Surgeon Information-Sharing, Parent Verbal Engagement, and Parent Knowledge of Pediatric Adenotonsillectomy.

OBJECTIVE: We characterize clinician information-sharing and parent verbal engagement during pediatric adenotonsillectomy consultations and evaluate whether these behaviors relate to disease-specific knowledge for parents of children with obstructive sleep-disordered breathing (OSDB). STUDY DESIGN: Mixed-methods sequential explanatory analysis. SETTING: Outpatient otolaryngology clinics. METHODS: We analyzed audio-recorded communication during outpatient encounters for children undergoing initial evaluation for adenotonsillectomy. We identified discrete triadic instances of clinician discussion of individual risks and benefits, parent verbal responses coded as passive ("Right") or active ("Would that repeat the recovery time?"), and corresponding parent answer (correct or incorrect) on a postconsult knowledge questionnaire. Primary outcomes included parent knowledge and decisional conflict. We qualitatively analyzed substantive questions asked by parents during the encounter. RESULTS: In 30 consults, clinicians (n = 8) provided 156 instances of discussion (101 risk, 55 benefit), to which parents provided 34% active responses. Clinician discussion of risks and benefits was associated with greater parent knowledge (odds ratio [OR] = 3.70, 95% confidence interval [CI]: 2.25-6.09; P < .001), however parent active engagement was not associated with greater parent knowledge (OR = 1.04, 95% CI: 0.42-2.58, P = .93). Parents demonstrated greater knowledge of benefits than risks (χ2 = 23.16, V = 1.13; P < .001). Parents who responded actively (OR = 0.26, 95% CI: 0.09-0.72; P = .010) or had greater knowledge (OR = 0.41, 95% CI: 0.21-0.81; P = .010) had less decisional conflict. CONCLUSION: Clinician information-sharing was associated with greater parent knowledge about OSDB treatment. Greater parent engagement and knowledge were independently associated with less decisional conflict. These findings may inform clinicians' approaches to counseling and engaging parents in decisions for surgery.

Does the Quality of Behavior Change Counseling in Routine HIV Care Vary According to Topic and Demand?

HIV clinicians face increasing time constraints. Our objective was to describe the prevalence and quality of behavior change counseling within routine HIV visits and to explore whether clinicians may provide lower quality counseling when facing increased counseling demands. We audio-recorded and transcribed encounters between 205 patients and 12 clinicians at an urban HIV primary care clinic. We identified and coded episodes of behavior change counseling to determine clinicians' consistency with motivational interviewing (MI) and used multi-level regression to evaluate counseling quality changes with each additional topic. Clinician counseling for at least one behavior was indicated in 92% of visits (mean 2.5/visit). Behavioral topics included antiretroviral medication adherence (80%, n = 163), appointment adherence (54%, n = 110), drug use (46%, n = 95), tobacco use (45%, n = 93), unsafe sex (43%, n = 89), weight management (39%, n = 80), and alcohol use (35%, n = 71). Clinician counseling was most MI-consistent when discussing drug and tobacco use and least consistent for medication and appointment adherence, unsafe sex, and alcohol use. In multilevel analyses, clinician counseling was significantly less MI-consistent (ß = - 0.14, 95% CI - 0.29 to - 0.001) with each additional behavior change counseling need. This suggests that HIV ambulatory care be restructured to allocate increased time for patients with greater need for behavior change.

Provider Perspectives Regarding Ambulatory Telemedicine at a Large Academic Health System During the COVID-19 Pandemic.

Purpose: To understand provider preferences regarding telemedicine across clinical departments and provider demographic groups. Methods: A cross-sectional online survey was distributed to providers at Johns Hopkins Medicine who had completed at least one outpatient telemedicine encounter. The survey included questions about clinical appropriateness and preferred use of telemedicine. Demographic data were obtained from institutional records. Descriptive statistics provided a profile of provider responses. Wilcoxon rank sum tests evaluated departmental and demographic differences. Results: A total of 1,342 of 3,576 providers responded (37.5%). Providers indicated that telemedicine was clinically appropriate for new patients a median of 31.5% of the time (Range: 20% in pediatrics, 80% in psychiatry/behavioral sciences). For existing patients, providers indicated that telemedicine was clinically appropriate a median of 70% of the time (Range: 50% in physical medicine, 90% in psychiatry/behavioral sciences). Providers desired a median of 30% of their schedule template be dedicated to telemedicine (Range: 20% in family medicine, 70% in psychiatry/behavioral sciences). Providers who were female, had fewer than 15 years in practice, or were psychiatrists/psychologists tended to find telemedicine more clinically appropriate (p < 0.05). Conclusions: A majority of providers across clinical departments felt that high-quality care could be delivered through telemedicine, although the amount of care varied widely based on department and patient type. Preferences for future telemedicine similarly showed wide variety across and within departments. These findings indicate that in this early adoption phase of widespread telemedicine integration, there is lack of consensus among providers about the amount of telemedicine appropriate for everyday practice.

Olfactory Loss and Beyond: A Practical Review of Chemosensory Dysfunction.

BACKGROUND: Our ability to smell and taste is dictated by 3 chemosensory systems with distinct physiologic mechanisms - olfaction, gustation, and chemesthesis. Although often overlooked, dysfunction of these special senses may have broad implications on multiple facets of patients' lives -including safety, nutritional status, quality of life, mental health, and even cognitive function. As "loss of smell or taste" emerged as a common symptom of coronavirus disease 2019 (COVID-19), the importance of intact chemosensory function has been thrust into the spotlight. Despite the growing recognition of chemosensory dysfunction, this already highly prevalent condition will increasingly impact a larger and more diverse population, highlighting the need for improved awareness and care of these patients. METHODS: Comtemporary review of chemosensory function and assessments. CONCLUSIONS: Although patient-reported chemosensory function measures highlight the ease of screening of chemosensory dysfunction, self-reported measures underestimate both the prevalence and degree of chemosensory dysfunction and do not adequately distinguish between olfaction, gustation, and chemesthesis. Meanwhile, psychophysical assessment tools provide opportunities for more accurate, thorough assessment of the chemosenses when appropriate. Primary care providers are uniquely situated to identify patients burdened by chemosensory dysfunction and raise patient and provider awareness about the importance of chemosensory dysfunction. Identification of chemosensory dysfunction, particularly olfactory dysfunction, may raise suspicion for many underlying medical conditions, including early detection of neurodegenerative conditions. Furthermore, identification and awareness of patients with chemosensory dysfunction may help primary care providers to identify those who may benefit from additional therapeutic and safety interventions, or consultations with specialists for more detailed evaluations and management.

Caregiver perceptions and attitudes associated with oral immunotherapy on social media.

Background: Caregiver values and preferences with regard to oral immunotherapy (OIT) for treatment of food allergies are not widely reported. Understanding caregiver perspectives is integral to establishing shared decision-making in the treatment of food allergy. Objective: We aimed to understand caregiver opinions that may influence caregivers in their decisions about OIT through social media. Methods: We searched a popular parenting web site for posts related to OIT from December 2008 to September 2019. We applied a Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework to review posts for inclusion, performed thematic content analysis to determine common themes, and calculated frequencies for each theme and subtheme. Posts and comments were included if they contained discussions about OIT for immunoglobulin E-mediated food allergy and were excluded if they were duplicates, comments from an original post from the original user, or comments on a nonrelevant original post. Results: Of 1300 posts and comments retrieved, 174 were included (13%). Most were excluded because they did not directly address OIT for food allergy. Relevant posts could fall into multiple themes and were categorized under three main themes: attitudes (n = 128, "I am scared to do OIT but scared not to!"), logistics (n = 168, "We will be doing this once LO [little one] is a little older"), and questions (n = 32, "How does it work?"). Conclusion: Caregivers communicate with each other through social media, expressing attitudes, logistics, and questions about OIT. Understanding these lay perspectives may help guide clinicians in counseling and engage caregivers in decision-making.

Parent Experience of Communication about Children's Surgery: A Qualitative Analysis.

Parent experience is a core component of the quality of pediatric care and an increasingly common focus of quality improvement initiatives. However, the parent experience of communication in the pediatric surgical setting remains unexplored. METHODS: We conducted semi-structured interviews with 20 parents of children undergoing surgery. Interviews were analyzed using directed qualitative content analysis. RESULTS: Content analysis revealed 3 overarching themes. The theme of "provider-parent communication" included interpersonal behaviors and communication-originating skills of the surgeon. Parents valued surgeons incorporating multimodal information-sharing techniques, recognizing children's psychological needs, providing reassurance, engaging in teamwork, and including parents. The theme of "parental emotional experiences" included domains of parent worry, intimidation, offense, self-doubt, mistrust, and strength surrounding their child's surgery. Parents felt simultaneously responsible for their child's welfare and for understanding medical information. The theme of "process improvement" included preparation for surgery, efficiency, managing delays, anesthesia induction, emergence from anesthesia, privacy, and preparation for recovery. CONCLUSIONS: Themes identified through these parental narratives and proposed solutions inform quality improvement efforts related to surgeon communication strategies and facilitate family-centered surgical care for children. Parents often provided solutions after they described concerns, which attests to the utility of parent perspectives.

Site of metastatic recurrence impacts prognosis in patients with high-grade upper tract urothelial carcinoma.

PURPOSE: Metastatic recurrence occurs in over 25% of upper tract urothelial carcinoma patients treated with radical nephroureterectomy. While metastatic recurrence suggests poor prognosis, the impact of the specific site of recurrence on prognosis is not well documented. MATERIALS AND METHODS: We retrospectively analyzed 188 patients who underwent radical nephroureterectomy for high-grade, node-negative upper tract urothelial carcinoma at our institution from 2003 to 2018 without receiving neoadjuvant or adjuvant chemotherapy. Competing-risks survival analysis was performed to evaluate the cumulative incidence and predictors of metastatic recurrence. The Kaplan-Meier method and log-rank test were used to estimate and compare recurrence site-specific survival probabilities following metastatic recurrence. Cox regression analyses were performed to assess site-specific prognoses. RESULTS: Of the 188 patients, 47 (25%) developed metastatic recurrence over a median follow-up of 30 months (interquartile range: 10.5-58.5 months). The 1- and 2-year cumulative incidences of metastatic recurrence were 13.6% and 23.6%, respectively. On multivariable analysis, lymphovascular invasion was significantly predictive of metastatic recurrence (subhazard ratio: 2.6, P = 0.01). Of the 47 patients who developed recurrence, 38 (80.9%) died over a median follow-up of 10 months (interquartile range: 5-20 months). Metastatic recurrence was most common in the lungs (n= 13, 28%) and at multiple sites (n= 14, 30%). Median time to recurrence was shorter for recurrences at multiple sites (6.5 months) and those in the liver (13 months) and bone (18 months) compared to other sites. Patients who recurred in the liver (hazard ratio: 6.3, P = 0.007), bone (hazard ratio: 4.9, P = 0.02), and multiple sites (hazard ratio: 4.6, P = 0.01) had significantly worse prognosis compared to those who recurred in lymph nodes. Statistical significance persisted after adjusting for treatment with salvage therapy. CONCLUSIONS: A significant proportion of high-grade upper tract urothelial carcinoma patients recur systemically after radical nephroureterectomy. Lymphovascular invasion is a predictor of metastatic recurrence and may inform decisions regarding perioperative chemotherapy. Hepatic and osseous recurrences have relatively quicker onset and less favorable prognosis compared to other sites. These findings may benefit future efforts to develop recurrence site-specific treatment plans and highlight the necessity of subsequent endeavors to explore the genetic associations of recurrence in upper tract urothelial carcinoma.