Pediatric obstructive sleep apnea: A prospective observational study of respiratory events in the immediate recovery period after adenotonsillectomy.

BACKGROUND: Adenotonsillectomy is often curative for pediatric obstructive sleep apnea, yet children remain at high risk of respiratory complications in the postoperative period. We sought to determine the incidence and risk factors for respiratory depression and airway obstruction, as well as clinically apparent respiratory events in the post-anesthesia care unit (PACU) in high-risk children after adenotonsillectomy. METHODS: In this prospective cohort study, we enrolled 60 high-risk children having adenotonsillectomy. Our primary outcome was respiratory depression and airway obstruction in the PACU measured using a noninvasive respiratory volume monitor (RVM) and defined by episodes of predicted minute ventilation less than 40% for at least 2 minutes. We measured clinically apparent respiratory events using continuous observation by trained study staff. RESULTS: The median (range) age of our sample was 4 years (1, 16) and 27 (45%) were female. Black and Hispanic race children comprised 80% (n = 48) of our cohort. Thirty-nine (65%) had at least one episode of PACU respiratory depression or airway obstruction measured using the RVM, while only 21 (35%) had clinically apparent respiratory events. Poisson regression demonstrated the following associations with an increase in episodes of respiratory depression and airway obstruction: BMI Z-score less than -1 (estimate 3.91; [95%CI 1.49-10.23]), BMI Z-score 1-2 (estimate 2.04; [1.20-3.48]), and two or more comorbidities (estimate 1.96; [1.11-3.46]). CONCLUSIONS: Respiratory volume monitoring in the immediate postoperative period after pediatric high-risk adenotonsillectomy identifies impaired ventilation more frequently than is clinically apparent.

Which clinician responses to emotion are associated with more positive patient experiences of communication?

OBJECTIVES: To identify communication strategies that may improve clinician-patient interactions, we assessed the association between clinician response to emotion and patient ratings of communication. METHODS: From a cohort of 1817 clinician-patient encounters, we designed a retrospective case-control study by identifying 69 patients who rated their interpersonal care as low-quality and 69 patients who rated their care as high-quality. We used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to identify patient emotional expressions and clinician responses. Using mixed-effects logistic regression, we evaluated the association between clinician responses to patients' emotions and patient ratings of their interpersonal care. RESULTS: In adjusted analyses, explicit responses that reduced space for further emotional communication were associated with high ratings of care (OR 1.94, 95% CI 1.25, 2.99); non-explicit responses providing additional space were associated with low ratings (OR 0.54, 95% CI 0.36-0.82). In terms of specific response types, neutral/passive responses were associated with low ratings (OR 0.59, 95% CI 0.39-0.90), whereas giving information/advice was associated with high ratings (OR, 95% 1.91 CI 1.17-3.1). CONCLUSIONS: Patients may prefer responses to their expressed emotions that demonstrate clinician engagement, with or without expressions of empathy. PRACTICE IMPLICATIONS: These findings may inform educational interventions to improve clinician-patient communication.

Food insecurity in pediatric HIV: understanding a critical challenge in the United States.

Advancing the well-being of individuals living with HIV necessitates attention to social determinants of health, including food insecurity. Through a clinical and community-based needs assessment, we aimed to gain insight into experiences of food insecurity among patients receiving care at a large pediatric HIV outpatient clinic in the Southeastern United States. We adopted a multimodal assessment approach involving a literature review, community profiling, key informant interviews, focus group discussions with staff, patients and parents and a community stakeholder advisory meeting. Our needs assessment demonstrates that food insecurity is an important aspect of the lived experience of children, adolescents and young adults living with HIV. Clinical staff agreed that food insecurity screening should be incorporated into the patient care workflow but ideally only in concert with providing resources that meet their needs. We formulated a recommendation matrix for addressing food insecurity based on priority importance and feasibility. Collaborative relationships between healthcare practitioners and leaders, community-based organizations and local and federal funding sources are vital for enhancing patients' access to sustainable, reliable solutions to this fundamental determinant of health. Our approach provides a tested model for other clinics seeking to identify and alleviate food insecurity among patients.

Sugammadex Versus Neostigmine for Reversal of Neuromuscular Blockade in Patients With Severe Renal Impairment: A Randomized, Double-Blinded Study.

BACKGROUND: Sugammadex is not advised for patients with severe renal impairment, but has been shown in a variety of other populations to be superior to neostigmine for reversal of neuromuscular blockade. The objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus reversal of cisatracurium-induced neuromuscular blockade with neostigmine results in a faster return to a train-of-four ratio (TOFR) ≥90% in patients with severe renal impairment. METHODS: We conducted a prospective, randomized, blinded, controlled trial at a large county hospital. A total of 49 patients were enrolled. Inclusion criteria included patients age ≥18, American Society of Anesthesiologists (ASA) physical status III and IV, with a creatinine clearance <30 mL/min, undergoing general anesthesia with expected surgical duration ≥2 hours and necessitating neuromuscular blockade. Subjects received either cisatracurium 0.2 mg/kg or rocuronium 0.6 mg/kg for induction of anesthesia to facilitate tracheal intubation. Subjects were kept at moderate neuromuscular blockade during surgery and received either 2 mg/kg sugammadex or 50 µg/kg neostigmine with 10 µg/kg glycopyrrolate for reversal of neuromuscular blockade. Neuromuscular monitoring was performed with electromyography (TwitchView), and the TOFR was recorded every minute after administration of the reversal agent. The time from administration of neuromuscular reversal until the patient reached a TOFR ≥90% was recorded as the primary outcome. RESULTS: The mean time to recovery of TOFR ≥90% was significantly faster with sugammadex at 3.5 (±1.6) min compared with neostigmine at 14.8 (±6.1) min ( P < .0001; mean difference, 11.3 minutes; 95% confidence interval [CI], 9.0-13.5 minutes). There were no major adverse events in either group. CONCLUSIONS: In patients with severe renal impairment, neuromuscular blockade with rocuronium followed by reversal with sugammadex provides a significantly faster return of neuromuscular function compared to cisatracurium and neostigmine, without any major adverse effects.

Taxonomy and effectiveness of clinician agenda-setting questions in routine ambulatory encounters: A mixed method study.

OBJECTIVES: Despite decades of communication training, studies repeatedly demonstrate that clinicians fail to elicit patients' agendas. Our goal was to provide clinicians with actionable guidance about the effectiveness of agenda-soliciting questions. METHODS: We coded clinician agenda-soliciting questions and patient responses in audio-recorded ambulatory encounters at an urban academic hospital. To evaluate the association between question type and odds of the patient raising a concern, we performed mixed-effects logistic regression. RESULTS: We identified 346 agenda-soliciting questions within 138 visits (mean 2.51/visit; range 0-9). Agenda-soliciting questions were categorized as personal state inquiries (37%, "How are you?"), feeling-focused (5% "How're you feeling?"), problem-focused (12%; "Are you having any problems"), direct solicitations (3%; "Anything you want to discuss today?"), "what else" (3%), "anything else" (14%), leading (16%; "Nothing else today?"), and space-reducing (11% "Anything else? Smoking?"). Patients raised a concern in response to 107 clinician questions (27%). Patients were more likely to raise a concern to direct solicitation (OR 22.95, 95% CI 2.62-200.70) or "what else" (OR 4.68, 95% CI 1.05-20.77) questions. CONCLUSIONS: The most effective agenda-soliciting questions are used least frequently by clinicians. PRACTICE IMPLICATIONS: Clinicians should elicit patient agendas by using direct language, and solicit additional concerns using "what else" vs. "anything else" questions.

The association of a scholarly concentrations program with medical students' matched residencies.

PURPOSE: Many medical school curricula include Scholarly Concentrations (SC) programs. While studies have examined how these programs affect students' future research involvement, the association of SC programs with students' specialty choices is uncertain. This study examines the SC program factors associated with congruence between the specialty focus of students' SC projects and the clinical specialty they matched into for residency. METHODS: The authors conducted a retrospective cohort study of all students participating in the SC program at Johns Hopkins University School of Medicine for graduating classes 2013-2020. They used data from program questionnaires to categorize students' specialty interests (baseline) and SC program experiences (post-program). The authors categorized each student's project into specialties according to their faculty mentors' primary appointments, abstracted student publications from SCOPUS, and abstracted residency program rankings from Doximity Residency Navigator. The authors used multivariable logistic regression to calculate adjusted odds ratios (aOR) for specialty-congruent matching (same specialty as SC project) and for matching into a Doximity-ranked top 20 or top 10 program. RESULTS: Overall, 35.3% of the 771 students matched into the same specialty as their SC projects. Increased odds of specialty-congruent matching occurred with 'definite' interest in the specialty at baseline [aOR (95% CI): 1.76 (0.98-3.15)] (P = 0.06) and with increasing publications with SC mentors [aOR (95% CI): 1.16 (1.03-1.30)] (P = 0.01). Congruence between SC specialty focus and matched specialty conferred no significant difference in odds of matching to a Doximity-ranked top 20 or top 10 program. CONCLUSIONS: Baseline certainty of specialty interest and research productivity were associated with specialty congruence. However, as completing an SC project in a given specialty was not associated with increased odds of matching into that specialty nor into a higher Doximity-ranked program, SC program directors should advise students to pursue SC projects in any topic of personal interest.

Electronic phenotypes to distinguish clinician attention to high body mass index, hypertension, lipid disorders, fatty liver and diabetes in pediatric primary care: Diagnostic accuracy of electronic phenotypes compared to masked comprehensive chart review.

BACKGROUND/OBJECTIVES: Electronic phenotyping is a method of using electronic-health-record (EHR) data to automate identifying a patient/population with a characteristic of interest. This study determines validity of using EHR data of children with overweight/obesity to electronically phenotype evidence of clinician 'attention' to high body mass index (BMI) and each of four distinct comorbidities. METHODS: We built five electronic phenotypes classifying 2-18-year-old children with overweight/obesity (n = 17,397) by electronic/health-record evidence of distinct attention to high body mass index, hypertension, lipid disorders, fatty liver, and prediabetes/diabetes. We reviewed, selected and cross-checked random charts to define items clinicians select in EHRs to build problem lists, and to order medications, laboratory tests and referrals to electronically classify attention to overweight/obesity and each comorbidity. Operating characteristics of each clinician-attention phenotype were determined by comparing comprehensive chart review by reviewers masked to electronic classification who adjudicated evidence of clinician attention to high BMI and each comorbidity. RESULTS: In a random sample of 817 visit-records reviewed/coded, specificity of each electronic phenotype is 99%-100% (with PPVs ranging from 96.8% for prediabetes/diabetes to 100% for dyslipidemia and hypertension). Sensitivities of the attention classifications range from 69% for hypertension (NPV, 98.9%) to 84.7% for high-BMI attention (NPV, 92.3%). CONCLUSIONS: Electronic phenotypes for clinician attention to overweight/obesity and distinct comorbidities are highly specific, with moderate (BMI) to modest (each comorbidity) sensitivity. The high specificity supports using phenotypes to identify children with prior high-BMI/comorbidity attention.

Dalbavancin for the Treatment of Acute Bacterial Skin and Skin Structure Infection in Patients With Obesity or Diabetes: A Subgroup Analysis of Pooled Phase 3 Clinical Trials.

Background: We assessed the efficacy and safety of dalbavancin, a long-acting lipoglycopeptide with activity against Gram-positive pathogens, for treatment of acute bacterial skin and skin structure infections (ABSSSI) in patients with high body mass index (BMI) and/or diabetes. Methods: Data from two phase 3 trials of dalbavancin (1000 mg intravenous [IV], day 1; 500 mg IV, day 8) versus comparator and one phase 3b trial of single-dose (1500 mg IV, day 1) versus 2-dose (1000 mg IV, day 1; 500 mg IV, day 8) dalbavancin in adults with ABSSSI were pooled and summarized separately by baseline BMI and diabetes status. Clinical success at 48 to 72 hours (≥20% reduction in lesion size), end of treatment ([EOT] day 14), and day 28 was evaluated in the intent-to-treat (ITT) and microbiological ITT (microITT) populations. Safety data were reported in patients who received ≥1 dose of study drug. Results: In the dalbavancin ITT population (BMI, n = 2001; diabetes, n = 2010), at 48 to 72 hours (and EOT) clinical success was achieved in 89.3% (EOT, 90.9%) of patients with normal BMI and 78.9% to 87.6% (EOT, 91.0% to 95.2%) of patients with elevated BMI. Clinical success after dalbavancin treatment was achieved in 82.4% (EOT, 90.8%) of patients with diabetes and 86.0% (EOT, 91.6%) of patients without diabetes. Similar trends were observed for infections due to methicillin-resistant Staphylococcus aureus or methicillin-susceptible S aureus (microITT population). Conclusions: Dalbavancin is effective, with sustained clinical success rates in patients with obesity or diabetes, with a similar safety profile across patient groups.

Prescribing Alzheimer's Disease treatments by provider type and geographic region: a comparison among physicians, nurse practitioners, and physician assistants.

BACKGROUND: The estimated increase in Alzheimer's Disease (AD) caseload may present a logistical challenge to the US healthcare system. While nurse practitioners (NPs) and physician assistants (PAs) are increasingly delivering primary care to patients with chronic diseases, the nature of their prescribing of AD medications is largely unknown. The primary objective of this study was to compare the prescribing of AD medications across provider types (physician, NP, and PA) and geographic regions. METHODS: We conducted a retrospective cohort study using IBM MarketScan® commercial and Medicare supplemental claims to examine unique AD prescriptions prescribed between January 1, 2016, and December 31, 2019. Parallel analysis of prescriptions for another geriatric condition, osteoporosis (OP), was also conducted for comparison. RESULTS: A total of 103,067 AD prescriptions and 131,773 OP prescriptions were included in analyses. Physicians prescribed most AD prescriptions (95.65%), followed by NPs (3.37%) and PAs (0.98%). Small differences were identified among individual AD medications prescribed by physicians compared to NP/PAs. NPs/PAs prescribed a significantly higher proportion of AD prescriptions in rural as compared to urban areas (z = 0.023, 95%CI [0.018, 0.028]). CONCLUSION: Minimal variation exists in AD prescribing among physicians, NPs, and PAs, but NPs/PAs prescribe more AD prescriptions in rural areas. NPs/PAs, especially in rural areas, may play critical roles in alleviating projected workforce constraints. Further research assessing AD care, health outcomes, and costs by provider type and region is necessary to better guide healthcare workforce planning for AD care.

Lipid nanoparticle delivers phenylalanine ammonia lyase mRNA to the liver leading to catabolism and clearance of phenylalanine in a phenylketonuria mouse model.

Phenylketonuria (PKU) is a genetic disorder affecting around 1 in 12,000 live births (1), caused by a mutation in the phenylalanine hydroxylase (PAH) gene in the liver which facilitates the catabolism of phenylalanine (Phe). Without a functional copy of PAH, levels of Phe in the blood and tissues rise, resulting in potentially life-threatening damage to the central nervous system. (2) Treatment options for PKU are limited, and center around adherence to a strict PKU diet that suffers from poor patient compliance. There are two approved drugs available, one of which must be used in conjunction with the PKU diet and another that has serious immunological side effects. Here we demonstrate that the LUNAR® delivery technology is capable of delivering mRNA for a replacement enzyme, the bacterial phenylalanine ammonia lyase (avPAL), into the hepatic tissue of a PKU mouse, and that the enzyme is capable of metabolizing Phe and reducing serum levels of Phe for more than five days post-transfection. We further demonstrate the ability of LUNAR to deliver a plant-derived PAL protein with a similar impact on the level of serum Phe. Taken together these results demonstrate both the capability of LUNAR for the targeted delivery of PAL mRNA into hepatic tissue in vivo, replacing the defective PAH protein and successfully reducing serum Phe levels, thereby addressing the underlying cause of PKU symptoms. Secondly, that plant-based PAL proteins are a viable alternative to bacterial avPAL to reduce the immunogenic response.

Dysregulation of Oxygen Sensing/Response Pathways in Pregnancies Complicated by Idiopathic Intrauterine Growth Restriction and Early-Onset Preeclampsia.

Preeclampsia (PE) and intrauterine growth restriction (IUGR) are the leading causes of maternal and fetal morbidity/mortality. The central deficit in both conditions is impaired placentation due to poor trophoblast invasion, resulting in a hypoxic milieu in which oxidative stress contributes to the pathology. We examine the factors driving the hypoxic response in severely preterm PE (n = 19) and IUGR (n = 16) placentae compared to the spontaneous preterm (SPT) controls (n = 13) using immunoblotting, RT-PCR, immunohistochemistry, proximity ligation assays, and Co-IP. Both hypoxia-inducible factor (HIF)-1α and HIF-2α are increased at the protein level and functional in pathological placentae, as target genes prolyl hydroxylase domain (PHD)2, PHD3, and soluble fms-like tyrosine kinase-1 (sFlt-1) are increased. Accumulation of HIF-α-subunits occurs in the presence of accessory molecules required for their degradation (PHD1, PHD2, and PHD3 and the E3 ligase von Hippel-Lindau (VHL)), which were equally expressed or elevated in the placental lysates of PE and IUGR. However, complex formation between VHL and HIF-α-subunits is defective. This is associated with enhanced VHL/DJ1 complex formation in both PE and IUGR. In conclusion, we establish a significant mechanism driving the maladaptive responses to hypoxia in the placentae from severe PE and IUGR, which is central to the pathogenesis of both diseases.

Parental Expression of Emotions and Surgeon Responses During Consultations for Obstructive Sleep-Disordered Breathing in Children.

Importance: Little is known about emotional communication between parents and surgeons. Understanding the patterns and correlates of emotional communication may foster collaboration during surgical consultations. Objective: To describe the emotional expressions by parents when bringing their child for evaluation of obstructive sleep-disordered breathing (SDB) as well as surgeon responses to these emotional expressions and to evaluate the association between parental demographic characteristics and surgeon response types. Design, Setting, and Participants: This cross-sectional study analyzed the audio-recorded consultations between otolaryngologists and parents of children who underwent their initial otolaryngological examination for obstructive SDB at 1 of 3 outpatient clinical sites in Maryland from April 1, 2016, to May 31, 2017. Data analysis was performed from November 1 to December 31, 2019. Main Outcomes and Measures: Emotional expressions by parents and surgeon responses were audio recorded, transcribed, and coded using the Verona Coding Definitions of Emotional Sequences. Results: A total of 59 consultations, of which 40 (67.8%) contained at least 1 emotional expression, were included. Participants included 59 parents (53 women [89.8%]; mean [SD] age, 33.4 [6.4] years) and 7 surgeons (4 men [57.1%]; mean [SD] age, 42.8 [7.9] years). Parents made 123 distinct emotional expressions (mean [SD], 3.08 [2.29] expressions per visit), which were often expressed as subtle cues (n = 103 of 123 [83.7%]) vs explicit concerns (n = 20 [16.3%]). Most expressions (n = 98 [79.7%]) were related to medical issues experienced by the child (eg, symptoms and surgical risks). Most surgeon responses provided parents space for elaboration of emotional expressions (n = 86 [69.9%]) and were nonexplicit (n = 55 [44.7%]). Surgeons were less likely to explore the emotions of parents from racial and ethnic minority groups compared with White parents (OR, 0.47; 95% CI, 0.18-0.98). Conclusions and Relevance: This cross-sectional study found that emotional communication occurs between surgeons and parents of pediatric patients with obstructive SDB. However, surgeon responses varied according to parental race and ethnicity, suggesting the existence of implicit biases in surgeon-patient communication and calling for further research to inform efforts to promote family-centered, culturally competent communication in surgery.

Clinician Response to Patient Emotion: Impact on Subsequent Communication and Visit Length.

PURPOSE: It is widely cited-based on limited evidence-that attending to a patient's emotions results in shorter visits because patients are less likely to repeat themselves if they feel understood. We evaluated the association of clinician responses to patient emotions with subsequent communication and visit length. METHODS: We audio-recorded 41 clinicians with 342 unique patients and used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to time stamp patient emotional expressions and categorize clinician responses. We used random-intercept multilevel-regression models to evaluate the associations of clinician responses with timing of the expressed emotion, patient repetition, and subsequent length of visit. RESULTS: The mean visit length was 30.4 minutes, with 1,028 emotional expressions total. The majority of clinician responses provided space for the patient to elaborate on the emotion (81%) and were nonexplicit (56%). As each minute passed, clinicians had lower odds of providing space (odds ratio [OR] = 0.96; 95% CI, 0.95-0.98) and higher odds of being explicit (OR = 1.02; 95% CI, 1.00-1.03). Emotions were more likely to be repeated when clinicians provided space (OR = 2.33; 95% CI, 1.66-3.27), and less likely to be repeated when clinicians were explicit (OR = 0.61; 95% CI, 0.47-0.80). Visits were shorter (ß = -0.98 minutes; 95% CI, -2.19 to 0.23) when clinicians' responses explicitly focused on patient affect. CONCLUSION: If saving time is a goal, clinicians should consider responses that explicitly address a patient's emotion. Arguments for providing space for patients to discuss emotional issues should focus on other benefits, including patients' well-being.

Physician Use of Stigmatizing Language in Patient Medical Records.

Importance: Negative attitudes toward patients can adversely impact health care quality and contribute to health disparities. Stigmatizing language written in a patient's medical record can perpetuate negative attitudes and influence decision-making of clinicians subsequently caring for that patient. Objective: To identify and describe physician language in patient health records that may reflect, or engender in others, negative and positive attitudes toward the patient. Design, Setting, and Participants: This qualitative study analyzed randomly selected encounter notes from electronic medical records in the ambulatory internal medicine setting at an urban academic medical center. The 600 encounter notes were written by 138 physicians in 2017. Data were analyzed in 2019. Main Outcomes and Measures: Common linguistic characteristics reflecting an overall positive or negative attitude toward the patient. Results: A total of 138 clinicians wrote encounter notes about 507 patients. Of these patients, 350 (69%) were identified as female, 406 (80%) were identified as Black/African American, and 76 (15%) were identified as White. Of 600 encounter notes included in this study, there were 5 major themes representing negative language and 6 themes representing positive language. The majority of negative language was not explicit and generally fell into one or more of the following categories: (1) questioning patient credibility, (2) expressing disapproval of patient reasoning or self-care, (3) stereotyping by race or social class, (4) portraying the patient as difficult, and (5) emphasizing physician authority over the patient. Positive language was more often more explicit and included (1) direct compliments, (2) expressions of approval, (3) self-disclosure of the physician's own positive feelings toward the patient, (4) minimization of blame, (5) personalization, and (6) highlighting patient authority for their own decisions. Conclusions and Relevance: This qualitative study found that physicians express negative and positive attitudes toward patients when documenting in the medical record. Although often not explicit, this language could potentially transmit bias and affect the quality of care that patients subsequently receive. These findings suggest that increased physician awareness when writing and reading medical records is needed to prevent the perpetuation of negative bias in medical care.

Testimonial Injustice: Linguistic Bias in the Medical Records of Black Patients and Women.

BACKGROUND: Black Americans and women report feeling doubted or dismissed by health professionals. OBJECTIVE: To identify linguistic mechanisms by which physicians communicate disbelief of patients in medical records and then to explore racial and gender differences in the use of such language. DESIGN: Cross-sectional. SETTING/PARTICIPANTS: All notes for patients seen in an academic ambulatory internal medicine practice in 2017. MAIN MEASURES: A content analysis of 600 clinic notes revealed three linguistic features suggesting disbelief: (1) quotes (e.g., had a "reaction" to the medication); (2) specific "judgment words" that suggest doubt (e.g., "claims" or "insists"); and (3) evidentials, a sentence construction in which patients' symptoms or experience is reported as hearsay. We used natural language processing to evaluate the prevalence of these features in the remaining notes and tested differences by race and gender, using mixed-effects regression to account for clustering of notes within patients and providers. KEY RESULTS: Our sample included 9251 notes written by 165 physicians about 3374 unique patients. Most patients were identified as Black (74%) and female (58%). Notes written about Black patients had higher odds of containing at least one quote (OR 1.48, 95% CI 1.20-1.83) and at least one judgment word (OR 1.25, 95% CI 1.02-1.53), and used more evidentials (ß 0.32, 95% CI 0.17-0.47), compared to notes of White patients. Notes about female vs. male patients did not differ in terms of judgment words or evidentials but had a higher odds of containing at least one quote (OR 1.22, 95% CI 1.05-1.44). CONCLUSIONS: Black patients may be subject to systematic bias in physicians' perceptions of their credibility, a form of testimonial injustice. This is another potential mechanism for racial disparities in healthcare quality that should be further investigated and addressed.

Hypoglycemia Communication in Primary Care Visits for Patients with Diabetes.

BACKGROUND: Hypoglycemia is a common and serious adverse effect of diabetes treatment, especially for patients using insulin or insulin secretagogues. Guidelines recommend that these patients be assessed for interval hypoglycemic events at each clinical encounter and be provided anticipatory guidance for hypoglycemia prevention. OBJECTIVE: To determine the frequency and content of hypoglycemia communication in primary care visits. DESIGN: Qualitative study PARTICIPANTS: We examined 83 primary care visits from one urban health practice representing 8 clinicians and 33 patients using insulin or insulin secretagogues. APPROACH: Using a directed content analysis approach, we analyzed audio-recorded primary care visits collected as part of the Achieving Blood Pressure Control Together study, a randomized trial of behavioral interventions for hypertension. The coding framework included communication about interval hypoglycemia, defined as discussion of hypoglycemic events or symptoms; the components of hypoglycemia anticipatory guidance in diabetes guidelines; and hypoglycemia unawareness. Hypoglycemia documentation in visit notes was compared to visit transcripts. KEY RESULTS: Communication about interval hypoglycemia occurred in 24% of visits, and hypoglycemic events were reported in 16%. Despite patients voicing fear of hypoglycemia, clinicians rarely assessed hypoglycemia frequency, severity, or its impact on quality of life. Hypoglycemia anticipatory guidance was provided in 21% of visits which focused on diet and behavior change; clinicians rarely counseled on hypoglycemia treatment or avoidance of driving. Limited discussions of hypoglycemia unawareness occurred in 8% of visits. Documentation in visit notes had low sensitivity but high specificity for ascertaining interval hypoglycemia communication or hypoglycemic events, compared to visit transcripts. CONCLUSIONS: In this high hypoglycemia risk population, communication about interval hypoglycemia and counseling for hypoglycemia prevention occurred in a minority of visits. There is a need to support clinicians to more regularly assess their patients' hypoglycemia burden and enhance counseling practices in order to optimize hypoglycemia prevention in primary care.

Toward a broader concept of societal value: family spillovers in Alzheimer's disease.

Recognizing that the "healthcare sector perspective" can be too limited in some situations, the National Institute of Health and Care Excellence (NICE), Institute for Clinical and Economic Review (ICER), and the U.S. Second Panel on Cost-Effectiveness in Health and Medicine all recommend a "societal" perspective in "reference case" cost-effectiveness analyses (CEAs). Although costs of informal caregiving are sometimes included in the CEAs of Alzheimer's Disease (AD) drugs, the benefits and disutility to family members, referred to as "family spillovers" by the U.S. Second Panel, are usually omitted. We estimate that the aggregate cost of family spillovers could be substantial in the USA-on the order of USD 57 billion or over 10 percent of the total economic burden of AD in 2020. Incorporation of family spillovers in AD value frameworks and HTAs is important for comprehensively defining, rewarding, and providing high-value care in AD.

Are clinicians' self-reported empathic concern and perspective-taking traits associated with their response to patient emotions?: Communication Studies.

OBJECTIVE: To understand whether clinicians' empathic concern and perspective-taking traits are associated with their response to patient emotions. METHODS: We audio-recorded 41 HIV clinician interactions with 342 patients at two academic medical centers. We assessed clinicians' self-reported empathic concern and perspective-taking traits using the Interpersonal Reactivity Index and coded emotional communication using the Verona Coding Definitions of Emotional Sequences. We used random effects models to assess associations between clinician traits and clinician responses to patients' negative emotions, accounting for clustering of emotions within encounters and patients within clinicians. RESULTS: Clinicians with more self-reported empathic concern received fewer emotional expressions from their patients (ß -0.06; 95% CI -0.10, -0.01) and had greater odds of responding to emotions by giving information/advice (OR 1.10; 95% CI 1.01, 1.20). There were no associations between empathic concern or perspective-taking and any other clinician responses. CONCLUSION: Clinicians with higher levels of empathic concern respond to patient emotions by giving information and advice, a response traditionally thought of as a missed empathic opportunity, not by exploring emotions or providing empathy. Whether this is helpful to patients is unknown. PRACTICE IMPLICATIONS: Clinicians should be aware of their tendency to give information to patients with emotional distress, and consider whether this response is helpful to patients.

Racial disparities in clinician responses to patient emotions.

OBJECTIVE: In a previous study of patients newly enrolled in HIV care, we observed that clinicians were less likely to address emotional issues expressed by African-American patients compared to whites. We sought to verify and expand these findings in a larger group of patients established in HIV care. METHODS: We used VR-CoDES to analyze transcripts from 342 audio-recorded medical visits in the United States. We used random intercept multilevel logistic regression to assess associations between patient and clinician characteristics and patterns of emotional talk. RESULTS: African-American patients were less likely than others to spontaneously express emotions (OR 0.50; 95 % CI 0.29-0.85). Clinicians, who were predominantly white, were more likely to respond to emotional expressions by African-American patients explicitly (OR 1.56; 95 % CI 1.11-2.20) but less likely to offer neutral/passive responses that provide space for emotional conversation (OR 0.56; 95 % CI 0.37-0.84) and more likely to block discussion of the emotional issue (OR 2.20; 95 % CI 1.05-4.63). Emotional talk did not vary by patient age or gender. CONCLUSION: These results confirm our prior findings, demonstrating less open emotional communication between African-American patients and their providers. PRACTICE IMPLICATIONS: Addressing racial differences in communicating about emotions may reduce disparities in patient-clinician relationships.

Emotional Communication in HIV Care: An Observational Study of Patients' Expressed Emotions and Clinician Response.

Emotional support is essential to good communication, yet clinicians often miss opportunities to provide empathy to patients. Our study explores the nature of emotional expressions found among patients new to HIV care, how HIV clinicians respond to these expressions, and predictors of clinician responses. Patient-provider encounters were audio-recorded, transcribed, and coded using the VR-CoDES. We categorized patient emotional expressions by intensity (subtle 'cues' vs. more explicit 'concerns'), timing (initial vs. subsequent), and content (medical vs. non-medical). Emotional communication was present in 65 of 91 encounters. Clinicians were more likely to focus specifically on patient emotion for concerns versus cues (OR 4.55; 95% CI 1.36, 15.20). Clinicians were less likely to provide space when emotional expressions were repeated (OR 0.32; 95% CI 0.14, 0.77), medically-related (OR 0.36; 95% CI 0.17, 0.77), and from African American patients (OR 0.42; 95% CI 0.21, 0.84). Potential areas for quality improvement include raising clinician awareness of subtle emotional expressions, the emotional content of medically-related issues, and racial differences in clinician response.