Pain Medication Management Processes Used by Oncology Outpatients and Family Caregivers Part II: Home and Lifestyle Contexts

Context—Despite the increasing complexity of medication regimens for persistent cancer pain, little is known about how oncology outpatients and their family caregivers manage pain medications at home. Objectives—To describe the day-to-day management of pain medications from the perspectives of oncology outpatients and their family caregivers who participated in a randomized clinical trial (RCT) of a psycho-educational intervention called the Pro-Self © Plus Pain Control Program. In this article, we focus on pain medication management in the context of highly individualized home environments and lifestyles. Methods—This qualitative study was conducted as part of a RCT in which an embedded mixed methods research design was used. Audio-recorded dialogue among patients, family caregivers, and intervention nurses was analyzed using qualitative research methods. Results—Home and lifestyle contexts for managing pain medications included highly individualized home environments, work and recreational activities, personal routines, and family characteristics. Pain medication management processes particularly relevant in these contexts included understanding, organizing, storing, scheduling, remembering, and taking the medications. With the exception of their interactions with the intervention nurses, most study participants had little involvement with clinicians as they worked through these processes. Conclusion—Pain medication management is an ongoing multidimensional process, each step of which has to be mastered by patients and family caregivers when cancer treatment and supportive care is provided on an outpatient basis. Realistic patient- and family-centered skill-building interventions are needed to achieve effective and safe pain medication management in the contexts of individual home environments and lifestyles

Pain Medication Management Processes Used by Oncology Outpatients and Family Caregivers Part I: Health Systems Contexts

Context—Oncology patients with persistent pain treated in outpatient settings and their family caregivers have significant responsibility for managing pain medications. However, little is known about their practical, day-to-day experiences with pain medication management. Objective—To describe day-to-day pain medication management from the perspectives of oncology outpatients and their family caregivers who participated in a randomized clinical trial of a psycho-educational intervention called the Pro-Self© Plus Pain Control Program. In this article, we focus on pain medication management by patients and family caregivers in the context of multiple, complex health systems. Methods—We qualitatively analyzed audio-recorded intervention sessions that included extensive dialogue between patients, family caregivers, and nurses about pain medication management during the 10-week intervention. Results—The health systems context for pain medication management included multiple complex systems for clinical care, reimbursement, and regulation of analgesic prescriptions. Pain medication management processes particularly relevant to this context were getting prescriptions and obtaining medications. Responsibilities that fell primarily to patients and family caregivers included facilitating communication and coordination among multiple clinicians, overcoming barriers to access, and serving as a final safety checkpoint. Significant effort was required of patients and family caregivers to insure safe and effective pain medication management. Conclusion—Health systems issues related to access to needed analgesics, medication safety in outpatient settings, and the effort expended by oncology patients and their family caregivers require more attention in future research and healthcare reform initiatives

Xpert® MTB/RIF assay for extrapulmonary tuberculosis and rifampicin resistance.

BACKGROUND: Tuberculosis (TB) is the world's leading infectious cause of death. Extrapulmonary TB accounts for 15% of TB cases, but the proportion is increasing, and over half a million people were newly diagnosed with rifampicin-resistant TB in 2016. Xpert® MTB/RIF (Xpert) is a World Health Organization (WHO)-recommended, rapid, automated, nucleic acid amplification assay that is used widely for simultaneous detection of Mycobacterium tuberculosis complex and rifampicin resistance in sputum specimens. This Cochrane Review assessed the accuracy of Xpert in extrapulmonary specimens. OBJECTIVES: To determine the diagnostic accuracy of Xpert a) for extrapulmonary TB by site of disease in people presumed to have extrapulmonary TB; and b) for rifampicin resistance in people presumed to have extrapulmonary TB. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature (LILACS), Scopus, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number (ISRCTN) Registry, and ProQuest up to 7 August 2017 without language restriction. SELECTION CRITERIA: We included diagnostic accuracy studies of Xpert in people presumed to have extrapulmonary TB. We included TB meningitis and pleural, lymph node, bone or joint, genitourinary, peritoneal, pericardial, and disseminated TB. We used culture as the reference standard. For pleural TB, we also included a composite reference standard, which defined a positive result as the presence of granulomatous inflammation or a positive culture result. For rifampicin resistance, we used culture-based drug susceptibility testing or MTBDRplus as the reference standard. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data, assessed risk of bias and applicability using the QUADAS-2 tool. We determined pooled predicted sensitivity and specificity for TB, grouped by type of extrapulmonary specimen, and for rifampicin resistance. For TB detection, we used a bivariate random-effects model. Recognizing that use of culture may lead to misclassification of cases of extrapulmonary TB as 'not TB' owing to the paucibacillary nature of the disease, we adjusted accuracy estimates by applying a latent class meta-analysis model. For rifampicin resistance detection, we performed univariate meta-analyses for sensitivity and specificity separately to include studies in which no rifampicin resistance was detected. We used theoretical populations with an assumed prevalence to provide illustrative numbers of patients with false positive and false negative results. MAIN RESULTS: We included 66 unique studies that evaluated 16,213 specimens for detection of extrapulmonary TB and rifampicin resistance. We identified only one study that evaluated the newest test version, Xpert MTB/RIF Ultra (Ultra), for TB meningitis. Fifty studies (76%) took place in low- or middle-income countries. Risk of bias was low for patient selection, index test, and flow and timing domains and was high or unclear for the reference standard domain (most of these studies decontaminated sterile specimens before culture inoculation). Regarding applicability, in the patient selection domain, we scored high or unclear concern for most studies because either patients were evaluated exclusively as inpatients at tertiary care centres, or we were not sure about the clinical settings.Pooled Xpert sensitivity (defined by culture) varied across different types of specimens (31% in pleural tissue to 97% in bone or joint fluid); Xpert sensitivity was > 80% in urine and bone or joint fluid and tissue. Pooled Xpert specificity (defined by culture) varied less than sensitivity (82% in bone or joint tissue to 99% in pleural fluid and urine). Xpert specificity was ≥ 98% in cerebrospinal fluid, pleural fluid, urine, and peritoneal fluid.Xpert testing in cerebrospinal fluidXpert pooled sensitivity and specificity (95% credible interval (CrI)) against culture were 71.1% (60.9% to 80.4%) and 98.0% (97.0% to 98.8%), respectively (29 studies, 3774 specimens; moderate-certainty evidence).For a population of 1000 people where 100 have TB meningitis on culture, 89 would be Xpert-positive: of these, 18 (20%) would not have TB (false-positives); and 911 would be Xpert-negative: of these, 29 (3%) would have TB (false-negatives).For TB meningitis, ultra sensitivity and specificity against culture (95% confidence interval (CI)) were 90% (55% to 100%) and 90% (83% to 95%), respectively (one study, 129 participants).Xpert testing in pleural fluidXpert pooled sensitivity and specificity (95% CrI) against culture were 50.9% (39.7% to 62.8%) and 99.2% (98.2% to 99.7%), respectively (27 studies, 4006 specimens; low-certainty evidence).For a population of 1000 people where 150 have pleural TB on culture, 83 would be Xpert-positive: of these, seven (8%) would not have TB (false-positives); and 917 would be Xpert-negative: of these, 74 (8%) would have TB (false-negatives).Xpert testing in urineXpert pooled sensitivity and specificity (95% CrI) against culture were 82.7% (69.6% to 91.1%) and 98.7% (94.8% to 99.7%), respectively (13 studies, 1199 specimens; moderate-certainty evidence).For a population of 1000 people where 70 have genitourinary TB on culture, 70 would be Xpert-positive: of these, 12 (17%) would not have TB (false-positives); and 930 would be Xpert-negative: of these, 12 (1%) would have TB (false-negatives).Xpert testing for rifampicin resistanceXpert pooled sensitivity (20 studies, 148 specimens) and specificity (39 studies, 1088 specimens) were 95.0% (89.7% to 97.9%) and 98.7% (97.8% to 99.4%), respectively (high-certainty evidence).For a population of 1000 people where 120 have rifampicin-resistant TB, 125 would be positive for rifampicin-resistant TB: of these, 11 (9%) would not have rifampicin resistance (false-positives); and 875 would be negative for rifampicin-resistant TB: of these, 6 (1%) would have rifampicin resistance (false-negatives).For lymph node TB, the accuracy of culture, the reference standard used, presented a greater concern for bias than in other forms of extrapulmonary TB. AUTHORS' CONCLUSIONS: In people presumed to have extrapulmonary TB, Xpert may be helpful in confirming the diagnosis. Xpert sensitivity varies across different extrapulmonary specimens, while for most specimens, specificity is high, the test rarely yielding a positive result for people without TB (defined by culture). Xpert is accurate for detection of rifampicin resistance. For people with presumed TB meningitis, treatment should be based on clinical judgement, and not withheld solely on an Xpert result, as is common practice when culture results are negative

Effects of Partners Together in Health (PaTH) Intervention on Physical Activity and Healthy Eating Behaviors: A Pilot Study

Background—Despite proven efficacy of cardiac rehabilitation (CR) in helping patients initiate physical activity and healthy eating changes, less than 50% of CR participants maintain changes 6 months later. Objective—The objective of this feasibility study was to test the Partners Together in Health (PaTH) Intervention versus usual care (UC) in improving physical activity and healthy eating behaviors in coronary artery bypass graft (CABG) surgery patients and spouses. Methods—An experimental, two-group (n = 17 couples/group), repeated measures design was used. CABG patients in both groups participated in Phase II outpatient CR. Spouses in the PaTH group attended CR with the patient and were asked to make the same physical activity and healthy eating changes as patients. Spouses in the control group attended educational classes with patients. It was theorized that “two persons would be better than one” at making changes and sticking with them long-term. Physical activity behavior was measured using the Actiheart accelerometer; the activity biomarker was an exercise tolerance test. Eating behavior was measured using 3-day food records; the biomarker was the lipid profile. Data were collected at baseline (entrance in CR), 3-months (post-CR), and 6-months. Changes over time were examined using Mann-Whitney U statistics and effect sizes. Results—The PaTH intervention was successful primarily in demonstrating improved trends in healthy eating behavior for patients and spouses. No differences were found between the PaTH and UC patients or spouses at 3 or 6 months in the number of minutes/week of physical activity. By 6 months, patients in both groups were, on average, below the national guidelines for PA recommendations (≥ 150 min/week at \u3e 3 METs). Conclusions—The couple-focused PaTH intervention demonstrated promise in offsetting the decline in dietary adherence typically seen 6 months after CR

Effects of Partners Together in Health (PaTH) Intervention on Physical Activity and Healthy Eating Behaviors: A Pilot Study

Background—Despite proven efficacy of cardiac rehabilitation (CR) in helping patients initiate physical activity and healthy eating changes, less than 50% of CR participants maintain changes 6 months later. Objective—The objective of this feasibility study was to test the Partners Together in Health (PaTH) Intervention versus usual care (UC) in improving physical activity and healthy eating behaviors in coronary artery bypass graft (CABG) surgery patients and spouses. Methods—An experimental, two-group (n = 17 couples/group), repeated measures design was used. CABG patients in both groups participated in Phase II outpatient CR. Spouses in the PaTH group attended CR with the patient and were asked to make the same physical activity and healthy eating changes as patients. Spouses in the control group attended educational classes with patients. It was theorized that “two persons would be better than one” at making changes and sticking with them long-term. Physical activity behavior was measured using the Actiheart accelerometer; the activity biomarker was an exercise tolerance test. Eating behavior was measured using 3-day food records; the biomarker was the lipid profile. Data were collected at baseline (entrance in CR), 3-months (post-CR), and 6-months. Changes over time were examined using Mann-Whitney U statistics and effect sizes. Results—The PaTH intervention was successful primarily in demonstrating improved trends in healthy eating behavior for patients and spouses. No differences were found between the PaTH and UC patients or spouses at 3 or 6 months in the number of minutes/week of physical activity. By 6 months, patients in both groups were, on average, below the national guidelines for PA recommendations (≥ 150 min/week at \u3e 3 METs). Conclusions—The couple-focused PaTH intervention demonstrated promise in offsetting the decline in dietary adherence typically seen 6 months after CR

Generalized and specific anxiety in adolescents following heart transplant

Mental health concerns are associated with worse outcomes after adult heart transplant. Illness‐specific anxiety is associated with worsened psychological well‐being after other solid organ transplants but has never been characterized after pediatric heart transplant. This single‐center cross‐sectional study aimed to evaluate illness‐specific and generalized anxiety after heart transplantation in adolescents. A novel 12‐item PHTF, GAD‐7, and the PedsQL were administered. Univariate associations of demographics, clinical features, and medication adherence as measured by immunosuppression standard deviation with the PHTF and GAD‐7 scores were evaluated. Internal consistency and validity of the PHTF were examined. In total, 30 patients participated. The most common illness‐specific fears were retransplantation, rejection, and more generally post‐transplant complications. The PHTF had good internal consistency (Cronbach α = .88). Construct validity was demonstrated between PHTF and GAD‐7 (r = .62) and PedsQL (r = −.54 to −.62). 23% endorsed moderate to severe generalized anxiety symptoms. More severe symptoms were associated with older age at survey (P = .03), older age at listing (P = .01) and having post‐transplant complications (P = .004). Patients with moderate or severe symptoms were more likely to report late immunosuppression doses (P = .004). Illness‐specific and generalized anxiety may be prevalent after pediatric heart transplant. Screening for anxiety in adolescents post‐transplant may identify those at risk for adverse outcomes including non‐adherence. The PHTF is a brief, valid, and reliable instrument identifying illness‐specific anxiety in this population.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/153669/1/petr13647.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/153669/2/petr13647_am.pd

Wealth Building in Rural America: Programs, Policies, Research

Wealth Building in Rural America: Programs, Policies, Researc

Efeito da adubação fosfatada em Pinus taeda L. em Latossolo Vermelho na região de Telêmaco Borba, Paraná, Brasil

Currently the Pinus taeda is the most important species used in forest plantation in the southern region of Brazil, serving as the basis for the timber production chain. The purpose of this study was to evaluate the effect of phosphorus addition to the soil in Pinus taeda plantation at two and seven year olds after planting in clay and sandy clay Red Oxisol in the region of Telêmaco Borba, Paraná. Two field experiments were carried out, one in clay soil and the other in sandy clay soil, in a randomized block design with four replications, in which treatments consisted of increasing doses of phosphorus (0, 50, 75 and 100 kg ha-1 P2O5). The doses of phosphorus were applied in the form of triple superphosphate (46% P2O5) in two lateral hole at 30 days after planting. The available soil phosphorus content was characterized as very low. At two and seven years, the diameter and total height of 20 plants per plot were measured, and volume was calculated by area. The results indicated that the use of phosphate fertilization promoted significant gains in the productivity of Pinus taeda up to seven years in sandy clay Red Oxisol, and the response was linear with maximum production for the dose of 100 kg ha-1 P2O5. For clay Red Oxisol there was no significant response to the use of phosphate fertilization until seven years of age.Atualmente o Pinus taeda é a espécie de maior importância utilizada em reflorestamentos na região Sul do Brasil servindo de base para a cadeia produtiva do setor madeireiro. O objetivo deste trabalho foi avaliar aos dois e sete anos de idade a resposta de Pinus taeda a adição de doses de fósforo logo após o plantio em Latossolo Vermelho de textura argilosa e média na região de Telêmaco Borba, Paraná. Foram instalados dois experimentos de campo, um no solo de textura argilosa e o outro em textura média, em delineamento de blocos ao acaso, com quatro repetições, no qual os tratamentos consistiram em doses crescentes de fósforo (0, 50, 75 e 100 kg ha-1 de P2O5). As doses de fósforo foram aplicadas na forma de superfosfato triplo (46% P2O5) em duas covetas laterais aos 30 dias após o plantio. O teor de fósforo disponível no solo foi caracterizado como muito baixo. Aos dois e sete anos foram medidos o diâmetro e altura total de 20 plantas por parcela, e o cálculo de volume por área. Os resultados indicaram que o uso de adubação fosfatada promoveu ganhos significativos na produtividade de Pinus taeda até sete anos de idade no Latossolo Vermelho de textura média, e a resposta se deu de forma linear com máxima produção para a dose de 100 kg ha-1 de P2O5. Para o Latossolo Vermelho de textura argilosa não houve resposta significativa ao uso de adubação fosfatada até os sete anos de idade

CD44 Plays a Functional Role in Helicobacter pylori-induced Epithelial Cell Proliferation

The cytotoxin-associated gene (Cag) pathogenicity island is a strain-specific constituent of Helicobacter pylori (H. pylori) that augments cancer risk. CagA translocates into the cytoplasm where it stimulates cell signaling through the interaction with tyrosine kinase c-Met receptor, leading cellular proliferation. Identified as a potential gastric stem cell marker, cluster-of-differentiation (CD) CD44 also acts as a co-receptor for c-Met, but whether it plays a functional role in H. pylori-induced epithelial proliferation is unknown. We tested the hypothesis that CD44 plays a functional role in H. pylori-induced epithelial cell proliferation. To assay changes in gastric epithelial cell proliferation in relation to the direct interaction with H. pylori, human- and mouse-derived gastric organoids were infected with the G27 H. pylori strain or a mutant G27 strain bearing cagA deletion (ΔCagA::cat). Epithelial proliferation was quantified by EdU immunostaining. Phosphorylation of c-Met was analyzed by immunoprecipitation followed by Western blot analysis for expression of CD44 and CagA. H. pylori infection of both mouse- and human-derived gastric organoids induced epithelial proliferation that correlated with c-Met phosphorylation. CagA and CD44 co-immunoprecipitated with phosphorylated c-Met. The formation of this complex did not occur in organoids infected with ΔCagA::cat. Epithelial proliferation in response to H. pylori infection was lost in infected organoids derived from CD44-deficient mouse stomachs. Human-derived fundic gastric organoids exhibited an induction in proliferation when infected with H. pylori, that was not seen in organoids pre-treated with a peptide inhibitor specific to CD44. In the wellestablished Mongolian gerbil model of gastric cancer, animals treated with CD44 peptide inhibitor Pep1, resulted in the inhibition of H. pylori-induced proliferation and associated atrophic gastritis. The current study reports a unique approach to study H. pylori interaction with the human gastric epithelium. Here, we show that CD44 plays a functional role in H. pyloriinduced epithelial cell proliferation