Developing Consensus on Clinical Outcomes for Children with Mild Pneumonia: A Delphi Study.

BACKGROUND: The absence of consensus for outcomes in pediatric antibiotic trials is a major barrier to research harmonization and clinical translation. We sought to develop expert consensus on study outcomes for clinical trials of children with mild community-acquired pneumonia (CAP). METHODS: Applying the Delphi method, a multispecialty expert panel ranked the importance of various components of clinical response and treatment failure outcomes in children with mild CAP for use in research. During Round 1, panelists suggested additional outcomes in open-ended responses that were added to subsequent rounds of consensus building. For Rounds 2 and 3, panelists were provided their own prior responses and summary statistics for each item in the previous round. The consensus was defined by >70% agreement. RESULTS: The expert panel determined that response to and failure of treatment should be addressed at a median of 3 days after initiation. Complete or substantial improvement in fever, work of breathing, dyspnea, tachypnea when afebrile, oral intake, and activity should be included as components of adequate clinical response outcomes. Clinical signs and symptoms including persistent or worsening fever, work of breathing, and reduced oral intake should be included in treatment failure outcomes. Interventions including receipt of parenteral fluids, supplemental oxygen, need for high-flow nasal cannula oxygen therapy, and change in prescription of antibiotics should also be considered in treatment failure outcomes. CONCLUSIONS: Clinical response and treatment failure outcomes determined by the consensus of this multidisciplinary expert panel can be used for pediatric CAP studies to provide objective data translatable to clinical practice.

Fast skeletal myosin-binding protein-C regulates fast skeletal muscle contraction.

Fast skeletal myosin-binding protein-C (fMyBP-C) is one of three MyBP-C paralogs and is predominantly expressed in fast skeletal muscle. Mutations in the gene that encodes fMyBP-C, MYBPC2, are associated with distal arthrogryposis, while loss of fMyBP-C protein is associated with diseased muscle. However, the functional and structural roles of fMyBP-C in skeletal muscle remain unclear. To address this gap, we generated a homozygous fMyBP-C knockout mouse (C2-/-) and characterized it both in vivo and in vitro compared to wild-type mice. Ablation of fMyBP-C was benign in terms of muscle weight, fiber type, cross-sectional area, and sarcomere ultrastructure. However, grip strength and plantar flexor muscle strength were significantly decreased in C2-/- mice. Peak isometric tetanic force and isotonic speed of contraction were significantly reduced in isolated extensor digitorum longus (EDL) from C2-/- mice. Small-angle X-ray diffraction of C2-/- EDL muscle showed significantly increased equatorial intensity ratio during contraction, indicating a greater shift of myosin heads toward actin, while MLL4 layer line intensity was decreased at rest, indicating less ordered myosin heads. Interfilament lattice spacing increased significantly in C2-/- EDL muscle. Consistent with these findings, we observed a significant reduction of steady-state isometric force during Ca2+-activation, decreased myofilament calcium sensitivity, and sinusoidal stiffness in skinned EDL muscle fibers from C2-/- mice. Finally, C2-/- muscles displayed disruption of inflammatory and regenerative pathways, along with increased muscle damage upon mechanical overload. Together, our data suggest that fMyBP-C is essential for maximal speed and force of contraction, sarcomere integrity, and calcium sensitivity in fast-twitch muscle.

Trusted Colleagues or Incompetent Hacks? Development of the Attitudes About Abortion-Providing Physicians Scale.

BACKGROUND: Many physicians who provide abortion care report feeling marginalized within medicine. Because abortion care can require consultation with many types of physicians, physician opinions of providers may have implications for quality of care. However, no measure of physicians' attitudes about abortion-providing colleagues currently exists. METHODS: We developed a 24-item pool to measure perceptions of the motivations, competence, and standing within the medical profession of physicians who provide abortion care. We administered the survey to a sample of 1,640 faculty physicians at a Midwestern teaching hospital. We used Stata SE/14.0 for all analyses. RESULTS: Our response rate was 34% (n = 560), comparable with other studies of physicians. Exploratory factor analysis resulted in a three-factor solution: opinion, motivations, and competence. The scale demonstrated good internal consistency. Attitudes were largely favorable: 84% of participants agreed that abortion providers provide necessary care for women and 81% felt that abortion providers contribute positively to society. Compared with those who felt abortion should be illegal in all circumstances, attitudes were more favorable among those who felt that abortion should be legal. We observed an inverse relationship between religious attendance and attitudes. Participants with children held more favorable attitudes compared with those without children. CONCLUSIONS: The Attitudes About Abortion-Providing Physicians Scale captures physicians' perceptions of their abortion-providing colleagues along three important dimensions: opinion, motivations, and competence. This sample of physicians held generally favorable views of their colleagues who provide abortion care.

Stigma and abortion complications: stories from three continents.

Complications from abortion, while rare, are to be expected, as with any medical procedure. While the vast majority of serious abortion complications occur in parts of the world where abortion is legally restricted, legal access to abortion is not a guarantee of safety, particularly in regions where abortion is highly stigmatised. Women who seek abortion and caregivers who help them are universally negatively "marked" by their association with abortion. While attention to abortion stigma as a sociological phenomenon is growing, the clinical implications of abortion stigma - particularly its impact on abortion complications - have received less consideration. Here, we explore the intersections of abortion stigma and clinical complications, in three regions of the world with different legal climates. Using narratives shared by abortion caregivers, we conducted thematic analysis to explore the ways in which stigma contributes, both directly and indirectly, to abortion complications, makes them more difficult to treat, and impacts the ways in which they are resolved. In each narrative, stigma played a key role in the origin, management and outcome of the complication. We present a conceptual framework for understanding the many ways in which stigma contributes to complications, and the ways in which stigma and complications reinforce one another. We present a range of strategies to manage stigma which may prove effective in reducing abortion complications.

Evaluation of Abortion Stigma in the Workforce: Development of the Revised Abortion Providers Stigma Scale.

OBJECTIVES: We report on the development of a scale measuring abortion providers' experiences of stigma. STUDY DESIGN: Using previous measures, qualitative data, and expert review, we created a 49-item question pool. We administered questions to 315 abortion providers before participation in the Providers Share Workshop. We explored the factor structure and item quality using exploratory factor analysis. We assessed reliability using Cronbach's alpha. To test construct validity, we calculated Pearson's correlation coefficients between the stigma scales, the Maslach Burnout Inventory, and the K10 measure of psychological distress. We used Stata SE/12.0 for analyses. RESULTS: Factor analysis revealed a 35-item, five-factor model: worries about disclosure, internalized states, social judgment, social isolation, and discrimination (Cronbach's alphas 0.79-0.94). Our stigma measure was correlated with psychological distress (r = 0.40; p < .001), and with Maslach Burnout Inventory's emotional exhaustion (r = 0.27; p < .001), and depersonalization (0.23; p < .001) subscales, and was inversely correlated with Maslach Burnout Inventory's personal accomplishment subscale (r = -0.15; p < .05). CONCLUSIONS: Psychometric analysis of this scale reveals that it is a reliable and valid tool for measuring stigma in abortion providers, and may be helpful in evaluating stigma reduction programs.

Eating attitudes and behaviours of students enrolled in undergraduate nutrition and dietetics degrees.

AIM: The prevalence of disordered eating has been frequently reported in university students; however, the prevalence amongst Australian undergraduate students studying degrees with a focus on nutrition is uncertain. The aims of this study were to: (i) assess eating attitudes and behaviours of students enrolled in nutrition and dietetics, (ii) compare those to students enrolled in another health degree of occupational therapy (OT) and (iii) explore possible relationships between eating attitudes and behaviours and other characteristics of both cohorts. METHODS: This cross-sectional observational study investigated self-reported anthropometric characteristics, eating attitudes and behaviours and self-esteem using a series of questionnaires. RESULTS: Participants included 137 students (119 females, 18 males) with a mean age of 27.1 ± 8.7 years. Fourteen percent of nutrition and dietetics and 11% of OT students had disordered eating attitudes scores that were symptomatic of an eating disorder. Mean eating attitude scores did not differ between the degrees of study. Students in nutrition and dietetics showed significantly higher levels of cognitive restraint and less emotional eating than OT students. Enrolment in the first year of study was the strongest predictor of symptomatic eating attitudes. CONCLUSIONS: These findings support previously expressed concern about presence of disordered eating in nutrition and dietetics undergraduates. Collaboratively developed support mechanisms for preventing and managing disordered relationships with food would be of benefit to students enrolled in nutrition degrees to ensure ongoing professional integrity.

Dangertalk: Voices of abortion providers.

Researchers have described the difficulties of doing abortion work, including the psychosocial costs to individual providers. Some have discussed the self-censorship in which providers engage in to protect themselves and the pro-choice movement. However, few have examined the costs of this self-censorship to public discourse and social movements in the US. Using qualitative data collected during abortion providers' discussions of their work, we explore the tensions between their narratives and pro-choice discourse, and examine the types of stories that are routinely silenced - narratives we name "dangertalk". Using these data, we theorize about the ways in which giving voice to these tensions might transform current abortion discourse by disrupting false dichotomies and better reflecting the complex realities of abortion. We present a conceptual model for dangertalk in abortion discourse, connecting it to functions of dangertalk in social movements more broadly.

A design thinking approach to primary ovarian insufficiency.

Most clinicians are not prepared to provide integrated personal care to address all the clinical needs of women with primary ovarian insufficiency. Design thinking is an engineering methodology used to develop and evaluate novel concepts for systems operation. Here we articulate the need for a seamlessly integrated mobile health system to support genomic research as well as patient care. We also review the pathophysiology and management of primary ovarian insufficiency. Molecular understanding regarding the pathogenesis is essential to developing strategies for prevention, earlier diagnosis, and appropriate management of the disorder. The syndrome is a chronic disorder characterized by oligo/amenorrhea and hypergonadotropic hypogonadism before age 40 years. There may be significant morbidity due to: 1) depression and anxiety related to the loss of reproductive hormones and infertility; 2) associated autoimmune adrenal insufficiency or hypothyroidism; and 3) reduced bone mineral density and increased risk of cardiovascular disease related to estrogen deficiency. Approximately 5% to 10% of women with primary ovarian insufficiency conceive and have a child. Women who develop primary ovarian insufficiency related to a premutation in FMR1 are at risk of having a child with fragile X syndrome, the most common cause of inherited intellectual disability. In most cases of spontaneous primary ovarian insufficiency no environmental exposure or genetic mechanism can be identified. As a rare disease, the diagnosis of primary ovarian insufficiency presents special challenges. Connecting patients and community health providers in real time with investigators who have the requisite knowledge and expertise would help solve this dilemma.

Experiences With the Providers Share Workshop Method: Abortion Worker Support and Research in Tandem.

Abortion providers work in an environment characterized by the stresses of the helping professions as well as by the marginalization and devaluation that accompany work in a stigmatized field. We created the Providers Share Workshop (PSW), a five-session workshop carried out at seven abortion care sites around the United States, to support workers and better understand the complexities of working in abortion care. Qualitative analysis suggests that the experience of participating in the workshop fosters connection, and that the group process creates unique data about the abortion care team. Taken together, these results show that PSW fulfills the dual role of a supportive group intervention-helping create connections and foster resilience-and a research tool, producing rich, multi-perspective narratives of the abortion provision team. This method provides useful insight into supporting abortion care workers specifically, and may also prove useful in the study and support of other stigmatized workers generally.

Developing patient-centered teams: The role of sharing stories about patients and patient care.

Research indicates that health care teams are good for staff, patients, and organizations. The characteristics that make teams effective include shared objectives, mutual respect, clarity of roles, communication, trust, and collaboration. We were interested in examining how teams develop these positive characteristics. This paper explores the role of sharing stories about patients in developing patient-centered teams. Data for this paper came from 1 primary care clinic as part of a larger Providers Share Workshop study conducted by the University of Michigan. Each workshop included 5 facilitated group sessions in which staff met to talk about their work. This paper analyzes qualitative data from the workshops. Through an iterative process, research team members identified major themes, developed a coding scheme, and coded transcripts for qualitative data analysis. One of the most powerful ways group members connected was through sharing stories about their patients. Sharing clinical cases and stories helped participants bond around their shared mission of patient-centered care, build supportive relationships, enhance compassion for patients, communicate and resolve conflict, better understand workflows and job roles, develop trust, and increase morale. These attributes highlighted by participants correspond to those documented in the literature as important elements of teambuilding and key indicators of team effectiveness. The sharing of stories about patients seems to be a promising tool for positive team development in a primary care clinical setting and should be investigated further.

RNA extraction from healthy and failing human myocardium: a comparative evaluation.

BACKGROUND: Isolation of high-quality RNA from tissue is mandatory for producing reliable data for downstream applications. In heart tissue, the relative strengths and weaknesses of different approaches to isolate total RNA are unknown. The objective of this study was to compare different RNA isolation methods in healthy and diseased human myocardium. METHODS: Frozen left ventricular myocardium was obtained from individuals with heart failure and individuals who died from non-cardiac causes with normal heart function (control). Three extraction methods, including guanidine isothiocyanate (TRIzol), silica-gel column (RNeasy), and the combination method (TRIzol/RNeasy), were assessed for their effect on the yield, integrity, and gene expression levels of RNA using quantitative real-time PCR. RESULTS: In the control group (n=5), the highest RNA yield per tissue mass was obtained with TRIzol, and a significantly higher RNA integrity was obtained from the RNeasy method. The quantification cycle (Cq) values for both the reference gene GAPDH and two target genes were lower with TRIzol. Normalization by GAPDH showed the highest gene expression levels with RNeasy. Similar patterns were observed in the heart failure group (n=5), suggesting assays were not negatively impacted by myocardial disease processes. CONCLUSION: In both healthy and diseased heart tissue, the TRIzol method provides the highest RNA yield, while the RNeasy method shows superior RNA integrity, demonstrating comparable RNA quality in studies examining myocardial disease. A balanced approach to RNA quality is necessary for the successful downstream applications of RNA.

Abortion providers, stigma and professional quality of life.

OBJECTIVES: The Providers Share Workshop (PSW) provides abortion providers safe space to discuss their work experiences. Our objectives were to assess changes in abortion stigma over time and explore how stigma is related to aspects of professional quality of life, including compassion satisfaction, burnout and compassion fatigue for providers participating in the workshops. STUDY DESIGN: Seventy-nine providers were recruited to the PSW study. Surveys were completed prior to, immediately following and 1 year after the workshops. The outcome measures were the Abortion Provider Stigma Survey and the Professional Quality of Life (ProQOL) survey. Baseline ProQOL scores were compared to published averages using t tests. Changes in abortion stigma and aspects of professional quality of life were assessed by fitting a two-level random-effects model with repeated measures at level 1 (period-level) and static measures (e.g., demographic data) at level 2 (person-level). Potential covariates included age, parenting status, education, organizational tenure, job type and clinic type (stand-alone vs. hospital-based clinics). RESULTS: Compared to other healthcare workers, abortion providers reported higher compassion satisfaction (t=2.65, p=.009) and lower burnout (t=5.13, p<.0001). Repeated-measures analysis revealed statistically significant decreases in stigma over time. Regression analysis identified abortion stigma as a significant predictor of lower compassion satisfaction, higher burnout and higher compassion fatigue. CONCLUSIONS: Participants in PSW reported a reduction in abortion stigma over time. Further, stigma is an important predictor of compassion satisfaction, burnout and compassion fatigue, suggesting that interventions aimed at supporting the abortion providing workforce should likely assess abortion stigma. IMPLICATIONS: Stigma is an important predictor of compassion satisfaction, burnout and compassion fatigue among abortion care providers. Therefore, strengthening human resources for abortion care requires stigma reduction efforts. Participants in the PSWs show reductions in stigma over time.

Measuring stigma among abortion providers: assessing the Abortion Provider Stigma Survey instrument.

We explored the psychometric properties of 15 survey questions that assessed abortion providers' perceptions of stigma and its impact on providers' professional and personal lives referred to as the Abortion Provider Stigma Survey (APSS). We administered the survey to a sample of abortion providers recruited for the Providers' Share Workshop (N = 55). We then completed analyses using Stata SE/12.0. Exploratory factor analysis, which resulted in 13 retained items and identified three subscales: disclosure management, resistance and resilience, and discrimination. Stigma was salient in abortion provider's lives: they identified difficulties surrounding disclosure (66%) and felt unappreciated by society (89%). Simultaneously, workers felt they made a positive contribution to society (92%) and took pride in their work (98%). Paired t-test analyses of the pre- and post-Workshop APSS scores showed no changes in the total score. However, the Disclosure Management subscale scores were significantly lower (indicating decreased stigma) for two subgroups of participants: those over the age of 30 and those with children. This analysis is a promising first step in the development of a quantitative tool for capturing abortion providers' experiences of and responses to pervasive abortion stigma.

Why women are dying from unsafe abortion: narratives of Ghanaian abortion providers.

In Ghana, despite the availability of safe, legally permissible abortion services, high rates of morbidity and mortality from unsafe abortion persist. Through interviews with Ghanaian physicians on the front lines of abortion provision, we begin to describe major barriers to widespread safe abortion. Their stories illustrate the life-threatening impact that stigma, financial restraints, and confusion regarding abortion law have on the women of Ghana who seek abortion. They posit that the vast majority of serious abortion complications arise in the setting of clandestine or self-induced second trimester attempts, suggesting that training greater numbers of physicians to perform second trimester abortion is prerequisite to reducing maternal mortality. They also recognized that an adequate supply of abortion providers alone is a necessary but insufficient step toward reducing death from unsafe abortion. Rather, improved accessibility and cultural acceptability of abortion are integral to the actual utilization of safe services. Their insights suggest that any comprehensive plan aimed at reducing maternal mortality must consider avenues that address the multiple dimensions which influence the practice and utilization of safe abortion, especially in the second trimester.

The experience of symptoms of depression in men vs women: analysis of the National Comorbidity Survey Replication.

IMPORTANCE: When men are depressed they may experience symptoms that are different than what is included in the current diagnostic criteria. OBJECTIVE: To explore whether sex disparities in depression rates disappear when alternative symptoms are considered in the place of, or in addition to, more conventional depression symptoms. DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOMES AND MEASURES: Using data from the National Comorbidity Survey Replication, a nationally represented mental health survey, we evaluated sex differences in symptom endorsement in 2 new scales that included alternative depression symptoms. We analyzed sex differences in symptom endorsement using 2-sided, design-based, .05-level t tests and multivariate logistic regression to identify predictors of depression. RESULTS; Men reported higher rates of anger attacks/aggression, substance abuse, and risk taking compared with women. Analyses using the scale that included alternative, male-type symptoms of depression found that a higher proportion of men (26.3%) than women (21.9%) (P = .007) met criteria for depression. Analyses using the scale that included alternative and traditional depression symptoms found that men and women met criteria for depression in equal proportions: 30.6% of men and 33.3% of women (P = .57). CONCLUSIONS AND RELEVANCE: When alternative and traditional symptoms are combined, sex disparities in the prevalence of depression are eliminated. Further study is needed to clarify which symptoms truly describe men's experiences of depression.

Racial and ethnic differences in incident hospitalized heart failure in postmenopausal women: the Women's Health Initiative.

BACKGROUND: The differences in the incidence of heart failure by race/ethnicity and the potential mechanisms for these differences are largely unexplored in women. METHODS AND RESULTS: A total of 156 143 postmenopausal women free of self-reported heart failure enrolled from 1993 to 1998 at 40 clinical centers throughout the United States as part of the Women's Health Initiative and were followed up until 2005, for an average of 7.8 years, for incident hospitalized heart failure. Incident rates, hazard ratios (HRs), and 95% confidence intervals were determined by use of the Cox proportional hazard model comparing racial/ethnic groups, and population-attributable risk percentages were calculated for each racial/ethnic group. Blacks had the highest age-adjusted incidence of heart failure (380 in 100 000 person-years), followed by whites (274), Hispanics (193), and Asian/Pacific Islanders (103). The excess risk in blacks compared with whites (age-adjusted HR=1.45) was significantly attenuated by adjustment for household income (HR=0.97) and diabetes mellitus (HR=0.89), but the lower risk in Hispanics (age-adjusted HR=0.72) and Asian/Pacific Islanders (age-adjusted HR=0.44) remained despite adjustment for traditional risk factors, socioeconomic status, lifestyle, and access-to-care variables. The effect of adjustment for interim coronary heart disease on nonwhite versus white HRs for heart failure differed by race/ethnic group. CONCLUSIONS: Asian/Pacific Islander and Hispanic women have a lower incidence of heart failure and black women have higher rates of heart failure compared with white women. The excess risk of incident heart failure in black women is explained largely by adjustment for lower household incomes and diabetes mellitus in black women, whereas the lower rates of heart failure in Asian/Pacific Islanders and Hispanics are largely unexplained by the risk factors measured in this study. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000611.

Tobacco-related documentation in pediatric practice.

OBJECTIVE: The goal of this study was to evaluate tobacco-related documentation in children's medical records. METHOD: A cross-sectional, consecutive sample of 4216 parents at 13 primary care practices was surveyed on demographics, health habits, and smoking status of household members. The medical records of 2085 children from a subsample of 1149 families (all households with smokers and a sample of nonsmoking households) were reviewed for tobacco-related documentation at the first visit to the practice and visits in the 14 months preceding recruitment. Relationships of documentations with visit type, household smoking status, and use of charting prompts were examined. RESULTS: Most children (93%) had > or =1 visit during the reviewed period (77% had a health supervision visit), 23% were aged > or =11 years, 52% were Medicaid/uninsured, and 70% lived with smokers; 30.6% of children had family tobacco use status documented at a first visit to the practice and 15.4% had prenatal tobacco use status documented. Among children with a visit in the reviewed period, 39.3% with a health supervision visit and 9.6% without had a tobacco-related notation at a visit (P < .001). Overall, 15.2% of children living with a smoker had a visit notation indicating that someone in the household smoked. In households with smokers, documentation of household tobacco use status often disagreed with parent survey. Charting prompts significantly increased rates of identification of family tobacco use history and prenatal tobacco use history. CONCLUSIONS: Correct identification of household smoking status was absent for most children living with smokers. Improved documentation systems may facilitate tobacco-related surveillance and counseling.

Seconds for care: evaluation of five health supervision visit topics using a new method.

OBJECTIVE: To describe content and time devoted to 5 preventive health topics during health supervision visits (HSVs). STUDY DESIGN: New software (Pediatric Health Supervision Timer Software, PHSTS) run in handheld computers was developed to record time and content while observing HSVs. 185 visits of children ages 2 to 10 years (58% Medicaid/self-pay) to 28 clinicians were observed at 6 practices. Parents were surveyed on demographics. Data on times and actions related to assessments and counseling of growth, diet, physical activity, safety, and tobacco were collected using PHSTS. RESULTS: The PHSTS method was well accepted (89% participation rate). Most visits included assessment/counseling for diet (95%), growth (84%), and safety (71%) and less often physical activity (52%) and tobacco (43%). Discussions occurring were short (median time [25th to 75th percentiles]: diet, 42 seconds [21 to 85 seconds]; safety, 24 seconds [11 to 61 seconds]; growth, 15 seconds [7 to 31 seconds]; physical activity, 12 seconds [5 to 22 seconds]; and tobacco, 3 seconds [2 to 6 seconds]). Clinicians expressed concerns about child weight during 18 of 33 visits (55%) that included an obese child and provided tobacco-related counseling at 6 of 30 visits (20%) that included a child living with a smoker. CONCLUSIONS: The PHSTS method was successfully used. Our observations found that limited time was devoted to assessment and counseling on key health topics during HSVs.