A critical care follow-up service evaluation: Acquired peripheral nerve injury after admission with COVID-19 respiratory disease.

Anticipated sequelae of critical care admission for COVID-19 disease remain unclear. Our Edinburgh-based critical care follow-up service identified patterns with nerve injury in 13 of 35 patients who attended following a critical care admission between 15/03/2020 and 25/12/2020. This included 7 cases of meralgia parasthetica, 1 brachial plexopathy, 2 common peroneal neuropathies and 3 ulnar neuropathies. All cases of upper limb neuropathy and foot drop occurred in patients in whom prone positioning was used, with meralgia parasthetica occurring additionally in patients who remained supine.

Physicians' use of plain language during discussions of prostate cancer clinical trials with patients.

OBJECTIVE: This study described physicians' use of plain language during patient-physician cancer clinical trial discussions. METHODS: Video-recorded clinical interactions and accompanying transcripts were taken from a larger study of communication and clinical trials (PACCT). Interactions (n = 25) were selected if they included invitations to participate in a clinical trial. We used descriptive, qualitative discourse analysis, a method that identifies language patterns at or above the sentence level. We first excerpted discussions of clinical trials, then identified instances of plain language within those discussions. Finally, we inductively coded those instances to describe physicians' plain language practices. RESULTS: The analysis identified four plain language practices. Lexical simplification replaced medical terminology with simpler words. Patient-centered definition named, categorized, and explained complex medical terminology. Metaphor explained medical terminology by comparing it with known concepts. Finally, experience-focused description replaced medical terminology with descriptions of patients' potential physical experiences. CONCLUSION: These plain language practices hold promise as part of effective information exchange in discussions of cancer clinical trials. Testing is needed to identify patient preferences and the extent to which these practices address patient health literacy needs. PRACTICE IMPLICATIONS: Pending further testing, these plain language practices may be integrated into physician clinical trial and other communication training.

User acceptability of saliva and gargle samples for identifying COVID-19 positive high-risk workers and household contacts.

Throughout the COVID-19 pandemic nasopharyngeal or nose and/or throat swabs (NTS) have been the primary approach for collecting patient samples for the subsequent detection of viral RNA. However, this procedure, if undertaken correctly, can be unpleasant and therefore deters individuals from providing high quality samples. To overcome these limitations other modes of sample collection have been explored. In a cohort of frontline health care workers we have compared saliva and gargle samples to gold-standard NTS. 93% of individuals preferred providing saliva or gargle samples, with little sex-dependent variation. Viral titers collected in samples were analyzed using standard methods and showed that gargle and saliva were similarly comparable for identifying COVID-19 positive individuals compared to NTS (92% sensitivity; 98% specificity). We suggest that gargle and saliva collection are viable alternatives to NTS swabs and may encourage testing to provide better disease diagnosis and population surveillance.

Are Transmetatarsal Amputations a Durable Limb Salvage Option? A Single-Institution Descriptive Analysis.

In limb and life-threatening diabetic foot infections, transmetatarsal amputations are often indicated as a limb salvage procedure. The aim of this study is to analyze the long-term durability of initially successful transmetatarsal amputations in the diabetic population. We defined a successful transmetatarsal amputation as one which had clinical healing 1 year after surgery. A retrospective review of transmetatarsal amputations completed at our institution over an 11-year period was performed. We identified 83 amputations that met inclusion criteria. The mean follow-up was 4 years. The mean time to surgical healing was 109.8 days. After successfully healing the transmetatarsal amputation the long-term outcomes were analyzed. Re-ulcerations occurred in 44% of the transmetatarsal amputations a mean of 15 months after surgical healing. Patients who re-ulcerated were noted to be significantly younger (p value 0.02) with a significantly higher preprocedure hemoglobin A1c (p value < .001). Additional procedures after successful healing included 13 (15.66%) revision surgeries and 12 (14.46%) more proximal amputations. While transmetatarsal amputations remain a viable and durable limb preserving surgery, all patients who have undergone a transmetatarsal amputation should be monitored lifelong as they remain at risk for re-ulceration and more proximal amputation.

The impact of age on patient tolerance of mycophenolate following kidney transplantation.

BACKGROUND: In Scotland, standard maintenance immunosuppression following kidney transplantation consists of mycophenolate (MPA), tacrolimus and prednisolone irrespective of recipient age. We analyzed the tolerability of this immunosuppression regimen and the association with transplant outcomes. METHODS: A national, multicentre retrospective analysis of patients transplanted in 2015 and 2016, comparing graft function, acute rejection, significant infection rates and immunosuppression dosing between patients aged 18 and 59 years (Group 1) and ≥60 years (Group 2). RESULTS: Of the 490 patients, 26% were aged ≥60 years. Acute rejection (AR) rates at 1 year were 15% and 11% in Groups 1 and 2, respectively. Full-dose MPA was poorly tolerated with 53% in Group 1 and 77% in Group 2 requiring dose reduction or cessation. Female gender and age ≥60 years were independent predictors for MPA dose changes. One year following MPA dose reduction, AR risk was low (5%) in Group 2, however, those remaining on full dose MPA had a 79% increased rate of serious infections. CONCLUSION: The majority of renal transplant recipients aged ≥60 fail to tolerate full-dose MPA. In this group, MPA dose reduction is associated with low rejection rates, but full-dose MPA is associated with high infection rates. We suggest that a tailored approach to immunosuppression in elderly recipients incorporating lower doses of MPA may be appropriate.

In vitro characterisation of the erosion of soft tissues by surgical mesh.

Surgical mesh is used widely in operations to treat hernias, prolapsed organs, urinary incontinence, etc. A major complication following surgery is so-called "mesh erosion", in which the mesh material rubs on adjacent soft tissue, causing it to wear away. Mesh erosion is the subject of a large body of clinical case histories, but there is no literature reporting in vitro laboratory experiments to investigate this phenomenon. In this paper we describe a preliminary study to generate and measure the erosion of soft tissue (porcine muscle) by a surgical mesh material (knitted polypropylene fibres). We found significant differences in the rate of erosion depending on the applied force and the direction of loading and on the presence or absence of connective tissue (perimysium). Two different methods of making the edge of the mesh sample gave similar erosion rates: this may be due to changes in the nature of the edge during erosion. Overall the rates measured were consistent with the clinical experience that mesh can erode completely through the walls of organs such as the bladder and vagina in a few weeks or months. In our opinion, the phenomenon of mesh erosion should be more extensively investigated and different mesh products characterised in order to prevent future clinical complications.

The influence of a question prompt list on patient-oncologist information exchange in an African-American population.

OBJECTIVES: Question Prompt Lists (QPL) increase patient active participation in oncology interactions, but questions remain regarding how QPLs influence patient-oncologist information exchange. We examined how a QPL influenced information exchange during oncology interactions with African-American patients. METHODS: Data were self-reports and video recordings from a parent study testing the effects of a QPL in the outpatient clinics of two urban cancer hospitals. In this secondary analysis, we investigated which QPL questions patients identified as ones they wanted to ask their oncologists, how frequently patients/companions used patient active participation statements to seek information related to each QPL question, whether oncologists provided QPL-related information unprompted or prompted by patients/companions, and how frequently patients' QPL-related information needs were addressed or unaddressed. RESULTS: The QPL influenced information exchange by increasing patients' and companions' (if present) prompting for QPL-related information from their oncologists. Patients/companions most often prompted for QPL-related information about side effects and patient experience. CONCLUSION: This study builds on prior research on QPL interventions by expanding the object of study to information exchange and by analyzing patients' information needs. PRACTICE IMPLICATIONS: This research demonstrates that a QPL supports patient/companion participation in oncology consultations by making information exchange more interactive.

Partnering around cancer clinical trials (PACCT): study protocol for a randomized trial of a patient and physician communication intervention to increase minority accrual to prostate cancer clinical trials.

BACKGROUND: Cancer clinical trials are essential for testing new treatments and represent state-of-the-art cancer treatment, but only a small percentage of patients ever enroll in a trial. Under-enrollment is an even greater problem among minorities, particularly African Americans, representing a racial/ethnic disparity in cancer care. One understudied cause is patient-physician communication, which is often of poor quality during clinical interactions between African-American patients and non-African-American physicians. Partnering Around Cancer Clinical Trials (PACCT) involves a transdisciplinary theoretical model proposing that patient and physician individual attitudes and beliefs and their interpersonal communication during racially discordant clinical interactions influence outcomes related to patients' decisions to participate in a trial. The overall goal of the study is to test a multilevel intervention designed to increase rates at which African-American and White men with prostate cancer make an informed decision to participate in a clinical trial. METHODS/DESIGN: Data collection will occur at two NCI-designated comprehensive cancer centers. Participants include physicians who treat men with prostate cancer and their African-American and White patients who are potentially eligible for a clinical trial. The study uses two distinct research designs to evaluate the effects of two behavioral interventions, one focused on patients and the other on physicians. The primary goal is to increase the number of patients who decide to enroll in a trial; secondary goals include increasing rates of physician trial offers, improving the quality of patient-physician communication during video recorded clinical interactions in which trials may be discussed, improving patients' understanding of trials offered, and increasing the number of patients who actually enroll. Aims are to 1) determine the independent and combined effects of the two interventions on outcomes; 2) compare the effects of the interventions on African-American versus White men; and 3) examine the extent to which patient-physician communication mediates the effect of the interventions on the outcomes. DISCUSSION: PACCT has the potential to identify ways to increase clinical trial rates in a diverse patient population. The research can also improve access to high quality clinical care for African American men bearing the disproportionate burden of disparities in prostate and other cancers. TRIAL REGISTRATION: Clinical Trials.gov registration number: NCT02906241 (September 8, 2016).

Building Motivation in African American Caregivers of Adolescents With Obesity: Application of Sequential Analysis.

Objective: We sought to examine communication between counselors and caregivers of adolescents with obesity to determine what types of counselor behaviors increased caregivers' motivational statements regarding supporting their child's weight loss. Methods: We coded 20-min Motivational Interviewing sessions with 37 caregivers of African American 12-16-year-olds using the Minority Youth Sequential Coding for Observing Process Exchanges. We used sequential analysis to determine which counselor communication codes predicted caregiver motivational statements. Results: Counselors' questions to elicit motivational statements and emphasis on autonomy increased the likelihood of both caregiver change talk and commitment language statements. Counselors' reflections of change talk predicted further change talk, and reflections of commitment language predicted more commitment language. Conclusions: When working to increase motivation among caregivers of adolescents with overweight or obesity, providers should strive to reflect motivational statements, ask questions to elicit motivational statements, and emphasize caregivers' autonomy.

Exploring ambivalence in motivational interviewing with obese African American adolescents and their caregivers: A mixed methods analysis.

OBJECTIVE: We conducted an exploratory mixed methods study to describe the ambivalence African-American adolescents and their caregivers expressed during motivational interviewing sessions targeting weight loss. METHODS: We extracted ambivalence statements from 37 previously coded counseling sessions. We used directed content analysis to categorize ambivalence related to the target behaviors of nutrition, activity, or weight. We compared adolescent-caregiver dyads' ambivalence using the paired sample t-test and Wilcoxon signed-rank test. We then used conventional content analysis to compare the specific content of adolescents' and caregivers' ambivalence statements. RESULTS: Adolescents and caregivers expressed the same number of ambivalence statements overall, related to activity and weight, but caregivers expressed more statements about nutrition. Content analysis revealed convergences and divergences in caregivers' and adolescents' ambivalence about weight loss. CONCLUSION: Understanding divergences in adolescent-caregiver ambivalence about the specific behaviors to target may partially explain the limited success of family-based weight loss interventions targeting African American families and provides a unique opportunity for providers to enhance family communication, foster teamwork, and build self-efficacy to promote behavior change. PRACTICE IMPLICATIONS: Clinicians working in family contexts should explore how adolescents and caregivers converge and diverge in their ambivalence in order to recommend weight loss strategies that best meet families' needs.

A disparity of words: racial differences in oncologist-patient communication about clinical trials.

BACKGROUND: African Americans are consistently underrepresented in cancer clinical trials. Minority under-enrolment may be, in part, due to differences in the way clinical trials are discussed in oncology visits with African American vs. White patients. OBJECTIVE: To investigate differences in oncologist-patient communication during offers to participate in clinical trials in oncology visits with African American and White patients. METHODS: From an archive of video-recorded oncology visits, we selected all visits with African American patients that included a trial offer (n = 11) and a matched sample of visits with demographically/medically comparable White patients (n = 11). Using mixed qualitative-quantitative methods, we assessed differences by patient race in (i) word count of entire visits and (ii) frequency of mentions and word count of discussions of clinical trials and key elements of consent. RESULTS: Visits with African American patients, compared to visits with White patients, were shorter overall and included fewer mentions of and less discussion of clinical trials. Also, visits with African Americans included less discussion of the purpose and risks of trials offered, but more discussion of voluntary participation. DISCUSSION AND CONCLUSIONS: African American patients may make decisions about clinical trial participation based on less discussion with oncologists than do White patients. Possible explanations include a less active communication style of African Americans in medical visits, oncologists' concerns about patient mistrust, and/or oncologist racial bias. Findings suggest oncologists should pay more conscious attention to developing the topic of clinical trials with African American patients, particularly purpose and risks.

Strategies of persuasion in offers to participate in cancer clinical trials I: Topic placement and topic framing.

Clinical trials are the gold standard in medical research evaluating new treatments in cancer care; however, in the United States, too few patients enroll in trials, especially patients from minority groups. Offering patients the option of a clinical trial is an ethically-charged communicative event for oncologists. One particularly vexed ethical issue is the use of persuasion in trial offers. Based on a corpus of 22 oncology encounters with Caucasian-American (n = 11) and African-American (n = 11) patients, this discourse analysis describes oncologists' use of two persuasive strategies related to the linguistic structure of trial offers: topic placement and topic framing. Findings are presented in total and by patient race, and discussed in terms of whether these strategies may constitute ethical or unethical persuasion, particularly with respect to the ethical issue of undue influence and the social issue of underrepresentation of minorities in cancer clinical trials.

Provider communication behaviors that predict motivation to change in black adolescents with obesity.

OBJECTIVE: The goal of this research was to identify communication behaviors used by weight loss counselors that mostly strongly predicted black adolescents' motivational statements. Three types of motivational statements were of interest: change talk (CT; statements describing their own desires, abilities, reasons, and need for adhering to weight loss recommendations), commitment language (CML; statements about their intentions or plans for adhering), and counterchange talk (CCT; amotivational statements against change and commitment). METHODS: Thirty-seven black adolescents with obesity received a single motivational interviewing session targeting weight-related behaviors. The video-recorded transcribed sessions were coded using the Minority Youth Sequential Coding for Observing Process Exchanges generating a sequential chain of communication. Data were then subjected to sequential analysis to determine causal relationships between counselor and adolescent communication. RESULTS: Asking open-ended questions to elicit adolescent CT and emphasizing adolescents' autonomy most often led to CT. Open-ended questions to elicit CML, reflecting adolescent CML, and emphasizing autonomy most often led to CML. In contrast, open-ended questions to elicit CCT, reflecting CCT, reflecting ambivalence, and neutral open-ended questions about the target behavior led to CCT. CONCLUSIONS: This study provides clinicians with insight into the most effective way to communicate with black adolescents with obesity about weight loss. Specifically, reflective statements and open questions focusing on their own desires, abilities, reasons, need, and commitment to weight loss recommendations are more likely to increase motivational statements, whereas other types of reflections and questions may be counterproductive. Finally, because adolescents have a strong need for autonomous decision making, emphasizing their autonomy may be particularly effective in evoking motivational statements.

Accounting for medical communication: parents' perceptions of communicative roles and responsibilities in the pediatric intensive care unit.

Through discourse analysis of transcribed interviews conducted over the phone with parents whose child died in the Pediatric Intensive Care Unit (PICU) (n = 51), this study uncovers parents' perceptions of clinicians' and their own communicative roles and responsibilities in the context of team-based care. We examine parents' descriptions and narratives of communicative experiences they had with PICU clinicians, focusing on how parents use accounts to evaluate the communicative behaviors they report (n = 47). Findings indicate that parental perceptions of communicative responsibilities are more nuanced than assumed in previous research: Parents identified their own responsibilities as participating as part of the team of care, gathering information, interacting with appropriate affect, and working to understand complex and uncertain medical information. Complementarily, parents identified clinician responsibilities as communicating professionally, providing medical information clearly, managing parents' hope responsibly, and communicating with appropriate affect. Through the accounts they provide, parents evaluate both parental and clinician role-responsibilities as fulfilled and unfulfilled. Clinicians' management of prognostic uncertainty and parents' struggles to understand that uncertainty emerged as key, complementary themes with practical implications for incorporating parents into the PICU care team. The study also highlights insights retrospective interview data bring to the examination of medical communication.

Coordination of eye and head components of movements evoked by stimulation of the paramedian pontine reticular formation.

Constant frequency microstimulation of the paramedian pontine reticular formation (PPRF) in head-restrained monkeys evokes a constant velocity eye movement. Since the PPRF receives significant projections from structures that control coordinated eye-head movements, we asked whether stimulation of the pontine reticular formation in the head-unrestrained animal generates a combined eye-head movement or only an eye movement. Microstimulation of most sites yielded a constant-velocity gaze shift executed as a coordinated eye-head movement, although eye-only movements were evoked from some sites. The eye and head contributions to the stimulation-evoked movements varied across stimulation sites and were drastically different from the lawful relationship observed for visually-guided gaze shifts. These results indicate that the microstimulation activated elements that issued movement commands to the extraocular and, for most sites, neck motoneurons. In addition, the stimulation-evoked changes in gaze were similar in the head-restrained and head-unrestrained conditions despite the assortment of eye and head contributions, suggesting that the vestibulo-ocular reflex (VOR) gain must be near unity during the coordinated eye-head movements evoked by stimulation of the PPRF. These findings contrast the attenuation of VOR gain associated with visually-guided gaze shifts and suggest that the vestibulo-ocular pathway processes volitional and PPRF stimulation-evoked gaze shifts differently.

Situating end-of-life decision making in a hybrid ethical frame.

Good communication in EOL (end-of-life) discussions is described at a general level in the literature, but there are few studies of EOL discussions at the level of interaction, with data drawn from the actual talk between physicians and families. In this article I present a discourse analysis of EOL discussions from an American ICU (intensive care unit) where the decision to withdraw life support is situated in a hybrid ethical frame co-constructed as the final phase of the EOL discussion. In Mishler's (1984) terms, the final phase of the EOL discussion merges the voice of medicine and the voice of the lifeworld, with both physicians and families initiating, developing, and repeating particular topics that encompass not only the logistics of death but also the ethics of the end-of-life decision. Physicians index their ethical accountability in terms of medical futility, and families express their accountability in terms of an ethics of consciousness. The hybrid ethical frame that is co-constructed ultimately centers upon consensus that the 'right' decision has been made from both ethical perspectives.

Establishing terminal status in end-of-life discussions.

The communicative purpose of an end-of-life discussion is to change the goals of treatment for a terminal patient from therapeutic to comfort care. In this study, the authors present a comparative discourse analysis of end-of-life discussions that reached a consensus to change the goals of treatment and discussions that did not. They found that the presentation of medical information was subtly different across these discussions: Decision-making discussions were based on a consistent accumulation of negative evidence, whereas non-decision-making discussions were inconsistent in this respect, including mention of positive rather than negative outcomes of medical problems, discussion of possible treatment options, and mitigating summary statements. The authors note that end-of-life discussions with these specific features do not progress to a decision to change the goals of treatment to comfort care.

The cause and clinical significance of central tumor photopenia on thallium scintigraphy of pediatric osteosarcoma of the extremity.

OBJECTIVE: The objectives of our study were to determine whether central tumor photopenia on thallium-201 (201Tl) scintigraphy of primary osteosarcoma results from central tumor necrosis or dense central tumor ossification and to determine the relation of this finding to tumor response to chemotherapy and to patient survival. MATERIALS AND METHODS: After the institutional review board approved our study and waived the need for patient or parental consent, two radiologists independently reviewed 201Tl scans, conventional radiographs, and MR images of 57 patients obtained at diagnosis of extremity primary nonmetastatic osteosarcoma to detect the presence of central tumor photopenia on 201Tl scintigraphy and estimate outer tumor ossification versus inner tumor ossification and enhancement. The dynamic enhanced MRI parameters dynamic vector magnitude (DVM) and k(ep) (measure of the exchange rate between plasma and extracellular fluid space) were compared for outer tumor versus inner tumor, and the relation among 201Tl scintigraphy, conventional radiography, MRI, and the dynamic enhanced MRI parameters was analyzed. We examined whether central tumor photopenia on 201Tl imaging was related to histologic response or to patient survival. RESULTS: Thirty-three patients (58%) had central tumor photopenia on 201Tl imaging that was not associated with central tumor ossification (p = 0.8) or with the difference between outer tumor and inner tumor contrast enhancement (p = 0.4). Central tumor photopenia on 201Tl scintigraphy was significantly associated with an increasing difference between outer tumor DVM and inner tumor DVM (i.e., outer tumor DVM minus inner tumor DVM) (p = 0.05), an increasing difference between outer tumor k(ep) and inner tumor k(ep) (i.e., outer k(ep) minus inner k(ep)) (p = 0.01), and an increasing outer k(ep)-inner k(ep) ratio (p = 0.02). We found no relation between central tumor photopenia and histologic response (p > or = 0.2). Older patients (age, > or = 13 years) with central tumor photopenia were least likely to survive, whereas younger patients (age, < 13 years) without central tumor photopenia were most likely to survive (p = 0.07). CONCLUSION: Central tumor photopenia on 201Tl scintigraphy of primary osteosarcoma is unlikely to reflect central ossification but may be due to central necrosis reflected by higher outer tumor DVM and k(ep) than inner tumor DVM and k(ep) and may be negatively associated with survival in older patients. Prospective studies are needed to determine the value of this information in planning treatment.

Effect of Native American ancestry on iron-related phenotypes of Alabama hemochromatosis probands with HFE C282Y homozygosity.

BACKGROUND: In age-matched cohorts of screening study participants recruited from primary care clinics, mean serum transferrin saturation values were significantly lower and mean serum ferritin concentrations were significantly higher in Native Americans than in whites. Twenty-eight percent of 80 Alabama white hemochromatosis probands with HFE C282Y homozygosity previously reported having Native American ancestry, but the possible effect of this ancestry on hemochromatosis phenotypes was unknown. METHODS: We compiled observations in these 80 probands and used univariate and multivariate methods to analyze associations of age, sex, Native American ancestry (as a dichotomous variable), report of ethanol consumption (as a dichotomous variable), percentage transferrin saturation and loge serum ferritin concentration at diagnosis, quantities of iron removed by phlebotomy to achieve iron depletion, and quantities of excess iron removed by phlebotomy. RESULTS: In a univariate analysis in which probands were grouped by sex, there were no significant differences in reports of ethanol consumption, transferrin saturation, loge serum ferritin concentration, quantities of iron removed to achieve iron depletion, and quantities of excess iron removed by phlebotomy in probands who reported Native American ancestry than in those who did not. In multivariate analyses, transferrin saturation (as a dependent variable) was not significantly associated with any of the available variables, including reports of Native American ancestry and ethanol consumption. The independent variable quantities of excess iron removed by phlebotomy was significantly associated with loge serum ferritin used as a dependent variable (p < 0.0001), but not with reports of Native American ancestry or reports of ethanol consumption. Loge serum ferritin was the only independent variable significantly associated with quantities of excess iron removed by phlebotomy used as a dependent variable (p < 0.0001) (p < 0.0001; ANOVA of regression). CONCLUSION: We conclude that the iron-related phenotypes of hemochromatosis probands with HFE C282Y homozygosity are similar in those with and without Native American ancestry reports.