stable binding proteins derived from the hyperthermophilic Sso7d scaffold.

We have shown that highly stable binding proteins for a wide spectrum of targets can be generated through mutagenesis of the Sso7d protein from the hyperthermophilic archaeon Sulfolobus solfataricus. Sso7d is a small (~7 kDa, 63 amino acids) DNA-binding protein that lacks cysteine residues and has a melting temperature of nearly 100 °C. We generated a library of 10(8) Sso7d mutants by randomizing 10 amino acid residues on the DNA-binding surface of Sso7d, using yeast surface display. Binding proteins for a diverse set of model targets could be isolated from this library; our chosen targets included a small organic molecule (fluorescein), a 12 amino acid peptide fragment from the C-terminus of ß-catenin, the model proteins hen egg lysozyme and streptavidin, and immunoglobulins from chicken and mouse. Without the application of any affinity maturation strategy, the binding proteins isolated had equilibrium dissociation constants in the nanomolar to micromolar range. Further, Sso7d-derived binding proteins could discriminate between closely related immunoglobulins. Mutant proteins based on Sso7d were expressed at high yields in the Escherichia coli cytoplasm. Despite extensive mutagenesis, Sso7d mutants have high thermal stability; five of six mutants analyzed have melting temperatures >89 °C. They are also resistant to chemical denaturation by guanidine hydrochloride and retain their secondary structure after extended incubation at extreme pH values. Because of their favorable properties, such as ease of recombinant expression, and high thermal, chemical and pH stability, Sso7d-derived binding proteins will have wide applicability in several areas of biotechnology and medicine.

Superior lymph node resection is achievable with laparoscopic colectomy: even in initial 30 cases.

Recent studies demonstrated the validity of the laparoscopic technique in colon cancer resection. Recent node resection data for open colectomies show inadequate nodal removal is common. In this study, two experienced laparoscopic surgeons evaluated their initial outcomes with laparoscopic colectomy, including resections for malignancies. This retrospective review of clinic and hospital records involved 69 consecutive patients subjected to laparoscopic colectomies from July 2000 through December 2005. Outcomes were compared with 1000 patients from Senagore and Delaney. Adequacy of oncologic resection was compared with the published National Cancer Institute database. Sixty-nine resections were performed. Overall complication and conversion rates were comparable to Senagore and Delaney except for days of hospitalization at 6.0 compared with 3.7 (P < 0.01) and readmission of 4.2 per cent compared with 9.1 per cent (P < 0.01). Adequate node resection occurred in 26 of 32 patients (81%) compared with 37 per cent of open colectomies in the National Cancer Institute nationwide database (P < 0.05). The overall median number of nodes resected was 18. For veteran laparoscopic surgeons in a community hospital, the initial experience with laparoscopic colectomy can provide excellent results, meeting standards set in large published series. In addition, the resection of nodes in colon cancer can be significantly better when performed laparoscopically or by hand-assisted laparoscopy.

Mapping child molester treatment progress with the FoSOD: denial and explanations of accountability.

A continuing challenge in the treatment of sexual offenders involves the identification of measurement instruments that can be used to monitor treatment progress. This paper provides evidence that the Facets of Sexual Offender Denial (FoSOD; pronounced "façade") Scale maps critical aspects of treatment progress, yet avoids problems typically associated with self-report measures. Fifty-three child molesters completed the FoSOD twice with an 18-month interval between administrations. The Time 1 and Time 2 FoSOD scores were analyzed as a function of advancement through a court-sanctioned sexual offender treatment program. Results demonstrated not only that advancement in treatment corresponded with predictable changes in FoSOD scores, but also that FoSOD component scores, representing denial associated with refutation, minimization and depersonalization of the offense, revealed critical patterns indicative of the issues with which offenders contend at various points within treatment. These results are discussed within a conceptual framework that recognizes the relationships between denial in its various forms and the explanations that offenders develop to limit their accountability for alleged offenses, associated thoughts or behaviors, and deviant predispositions.

Understanding denial in sexual offenders: a review of cognitive and motivational processes to avoid responsibility.

Treatment of sexual offenders is routinely complicated by the presence of denial. This article examines how denial is related to the willingness to take responsibility for offense-related thoughts and actions and how conceptualizations of denial have developed and changed over time. Multiple facets of denial are described in detail, along with an assessment of how different forms of denial undermine acceptance of responsibility throughout treatment. Evidence is presented to show that resistance and denial often hinge on cognitive and motivational processes that are commonly accepted as fundamental treatment targets rather than treatment obstacles. The authors propose that denial may be best understood as the acceptance of explanations that reduce accountability and are reinforced by distorted beliefs and self-deceptive thinking processes. The article concludes with a discussion of the rich clinical information embedded in different expressions of denial and the benefits of treatment strategies designed to assess and work through them.

Improvement of laryngopharyngeal reflux symptoms after laparoscopic Hill repair.

BACKGROUND: People with proven gastroesophageal reflux disease may also experience symptoms such as voice loss, chronic cough, globus, and sore throat. These laryngopharyngeal reflux symptoms have been reported to respond to prolonged proton pump inhibitor therapy, but the Hill approach to resolving these specific individual symptoms has not been widely reported in surgical literature. METHODS: This clinical outcome study is an analysis of symptom improvement in 145 patients who underwent laparoscopic Hill hiatal hernia repair. A standardized questionnaire was used to score eight gastroesophageal reflux disease symptoms and four laryngopharyngeal reflux symptoms. Also, each patient's primary chief complaints were analyzed. RESULTS: Gastroesophageal reflux and laryngopharyngeal reflux symptoms significantly improved (P < 0.01) compared with preoperative symptoms. Each patient's primary chief complaints improved as well. CONCLUSIONS: This clinical outcome analysis documents symptomatic improvement of laryngopharyngeal reflux and gastroesophageal reflux. Likewise, when these laryngopharyngeal reflux symptoms are chief complaints, with proven gastroesophageal reflux disease, the Hill approach to symptom resolution is likely to be successful.