Capitalizing on the Teachable Moment: Improving Self-Help Smoking Cessation Interventions

The Teachable Moment (TM) model suggests that there are certain times when an individual is especially ready to change behavior and thus, especially open to receiving messages about behavior change. According to the TM model, experiences that jointly 1) increase risk perceptions, 2) prompt concordant emotional responses, and 3) impact self-concept may offer a powerful motivational context for promoting behavior change. Further, tailoring smoking cessation interventions on TM components may increase the salience of health messages. The TM model was used to examine desire to quit smoking among family members of lung cancer patients. Further, the relationship between desire to quit and engagement with and reactions to self-help smoking cessation materials was examined. Participants were family members of lung cancer patients recruited for a randomized controlled trial testing a counseling intervention for smoking cessation. Study results indicate that components of the TM model were related to desire to quit in family members of lung cancer patients. Specifically, increased perceived risk, negative self image, and high subjective norm for quitting were related to high desire to quit. Nonwhites were more likely to have a high desire to quit than whites. There was a significant interaction between worry and gender, such that women with low worry were less likely to have a high desire to quit than were men and women with high worry. Findings on engagement with and reactions to materials were mixed. Engagement with materials was not related to baseline desire to quit, but was related to positive reactions to the materials. Those with a higher desire to quit were more likely to report that the information in the tailored booklet applied to them, and was new to them, interesting, trustworthy, and moving. Finally, family members with a higher desire to quit were more likely to say that the information in the booklet make them want to quit smoking. Evidence from this initial study indicates that the TM model provides a strong conceptual framework for 1) identifying specific determinants of desire to quit among family members of lung cancer patients; and 2) developing effective tailored self-help materials for this population

Balancing medical education with service in the workplace

Purpose: Finding a balance between the provision of quality individualized care and the ongoing education of junior doctors had been flagged as a concern at a large NHS teaching hospital in the north of England. In response to this, the organization introduced an intervention designed to improve educational culture by providing support to educators, leaders and clinical staff. Method: This article features themed results from eight in-depth interviews with educators, consultants and junior doctors to describe and evaluate the process and impact. Findings: Factors that contributed to a positive educational environment included: trainees and educators feeling valued, the presence of supportive leaders, and the provision of a safe space for learning. Perceived barriers included time constraints, differing motivation, and the generic format of formal education. Participants reflected on how the Wrap Around project helped improve the workplace educational culture and offered suggestions for further improvement including the provision of ongoing feedback to learners about their performance. Originality: Research aimed at recognising and resolving the perceived tensions between the priorities of education and healthcare delivery has been flagged as a gap in the literature. We argue that developing and enhancing collaborative leadership and educational culture within an organization can reduce these tensions for those working on the front line. Future work should focus on addressing the perceived distinction between the two within services.<br/

Ovarian Cancer Epidemiology, Healthcare Access and Disparities (ORCHiD): Methodology for a Population-Based Study of Black, Hispanic and White Patients with Ovarian Cancer

INTRODUCTION: Less than 40% of patients with ovarian cancer (OC) in the USA receive stage-appropriate guideline-adherent surgery and chemotherapy. Black patients with cancer report greater depression, pain and fatigue than white patients. Lack of access to healthcare likely contributes to low treatment rates and racial differences in outcomes. The Ovarian Cancer Epidemiology, Healthcare Access and Disparities study aims to characterise healthcare access (HCA) across five specific dimensions-Availability, Affordability, Accessibility, Accommodation and Acceptability-among black, Hispanic and white patients with OC, evaluate the impact of HCA on quality of treatment, supportive care and survival, and explore biological mechanisms that may contribute to OC disparities. METHODS AND ANALYSIS: We will use the Surveillance Epidemiology and Ends Results dataset linked with Medicare claims data from 9744 patients with OC ages 65 years and older. We will recruit 1641 patients with OC (413 black, 299 Hispanic and 929 white) from cancer registries in nine US states. We will examine HCA dimensions in relation to three main outcomes: (1) receipt of quality, guideline adherent initial treatment and supportive care, (2) quality of life based on patient-reported outcomes and (3) survival. We will obtain saliva and vaginal microbiome samples to examine prognostic biomarkers. We will use hierarchical regression models to estimate the impact of HCA dimensions across patient, neighbourhood, provider and hospital levels, with random effects to account for clustering. Multilevel structural equation models will estimate the total, direct and indirect effects of race on treatment mediated through HCA dimensions. ETHICS AND DISSEMINATION: Result dissemination will occur through presentations at national meetings and in collaboration with collaborators, community partners and colleagues across othercancer centres. We will disclose findings to key stakeholders, including scientists, providers and community members. This study has been approved by the Duke Institutional Review Board (Pro00101872). Safety considerations include protection of patient privacy. All disseminated data will be deidentified and summarised

Genomic investigations of unexplained acute hepatitis in children

Since its first identification in Scotland, over 1,000 cases of unexplained paediatric hepatitis in children have been reported worldwide, including 278 cases in the UK1. Here we report an investigation of 38 cases, 66 age-matched immunocompetent controls and 21 immunocompromised comparator participants, using a combination of genomic, transcriptomic, proteomic and immunohistochemical methods. We detected high levels of adeno-associated virus 2 (AAV2) DNA in the liver, blood, plasma or stool from 27 of 28 cases. We found low levels of adenovirus (HAdV) and human herpesvirus 6B (HHV-6B) in 23 of 31 and 16 of 23, respectively, of the cases tested. By contrast, AAV2 was infrequently detected and at low titre in the blood or the liver from control children with HAdV, even when profoundly immunosuppressed. AAV2, HAdV and HHV-6 phylogeny excluded the emergence of novel strains in cases. Histological analyses of explanted livers showed enrichment for T cells and B lineage cells. Proteomic comparison of liver tissue from cases and healthy controls identified increased expression of HLA class 2, immunoglobulin variable regions and complement proteins. HAdV and AAV2 proteins were not detected in the livers. Instead, we identified AAV2 DNA complexes reflecting both HAdV-mediated and HHV-6B-mediated replication. We hypothesize that high levels of abnormal AAV2 replication products aided by HAdV and, in severe cases, HHV-6B may have triggered immune-mediated hepatic disease in genetically and immunologically predisposed children

Empagliflozin in Patients with Chronic Kidney Disease

Background The effects of empagliflozin in patients with chronic kidney disease who are at risk for disease progression are not well understood. The EMPA-KIDNEY trial was designed to assess the effects of treatment with empagliflozin in a broad range of such patients. Methods We enrolled patients with chronic kidney disease who had an estimated glomerular filtration rate (eGFR) of at least 20 but less than 45 ml per minute per 1.73 m(2) of body-surface area, or who had an eGFR of at least 45 but less than 90 ml per minute per 1.73 m(2) with a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 200. Patients were randomly assigned to receive empagliflozin (10 mg once daily) or matching placebo. The primary outcome was a composite of progression of kidney disease (defined as end-stage kidney disease, a sustained decrease in eGFR to &lt; 10 ml per minute per 1.73 m(2), a sustained decrease in eGFR of &amp; GE;40% from baseline, or death from renal causes) or death from cardiovascular causes. Results A total of 6609 patients underwent randomization. During a median of 2.0 years of follow-up, progression of kidney disease or death from cardiovascular causes occurred in 432 of 3304 patients (13.1%) in the empagliflozin group and in 558 of 3305 patients (16.9%) in the placebo group (hazard ratio, 0.72; 95% confidence interval [CI], 0.64 to 0.82; P &lt; 0.001). Results were consistent among patients with or without diabetes and across subgroups defined according to eGFR ranges. The rate of hospitalization from any cause was lower in the empagliflozin group than in the placebo group (hazard ratio, 0.86; 95% CI, 0.78 to 0.95; P=0.003), but there were no significant between-group differences with respect to the composite outcome of hospitalization for heart failure or death from cardiovascular causes (which occurred in 4.0% in the empagliflozin group and 4.6% in the placebo group) or death from any cause (in 4.5% and 5.1%, respectively). The rates of serious adverse events were similar in the two groups. Conclusions Among a wide range of patients with chronic kidney disease who were at risk for disease progression, empagliflozin therapy led to a lower risk of progression of kidney disease or death from cardiovascular causes than placebo