Parental Conflict, Regret, and Short-term Impact on Quality of Life in Tracheostomy Decision-Making.

OBJECTIVES: The prevalence of tracheostomy-dependence in critically ill children is increasing in the United States. We do not know the impact of this decision on parental outcomes. We aimed to determine the prevalence of decisional conflict and regret and explore the impact on quality of life among parents considering tracheostomy placement for their child. SUBJECTS: Parents facing tracheostomy decision for their child. DESIGN: Prospective, mixed-methods longitudinal study. SETTING: PICU, cardiac ICU, and neonatal ICU of a single quaternary medical center. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Parents completed a decisional conflict survey at the time of tracheostomy decision and decisional regret and quality of life surveys at 2 weeks and 3 months after the decision regarding tracheostomy placement was made. We enrolled 39 parents, of which 25 completed surveys at all three time points. Thirty-five of 39 (89.7%) reported at least some decisional conflict, most commonly from feeling uninformed and pressured to make a decision. At 2 weeks, 13 of 25 parents (52%) reported regret, which increased to 18 of 25 participants (72%) at 3 months. Regret stemmed from feeling uninformed, ill-chosen timing of placement, and perceptions of inadequate medical care. At 2 weeks, the quality of life score was in the mid-range, 78.8 (SD 13.8) and decreased to 75.5 (SD 14.2) at 3 months. Quality of life was impacted by the overwhelming medical care and complexity of caring for a child with a tracheostomy, financial burden, and effect on parent's psychosocial health. CONCLUSIONS: The decision to pursue tracheostomy among parents of critically ill children is fraught with conflict with worsening regret and quality of life over time. Strategies to reduce contributing factors may improve parental outcomes after this life-changing decision.

Estimates of the current and future burden of cancer attributable to low fruit and vegetable consumption in Canada.

Low fruit and vegetable consumption is associated with colorectal cancer and may be associated with lung, breast, bladder, pancreatic, ovarian, liver, stomach, esophageal, head and neck cancers. We estimated the current attributable and future avoidable burden of cancer associated with low fruit and vegetable consumption in Canada. Using data on cancer incidence, exposure prevalence and risk effects, we estimated the population attributable risk (PAR) for cancers associated with low fruit and vegetable consumption as well as the future avoidable burden. The prevalence of fruit and vegetable consumption was projected to 2032 and cancer incidence was projected to 2042 to estimate the future potential impact fraction of cancer attributable to low fruit and vegetable consumption. Based on estimates from the Canadian Community Health Survey, the prevalence of low fruit (<4 servings/day) and vegetable (<4 servings/day) consumption in the Canadian population was 80.5% and 86.6%, respectively. The PARs for colorectal cancer associated with low fruit and vegetable consumption were 6.1% (1, 371 cases) and 2.2% (487 cases), respectively. For all incident cancers in 2015, 0.7% and 0.3% were attributable to low fruit and vegetable consumption, respectively. An increase of one serving/week of fruit could prevent 20,710 colorectal cancer cases cumulatively by 2042, and the same increase in vegetable consumption could prevent 10,185 cases. Although more research on the association between fruit and vegetable consumption and cancer risk is needed, our results demonstrate that with reasonable increases in current fruit and vegetable consumption by Canadians, over 30,000 colorectal cancer cases could be prevented by 2042.

Estimates of the current and future burden of cancer attributable to red and processed meat consumption in Canada.

Red meat and processed meat have been consistently associated with an increased risk of colorectal, stomach, pancreatic cancer and esophageal cancer (processed meat only). The purpose of this analysis was to estimate the current attributable and future avoidable burden of cancer related to red and processed meat consumption in Canada. We estimated the population attributable risk of cancer separately for red meat consumption (beef, lamb, and pork, excluding processed meat) and processed meat consumption (sausage and bacon) incorporating current cancer incidence data, relative risks, and exposure prevalence. We also estimated the future avoidable burden of cancer from 2015 to 2042 for Canada and by province using the potential impact fraction associated with various potential intervention scenarios intended to reduce consumption, ranging from a decrease of 0.2 servings/week to 2.0 servings/week among the adult Canadian population aged 20 and over. The estimated mean red meat consumption in the Canadian population in 2007 to 2011 was approximately 3.2 times per week. In addition, Canadians consume an average of 1.2 times of processed meat per week. In 2015, an estimated 5.9% of associated cancers and 0.9% of all cancers were attributable to red meat consumption. An estimated 4.5% of associated cancers and 0.7% of all cancers were attributable to processed meat consumption. A mean decrease of 0.5 servings/week of red meat or processed meat could prevent about 8700 or 16,600 cancer cases, respectively, between 2015 and 2042. In conclusion, a small but meaningful cancer burden is associated with red and processed meat consumption. Interventions aimed at reducing consumption at the population level have the potential in the prevention of many cancers in Canada.

Estimates of the current and future burden of cancer attributable to excess body weight and abdominal adiposity in Canada.

The increasing prevalence of obesity among Canadians has important implications for newly diagnosed cases of cancer given that excess body weight and abdominal adiposity are known to increase the risk of several cancers. The purpose of this analysis was to estimate the current attributable and future avoidable burden of cancer related to excess body weight and abdominal adiposity among Canadian adults. We estimated the population attributable risk (PAR) for all cancers associated with excess body weight and abdominal adiposity using contemporary cancer incidence, relative risk and exposure prevalence data for body mass index (BMI), waist circumference and waist-to-hip-ratio. Using the partial impact fraction (PIF), we also estimated the future avoidable burden of cancer from 2015 to 2042 in Canada, and by province, through various hypothetical intervention scenarios. In 2003, approximately half (50.5%) of the Canadian population was estimated to be overweight (BMI 25.0-29.9) or obese (BMI ≥30.0), 56.5% to have excess abdominal adiposity and 56.8% with a high waist-to-hip ratio. In 2015, the estimated PARs of all incident cancers associated with excess body weight, excess abdominal adiposity and high waist-to-hip ratio were 7.2%, 8.9% and 10.0%, respectively. If the population BMI could revert to its 1994 distribution, 72,157 associated cancer cases could be prevented cumulatively by 2042. A reduction in excess body weight and abdominal adiposity has the potential to decrease the future cancer burden in Canada substantially, and hence efforts to reverse increasing trends in obesity should be prioritized.

Discussing Benefits and Risks of Tracheostomy: What Physicians Actually Say.

OBJECTIVES: When contemplating tracheostomy placement in a pediatric patient, a family-physician conference is often the setting for the disclosure of risks and benefits of the procedure. Our objective was to compare benefits and risks of tracheostomy presented during family-physician conferences to an expert panel's recommendations for what should be presented. DESIGN: We conducted a retrospective review of 19 transcripts of audio-recorded family-physician conferences regarding tracheostomy placement in children. A multicenter, multidisciplinary expert panel of clinicians was surveyed to generate a list of recommended benefits and risks for comparison. Primary analysis of statements by clinicians was qualitative. SETTING: Single-center PICU of a tertiary medical center. SUBJECTS: Family members who participated in family-physician conferences regarding tracheostomy placement for a critically ill child from April 2012 to August 2014. MEASUREMENTS AND MAIN RESULTS: We identified 300 physician statements describing benefits and risks of tracheostomy. Physicians were more likely to discuss benefits than risks (72% vs 28%). Three broad categories of benefits were identified: 1) tracheostomy would limit the impact of being in the PICU (46%); 2) perceived obstacles of tracheostomy can be overcome (34%); and 3) tracheostomy optimizes respiratory health (20%). Risks fell into two categories: tracheostomy involves a big commitment (71%), and it has complications (29%). The expert panel's recommendations were similar to risks and benefits discussed during family conferences; however, they suggested physicians present an equal balance of discussion of risks and benefits. CONCLUSIONS: When discussing tracheostomy placement, physicians emphasized benefits that are shared by physicians and families while minimizing the risks. The expert panel recommended a balanced approach by equally weighing risks and benefits. To facilitate educated decision making, physicians should present a more extensive range of risks and benefits to families making this critical decision.

Various mutations compensate for a deleterious lacZα insert in the replication enhancer of M13 bacteriophage.

M13 and other members of the Ff class of filamentous bacteriophages have been extensively employed in myriad applications. The Ph.D. series of phage-displayed peptide libraries were constructed from the M13-based vector M13KE. As a direct descendent of M13mp19, M13KE contains the lacZα insert in the intergenic region between genes IV and II, where it interrupts the replication enhancer of the (+) strand origin. Phage carrying this 816-nucleotide insert are viable, but propagate in E. coli at a reduced rate compared to wild-type M13 phage, presumably due to a replication defect caused by the insert. We have previously reported thirteen compensatory mutations in the 5'-untranslated region of gene II, which encodes the replication initiator protein gIIp. Here we report several additional mutations in M13KE that restore a wild-type propagation rate. Several clones from constrained-loop variable peptide libraries were found to have ejected the majority of lacZα gene in order to reconstruct the replication enhancer, albeit with a small scar. In addition, new point mutations in the gene II 5'-untranslated region or the gene IV coding sequence have been spontaneously observed or synthetically engineered. Through phage propagation assays, we demonstrate that all these genetic modifications compensate for the replication defect in M13KE and restore the wild-type propagation rate. We discuss the mechanisms by which the insertion and ejection of the lacZα gene, as well as the mutations in the regulatory region of gene II, influence the efficiency of replication initiation at the (+) strand origin. We also examine the presence and relevance of fast-propagating mutants in phage-displayed peptide libraries.

Standardization of Postoperative Transitions of Care to the Pediatric Intensive Care Unit Enhances Efficiency and Handover Comprehensiveness.

INTRODUCTION: To determine the impact of standardization of postoperative transitions of care to the pediatric intensive care unit on handover efficiency and the quality of healthcare data exchange. METHODS: This was a prospective, pre-post observational study after standardization of postoperative transitions in a 44-bed pediatric intensive care unit in a 313-bed tertiary care pediatric hospital from April to July 2015. Standardization was completed using a multidisciplinary handover checklist. Primary outcomes were efficiency expressed as mean handover duration and the comprehensiveness of healthcare data exchange. RESULTS: Forty-seven postoperative transitions were observed of which 23 were preintervention and 24 were postintervention. After standardization, efficiency improved from 10.5 ± 5.4 to 7.8 ± 2.7 minutes (P < 0.05). Healthcare data exchanged between surgical, anesthesia, and critical care providers were more robust including intraoperative, historical, and anticipatory guidance (all P < 0.05). After intervention, attendance through completion of handover for surgical services increased from 13% to 88% (P < 0.05). CONCLUSIONS: Standardization of postoperative transitions improved efficiency, healthcare data exchange, and anticipatory planning. Future research is required to link standardization of transitions to improved patient outcomes and measure the development of shared mental models.

Identification and characterization of mutant clones with enhanced propagation rates from phage-displayed peptide libraries.

A target-unrelated peptide (TUP) can arise in phage display selection experiments as a result of a propagation advantage exhibited by the phage clone displaying the peptide. We previously characterized HAIYPRH, from the M13-based Ph.D.-7 phage display library, as a propagation-related TUP resulting from a G→A mutation in the Shine-Dalgarno sequence of gene II. This mutant was shown to propagate in Escherichia coli at a dramatically faster rate than phage bearing the wild-type Shine-Dalgarno sequence. We now report 27 additional fast-propagating clones displaying 24 different peptides and carrying 14 unique mutations. Most of these mutations are found either in or upstream of the gene II Shine-Dalgarno sequence, but still within the mRNA transcript of gene II. All 27 clones propagate at significantly higher rates than normal library phage, most within experimental error of wild-type M13 propagation, suggesting that mutations arise to compensate for the reduced virulence caused by the insertion of a lacZα cassette proximal to the replication origin of the phage used to construct the library. We also describe an efficient and convenient assay to diagnose propagation-related TUPS among peptide sequences selected by phage display.