Communicating with patients about goals of care is an important skill for internal medicine residents. However, many trainees are not competent to perform a code status discussion (CSD). A multimodality intervention improved skills in a group of first-year residents in 2011. How long these acquired CSD skills are retained is unknown.
To study CSD skill retention one year after a multimodality intervention.
This was a longitudinal cohort study.
Thirty-eight second-year internal medicine residents in a university-affiliated internal medicine residency program participated in the study. Nineteen completed the intervention and 19 served as controls.
Mean CSD clinical skills examination (CSE) scores using an 18-item checklist were compared after the intervention (2011) and one year later (2012).
Intervention group residents performed significantly better than residents in the control group (71.9% (standard deviation [SD]=16.0%) versus 54.7% (SD=17.1%; p<0.001) at one-year follow-up. Intervention group residents retained their CSD skills at one year as performance was 75.1% in 2011 and 71.9% in 2012 (p=0.46). Control group residents did not develop additional CSD skills as 2011 checklist performance was 53.2% and 2012 performance was 54.7% (p=0.78).
CSD skills taught in a rigorous curriculum are retained at one-year follow-up. Residents in the control group did not acquire new CSD skills despite an additional year of training and clinical experience. Further study is needed to link improved CSD skills to better patient care quality.
Inpatient Code Status Discussions (CSDs) are commonly facilitated by resident physicians, despite inadequate training. We studied the efficacy of a CSD communication skills training intervention for internal medicine residents.
This was a prospective, randomized controlled trial of a multimodality communication skills educational intervention for postgraduate year (PGY) 1 residents. Intervention group residents completed a 2 hour teaching session with deliberate practice of communication skills, online modules, self-reflection, and a booster training session in addition to assigned clinical rotations. Control group residents completed clinical rotations alone. CSD skills of residents in both groups were assessed 2 months after the intervention using an 18 item behavioral checklist during a standardized patient encounter. Average scores for intervention and control group residents were calculated and between-group differences on the CSD skills assessment were evaluated using two-tailed independent sample t tests.
Intervention group residents displayed higher overall scores on the simulated CSD (75.1% versus 53.2%, p<0.0001) than control group residents. The intervention group also displayed a greater number of key CSD communication behaviors and facilitated significantly longer conversations. The training, evaluation, and feedback sessions were rated highly.
A focused, multimodality curriculum can improve resident performance of simulated CSDs. Skill improvement lasted for at least 2 months after the intervention. Further studies are needed to assess skill retention and to set minimum performance standards.
Screening for EGFR mutation is a key molecular test for management of lung cancer patients. Outcome of patients with mutation receiving EGFR tyrosine kinase inhibitor is known to be better across different ethnic populations. However, frequency of EGFR mutations and the clinical response in most other ethnic populations, including India, remains to be explored. We conducted a retrospective analysis of Indian lung cancer patients who were managed with oral tyrosine kinase inhibitors. Majority of the patients in the study had adenocarcinoma and were non-smokers. 39/111 patients tested positive for EGFR kinase domain mutations determined by Taqman based real time PCR. The overall response to oral TKI therapy was 30%. Patients with an activating mutation of EGFR had a response rate of 74%, while the response rate in patients with wild type EGFR was 5%, which was a statistically significant difference. Progression free survival of patients with EGFR mutations was 10 months compared to 2 months for EGFR mutation negative patients. Overall survival was 19 months for EGFR mutation patients and 13 months for mutation negative patients. This study emphasizes EGFR mutation as an important predictive marker for response to oral tyrosine kinase inhibitors in the Indian population.
Although end-of-life care preferences vary across racial/ethnic groups, little is known about how cultural values affect end-of-life care preferences among South Asian immigrants and their offspring in the US.
To examine the perspectives of first- and second-generation South Asians living in the US regarding end-of-life care.
Focus group study. Discussions explored participant preferences and experiences with family members facing the end of life.
Twelve first-generation and 11 second-generation self-identified Asian Indians living in the mid-Atlantic region.
Content analysis of focus group transcripts.
First-generation participants ranged in age from 41 to 76 years and were evenly split by gender. Second-generation participants ranged in age from 23 to 36 years and included seven women and four men. All participants were highly educated, and two thirds were either studying or working in a health care field. All but two subjects were Hindu. Several themes emerged that highlighted cultural differences and challenges for this population in the context of end-of-life care: attitudes toward death and suffering; family duty; and preferences for information disclosure and decision making. Participants described cultural challenges due to the evolution of traditional roles, lack of explicit discussion between patients and family members about preferences and care expectations, and a tension between wanting to meet traditional expectations and the challenges in doing so given US social realities.
Traditional cultural values, such as duty to family, greatly influenced end-of-life care preferences and retained importance across generations. Clinicians caring for Asian Indian patients at the end of life may be better able to assess care preferences after exploring the complex interplay between traditional expectations and specific social realities for each patient. Particular attention should be given to attitudes toward death and suffering, family duty, and preferences for information disclosure and decision making.
cultural differences; end-of-life care; advance directives; immigrant health; qualitative research
Gram-negative bacteria cause approximately 70% of the infections in intensive care units. A growing number of bacterial isolates responsible for these infections are resistant to currently available antibiotics and to many in development. Most agents under development are modifications of existing drug classes, which only partially overcome existing resistance mechanisms. Therefore, new classes of Gram-negative antibacterials with truly novel modes of action are needed to circumvent these existing resistance mechanisms. We have previously identified a new a way to inhibit an aminoacyl-tRNA synthetase, leucyl-tRNA synthetase (LeuRS), in fungi via the oxaborole tRNA trapping (OBORT) mechanism. Herein, we show how we have modified the OBORT mechanism using a structure-guided approach to develop a new boron-based antibiotic class, the aminomethylbenzoxaboroles, which inhibit bacterial leucyl-tRNA synthetase and have activity against Gram-negative bacteria by largely evading the main efflux mechanisms in Escherichia coli and Pseudomonas aeruginosa. The lead analogue, AN3365, is active against Gram-negative bacteria, including Enterobacteriaceae bearing NDM-1 and KPC carbapenemases, as well as P. aeruginosa. This novel boron-based antibacterial, AN3365, has good mouse pharmacokinetics and was efficacious against E. coli and P. aeruginosa in murine thigh infection models, which suggest that this novel class of antibacterials has the potential to address this unmet medical need.
Hair pigmentation is one of the most conspicuous phenotypes in humans ranging from black, brown, and blonde to red. Premature graying of hair occurs more commonly without any underlying pathology but is said to be inherited in autosomal dominant pattern. Premature graying has been shown to be associated with a few of the autoimmune disorders. A role for environmental factors and nutritional deficiencies has also been postulated. However, to date the exact etiology of premature graying has not been established.
The objective of our study was to conduct an epidemiological and investigative study of premature graying of hair in higher secondary and pre-university school children of the semi-urban area.
Materials and Methods:
A total of 35 cases and controls were investigated for various parameter such as Hemoglobin, total iron binding capacity, serum ferritin (S. Ferritin), serum calcium (S. Ca), serum iron (S. Iron), vitamin B12, and vitamin D3 after taking informed consent. Epidemiological and investigations correlation was established using the Chi-square and Mann Whitney test and P < 0.05 values were considered significant.
Among the various laboratory parameters S. Ca, S. Ferritin and vitamin D3 were low in patients with premature graying of hair. There was significant high number of vitamin D3 deficient and insufficient among the cases compared to the controls.
According to our study S. Ca, S. Ferritin, vitamin D3 may play a role in premature graying of hair in our society.
Calcium; ferritin; premature graying of hair; vitamin D3
Total population of cellulose degrading bacteria was studied in a landfill ecosystem as a part of microbial diversity study. Samples were obtained from 3 and 5 feet depth of a local landfill being operated for past 10 years. Among many isolates, 22 bacterial strains were selected based on their capability to decompose carboxymethyl cellulose (CMC). These isolates were cultivated on agar medium with CMC as the carbon source. All isolates were Gram positive, endospore forming and alkalophilic bacteria with optimum growth pH 9–10. They were grouped based on the phenotypic and chemotaxonomic characters and representative strains of different groups along with high carboxymethyl cellulase (CMCase) producing strains were included for further characterization. Analysis of 16S rRNA gene indicated that these strains belong to different species of the genus Bacillus. Maximum CMCase activity of 4.8 U/ml at 50°C was obtained by strain LFC15. Results in the present study indicated the potential of waste land ecosystems such as landfill are potential source for isolation of industrially important microorganisms.
Landfill ecosystem; Bacillus; CMCase; 16S rRNA gene phylogeny
Surrogate accuracy in predicting patient treatment preferences (i.e., what patients want) has been studied extensively, but it is not known whether surrogates can predict how patients want loved ones to make end-of-life decisions on their behalf.
To evaluate the ability of family members to correctly identify the preferences of seriously-ill patients regarding family involvement in decision making.
Twenty-five pancreatic cancer and 27 amyotrophic lateral sclerosis (ALS) patients and their family members (52 dyads total).
Patients and family members completed the Decision Control Preferences (DCP) scale regarding patient preferences for family involvement in health care decisions using conscious and unconscious scenarios.
Patient and family member agreement was 56% (29/52 dyads) for the conscious scenario (kappa 0.29) and 46% (24/52 dyads) for the unconscious scenario (kappa 0.15). Twenty-four family members identified the patient’s preference as independent in the unconscious scenario, but six of these patients actually preferred shared decision making and six preferred reliant decision making. In the conscious scenario, preference for independent decision making was associated with higher odds of patient–family agreement (AOR 5.28, 1.07–26.06). In the unconscious scenario, cancer patients had a higher odds of agreement than ALS patients (AOR 3.86; 95% CI 1.02–14.54).
Family members were often unable to correctly identify patient preferences for family involvement in end-of-life decision making, especially when patients desired that decisions be made using the best-interest standard. Clinicians and family members should consider explicitly eliciting patient preferences for family involvement in decision making. Additional research is still needed to identify interventions to improve family member understanding of patient preferences regarding the decision-making process itself.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1717-6) contains supplementary material, which is available to authorized users.
decision making; patient preference; advance care planning; terminal care
While the Internet has the potential to educate persons living with HIV/AIDS (PLWHA), websites may contain inaccurate information and increase the risk of nonadherence with antiretroviral therapy (ART). The objectives of our study were to determine the extent to which PLWHA engage in Internet health information seeking behavior (IHISB) and to determine whether IHISB is associated with ART adherence. We conducted a survey of adult, English-speaking HIV-infected patients at four HIV outpatient clinic sites in the United States (Baltimore, Maryland; Detroit, Michigan; New York, and Portland, Oregon) between December 2004 and January 2006. We assessed IHISB by asking participants how much information they had received from the Internet since acquiring HIV. The main outcome was patient-reported ART adherence over the past three days. Data were available on IHISB for 433 patients, 334 of whom were on ART therapy. Patients had a mean age of 45 (standard error [SE] 0.45) years and were mostly male (66%), African American (58%), and had attained a high school degree (73%). Most (55%) reported no IHISB, 18% reported some, and 27% reported “a fair amount” or “a great deal.” Patients who reported higher versus lower levels of IHISB were significantly younger, had achieved a higher level of education, and had higher medication self-efficacy. In unadjusted analyses, higher IHISB was associated with ART adherence (odds ratio [OR], 2.96, 95% confidence interval [CI] 1.27–6.94). This association persisted after adjustment for age, gender, race, education, clinic site, and medication self-efficacy (adjusted odds ratio [AOR] 2.76, 95% CI 1.11–6.87). Our findings indicate that IHISB is positively associated with ART adherence even after controlling for potentially confounding variables. Future studies should investigate the ways in which Internet health information may promote medication adherence among PLWHA.
The clinical audit of vitamin D health promotion in one Australian general practice was undertaken by measuring health service use and serum 25-hydroxyvitamin D levels in 995 patients aged 45 to 49 years.
Over 3 years, 486 (51%) patients had a Medicare funded Health Assessment. More women (54%) were assessed than men (46%) p = 0.010. Mean 25-OHD was higher for men (70.0 nmol/l) than women (60.3 nmol/l) p < 0.001. More patients had their weight measured (50%) than 25-OHD tested (28%).
Among 266 patients who had a 25-OHD test, 68 (26%) had normal levels 80+ nmol/l, 109 (41%) were borderline 51-79 nmol/l, and 89 (33%) were low < 51 nmol/l. Mean 25-OHD was higher in summer (73.7 nmol/l) than winter (54.7 nmol/l) p < 0.001. Sending uninvited written information about 25-OHD had no effect on patients' subsequent attendance.
Health promotion information about vitamin D was provided to 50% of a targeted group of patients over a one-year period. Provision of this information had no effect on the uptake rates of an invitation to attend for a general health assessment.
Vitamin D; Health promotion; General practice; Clinical audit
Improved antiretroviral treatment (ART) access reduces AIDS mortality and lowers HIV incidence by reducing the viral load at the individual/community level.
To find out the epidemiological profile of the patients at ART Centre of Civil Hospital, Ahmadabad. Settings and Design: Centre-based cross-sectional study.
Materials and Methods:
132 AIDS patients (on ART) during Jan–Aug, 2009.
Statistical analysis used:
Proportions and Chi-square test.
Out of 132 cases, 60% were males, 70% from 15–44 years of age, 80% married, 78% literate, and 43% were gainfully employed. Sexual route accounted for infection in 63% cases while in 22% cases mode of transmission could not be elicited. Less common routes were injecting drug use (9%) and blood transfusion (6%). Heterosexual route was more common (70%) among migrants than the locals (50%). Half of them were diagnosed by VCTC. Thirteen clients did not receive pre-test counseling; 9 (6.6%) did not inform their spouse. Proportion of discordant couple was 42%.
Comparing these determinants of patients on ART with those detected at ICTC can help in identifying the characteristics helpful in sending people to ART centers and bridging the gap between those detected at ICTC and those who reach at ART centers.
Antiretroviral treatment; HIV/AIDS; modes of transmission; sociodemographic determinants
Allergy to fungi has been linked to a wide range of illnesses, including rhinitis and asthma. Therefore, exposure to fungi in home environment is an important factor for fungal allergy. The present study was aimed to investigate types of airborne fungi inside and outside the homes of asthmatic children and control subjects (nonasthmatic children). The dominant fungi were evaluated for their quantitative distribution and seasonal variation. The air samples were collected from indoors and immediate outdoors of 77 selected homes of children suffering from bronchial asthma/allergic rhinitis using Andersen volumetric air sampler. The isolated fungal genera/species were identified using reference literature, and statistical analysis of the dominant fungi was performed to study the difference in fungal concentration between indoor and immediate outdoor sites as well as in between different seasons. A total of 4423 air samples were collected from two indoor and immediate outdoor sites in a 1-year survey of 77 homes. This resulted in the isolation of an average of 110,091 and 107,070 fungal colonies per metric cube of air from indoor and outdoor sites, respectively. A total of 68 different molds were identified. Different species of Aspergillus, Alternaria, Cladosporium, and Penicillium were found to be the most prevalent fungi in Delhi homes, which constituted 88.6% of the total colonies indoors. Highest concentration was registered in autumn and winter months. Total as well as dominant fungi displayed statistically significant differences among the four seasons (p < 0.001). The largest number of isolations were the species of Aspergillus (>40% to total colony-forming units in indoors as well as outdoors) followed by Cladosporium spp. Annual concentration of Aspergillus spp. was significantly higher (p < 0.05) inside the homes when compared with outdoors. Most of the fungi also occurred at a significantly higher (p < 0.001) rate inside the homes when compared with immediate outdoors. Asthmatic children in Delhi are exposed to a substantial concentration of mold inside their homes as well as immediate outdoor air. The considerable seasonal distributions of fungi provide valuable data for investigation of the role of fungal exposure as a risk for respiratory disorders among patients suffering from allergy or asthma in Delhi.
Asthma; Delhi; indoor fungi; prevalence; respiratory allergy; seasonal variation
What is the immunization status of children in the slums of Surat and what changes has it undergone in recent times?
To assess the immunization status of children between the ages of 12 and 23 months in the slums of Surat and to compare it with the MICS from previous years.
This was a community-based cross-sectional study conducted in 15 clusters.
15 urban slums selected out of a total of 299 slums using the cluster sampling method.
The Multi Indicator Cluster Sampling (MICS) method was used for sample selection and the proforma designed by UNICEF was used as a study tool.
Simple proportions and a Chi-square test.
Only 25% of the children between the ages of 12 and 23 months were fully immunized; coverage was highest for BCG (75%) and lowest for measles (29.9%). As far as the dropout rate is concerned, it was 60.2%, 31.9%, and 31.5% for BCG to measles, DPT1 to DPT3, and OPV1 to OPV3, respectively. Vitamin A was taken by only 28.9% of the subjects. Between the two, female children were more disadvantaged in terms of vaccination. When compared with the coverage of 1997 and 1998, the current coverage is poor, more so in relation to DPT and OPV.
12-23 months; immunization status; MICS; slums
Human immunodeficiency virus (HIV) testing with pre and postcounseling aiming behavior change communication (BCC) for core/bridge population is the main element of holistic model of health care. Voluntary counseling and testing center (VCTC) remodeled as integrated counseling and testing center (ICTC)—general is the ‘gateways to care’. It was hospital-based cross sectional study of 811 clients registered at VCTC of Kesar SAL Hospital from January to December 2007. These patients either came voluntarily or by referral. Anonymous and unlinked information was collected on predesigned schedule and data was analyzed to find out the seropositivity, demographic characteristics (among attendees and HIV positives), and epidemiological vulnerability of different segments of population. Among the attendees, 64% were males, 75% in the age group of 20–49 years, 80% were currently married, and 70% were literate (< 10th standard). Also, 66% clients were gainfully employed, while one-fourth were housewives; 98% lived with families, 75% were referred by doctors, and only 19% walked in directly. Dominant reason for visiting ICTC was the history/presence of high risk behavior (HRB) (34%). 35% indulged in heterosexual route; other HRB (men having sex with men or MSM and injecting drug users or IDU) were rare. There were more positive among males, 20–49 years of age group, those living singly, unmarried, divorcee, widow(er) and separated. Similarly positives were more amongst illiterates, less educated and those engaged in unskilled and semi skilled jobs. Adolescent students (>14 years) accounted for one-fifth of the total positives. Direct walk in clients were more positive compared to those referred by doctors. Those who confessed of history/presence of HRB accounted for all except 3 (85%) positives. 51% indulged in heterosexual sex followed by MSM (8%). Overall sero positivity was 4.8%; high in males, 30–49 years age, unmarried and divorcee etc. Sero prevalence decreased with improvement in education and also with improvement in job nature. It was also high in those living alone compared to those staying with their family.
Such study shall in evaluating the performance of ICTC and designing the information, education, and communication (IEC) to increase the client uptake in terms of quality and quantity.
Integrated counseling testing center; voluntary counseling and testing attendees; HIV sero positivity; socio-demographic variables
Biological agents represent an important addition to the therapies for immuno-inflammatory conditions and have a great impact on the disease course and quality of life of these patients. However, recent reports of serious infections like tuberculosis, demyelinating and neurodegenerative diseases, pancytopenia, cardiovascular diseases, etc. after anti-TNF therapy raised questions on their safety. Hence, focus is shifted towards drugs targeting cytokine checkpoints in the inflammatory cascades beyond TNF-α. Existing therapeutic targets include the biological agents acting as antagonists of various inflammatory cytokines (Anakinra, Tocilizumab, Atlizumab) and modulators of CD80 or CD86-CD28 co-stimulatory signal (Abatacept), CD2 receptors on T-cells (Alefacept), CD11a, subunit of leukocyte function-associated antigen 1 (Efalizumab), vitronectin receptor and CD20 antigen on pre-B, immature and mature B cells (Rituximab). With the introduction of these novel molecules the future for immunomodulatory intervention in rheumatology, asthma, crohn's disease, septic shock etc. looks very promising. These novel therapeutic agents could truly give a new hope to the clinician to modify the disease and achieve tangible improvements in the lives of the patients.
Biological agents; cytokines; CD20 antigen; rheumatology; T-cells