scholarly journals Practicing safety: a quality improvement intervention to test tools to enhance pediatric psychosocial care for children 0–3 years

2017 ◽  
Vol 19 (04) ◽  
pp. 365-377 ◽  
Author(s):  
Diane J. Abatemarco ◽  
Ruth S. Gubernick ◽  
Marianna D. LaNoue ◽  
Ryan T. Pohlig ◽  
Sara R. Slovin ◽  
...  
Keyword(s):  
United States ◽  
At Risk ◽  
Quality Improvement ◽  
Child Maltreatment ◽  
Repeated Measures ◽  
Quantitative Methods ◽  
Psychosocial Care ◽  
The United States ◽  
Community Resources

BackgroundChild maltreatment is a significant public health issue in the United States. Yet, fewer than half of pediatricians discuss behavioral, developmental, or parenting issues with parents.ObjectiveThis paper describes the testing of bundles of tools and processes, part of a larger intervention, Practicing Safety, targeted at changing physician and staff behavior to identify families at risk for child maltreatment, provide anticipatory guidance, refer to community resources, and follow-up and track at-risk families. The intervention was implemented with 14 pediatric primary care practices throughout the United States; the study was completed in 2011.MethodsA within-subjects repeated measures pre-post follow-up design was used to evaluate the intervention. Baseline and repeated measurements of pediatric practices’ processes were collected using qualitative and quantitative methods. In total, 14 core improvement teams from across the country tested three bundles of tools (maternal, infant, toddler) within a quality improvement framework over seven months.ResultsQuantitative results showed statistically significant adoption of tools and processes and enhancement of practice behaviors and office environmental supports. The increase in tool use was immediate and was sustained for six months after implementation. Qualitative data provided insight as to how meaningful the intervention was to the core improvement teams, especially with more complicated behaviors (eg, engaging social workers or community agencies for referrals). Barriers included lack of community resources. Findings showed unanticipated outcomes such as helping practices to become medical homes.ConclusionLessons learned included that practices appreciate and can adopt brief interventions that have meaningful and useful tools and process to enhance psychosocial care for children 0–3 and that do not place a burden on pediatric practice. An innovative, quality improvement strategy, intuitive to pediatricians, with a brief intervention may help prevent child maltreatment.

Breast Cancer in Women with Cystic Disease of the Breast

1965 ◽  
Vol 51 (4) ◽  
pp. 227-236
Author(s):  
Umberto Veronesi ◽  
Giorgio Pizzocaro ◽  
Aldo Vittorio Bono
Keyword(s):  
Breast Cancer ◽  
United States ◽  
At Risk ◽  
National Cancer Institute ◽  
Metropolitan Areas ◽  
The United States ◽  
Contralateral Breast ◽  
Cystic Disease

From 1937 to 1960, 1051 women with cystic disease of the breast were hospitalized at the National Cancer Institute of Milan; 1008 of them were followed for a period ranging from 1 to 26 years, with an average of 8.5 years. All cases were histologically proved. Twenty-one of the patients developed a cancer of the breast; 16 in the breast with the cystic disease, 5 in the contralateral breast. In 667 cases the disease was histologically classified as «simple cystic disease »; 12 of these cases had a breast cancer. In 384 cases the disease was classififed as «hyperplastic cystic disease»; 9 of these developed a cancer of the breast. The follow-up of the 1008 cases provided 8539 person-years at risk; the number of the expected breast cases was calculated on the basis of the Dorn and Cutler data on morbidity of cancer in 10 metropolitan areas of the United States. The number of expected breast cancer was 12.2; the number of observed cases was 21, the ratio between observed and expected cases being 1.71.

scholarly journals Anthropometric Traits and Risk of Non-Hodgkin Lymphoma (NHL) and Major NHL Subtypes: A Pooled Prospective Analysis

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 2972-2972
Author(s):  
Brenda M Birmann ◽  
Ke Wang ◽  
Kimberly A Bertrand ◽  
Chun R Chao ◽  
Emily L. Deubler ◽  
...  
Keyword(s):  
United States ◽  
Risk Factors ◽  
Young Adult ◽  
Waist Circumference ◽  
Repeated Measures ◽  
B Cell Lymphoma ◽  
The United States ◽  
Prospective Analysis ◽  
Incident Cases

Abstract Background: Collectively, non-Hodgkin lymphomas (NHL) are expected to account for >95,000 new cancer diagnoses and >24,000 cancer deaths in the United States in 2018. Few NHL risk factors are known other than severe immune compromise, family history of lymphoid malignancies, and some pathogens. Evidence for modifiable risk factors that could inform prevention strategies is limited, especially from prospective studies. An association of anthropometric traits with NHL risk is biologically plausible given the emerging knowledge that obese individuals have heightened inflammation and deregulation of endogenous hormonal pathways that can influence cell cycle control and lymphocyte activation. We undertook the present prospective study to elucidate the associations of young (aged 18-21 years) and usual adult body mass index (BMI), height, weight, and waist circumference with risk of NHL and major histologic subtypes of NHL. The completed analysis will leverage the resources of several large population samples across the United States with prospectively assessed repeated measures of anthropometric traits and high rates of follow-up for disease ascertainment. Methods: We pooled data from large prospective cohort studies with repeated measures of anthropometric traits and follow-up over 23 - 38 years for cancer endpoints, including the Cancer Prevention Study-II (CPS-II) Nutrition Cohort, Health Professionals Follow-up Study (HPFS), Nurses' Health Study (NHS), and NHS II. Incident NHL diagnoses were confirmed by review of medical records or cancer registries, and classified for histologic subtype according to the WHO classification scheme and corresponding InterLymph-recommended analytic groups: chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), and T-cell NHL (T-NHL). Weight was ascertained approximately every two years throughout follow-up, all other anthropometric measures were ascertained on a single survey, usually at baseline. We considered cumulative average of BMI (hereafter "usual adult BMI") by averaging across all completed cohort-specific questionnaires. Current weight was analyzed as time-varying. In cohort- and sex-specific analyses, there was no evidence of statistically significant heterogeneity; thus we pooled directly across cohorts to maximize our sample size for statistical modeling. Cox proportional hazard regression models adjusted for age, cohort, and sex were used to estimate hazard ratios (HR) and 95% confidence intervals (CIs) for each trait's association with NHL or NHL subtype risk. Results: The pooled sample comprised 5,005 confirmed incident cases of NHL, including 1117 CLL/SLL, 918 DLBCL, 709 FL and 277 T-NHLs ascertained over 9.4 million person-years of follow-up. There was a significant, positive association of usual adult BMI with NHL overall (HR: 1.05, 95% CI: 1.01-1.08 per 5 kg/m2; Table 1), which was driven by DLBCL (HR: 1.21, 95% CI: 1.12-1.30 per 5 kg/m2). No association was apparent for FL, CLL/SLL or T-NHL. Similarly, waist circumference was associated with NHL risk overall (HR: 1.04, 95% CI: 1.00-1.09 per 15cm), but driven by the association for DLBCL (HR: 1.16, 95% CI: 1.05-1.27 per 15cm). In contrast, a statistically significant or suggestive association for BMI in young adulthood was observed for all NHL endpoints, but again, most strongly with DLBCL (HR: 1.28, 95% CI: 1.15-1.43 per 5 kg/m2). Height was positively associated with all NHL endpoints except T-NHL. Associations for current and young adult weight were similar to those for the corresponding BMI variables. Conclusions: Preliminary results from this prospective analysis suggest that, unlike BMI later in life, young adult BMI is consistently associated with all major subtypes of NHL. In contrast, usual adult BMI and waist circumference are uniquely associated with DLBCL. In general, the strongest associations with anthropometric factors were observed for DLBCL. Further analyses of these data are ongoing, including efforts to incorporate data from two additional large cohorts. These findings further demonstrate the etiologic heterogeneity of NHL subtypes and underscore the importance of maintaining a healthy body weight throughout life, including at younger ages. Disclosures Chao: Seattle Genetics: Research Funding.

scholarly journals All-Cause and Inhibitor-Related Mortality in Non-Severe Hemophilia Α Patients in the United States

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 902-902 ◽  
Author(s):  
Ming Y. Lim ◽  
Dunlei Cheng ◽  
Christine L. Kempton ◽  
Nigel S. Key
Keyword(s):  
United States ◽  
At Risk ◽  
Mortality Rate ◽  
Hemophilia A ◽  
The United States ◽  
Severe Hemophilia ◽  
All Cause Mortality ◽  
Related Mortality ◽  
Observation Period

Introduction: The majority of published studies evaluating inhibitors have focused mainly on patients with severe hemophilia A. In non-severe hemophilia A (NSHA) patients, the development of inhibitors can have a profound clinical impact, with major bleeding complications similar to that of patients with severe or acquired hemophilia. Yet, epidemiological data on inhibitors in NSHA patients, specifically mortality, is scarce and currently limited to the European and Australian cohort [Eckhardt CL, et al. J Thromb Haemost. 2015 Jul;13(7):1217-251]. Objectives: To determine the all-cause and inhibitor-related mortality in NSHA patients in the United States using the ATHNdataset Methods: Subjects and study design The ATHNdataset is a 'limited dataset' as defined under the United States Health Insurance Portability and Accountability Act (HIPAA) to be free of protected health information, with data collection by more than 130 hemophilia treatment centers (HTC) across the United States. It includes patients with congenital bleeding disorders in the United States who have authorized the sharing of their demographic and clinical information for research. Data collection and definitions The ATHNdataset was queried on December 31, 2018 to extract the following information on NSHA patients: Patient demographics, inhibitor status, date of death, and primary cause of death. The presence of inhibitors was defined as: (i) ≥ 2 positive Bethesda inhibitor assay titers of ≥ 1.0 BU/mL; or (ii) a decrease in plasma FVIII coagulant activity (FVIII:C) to at least 50% of baseline activity and/or spontaneous bleeding symptoms in patients with inhibitor titers between 0.6 and 1.0 BU/mL. Patients who had a negative inhibitor history or have never been tested for FVIII inhibitors were classified as negative for inhibitors. Statistical analyses The person-year mortality rate was calculated as the ratio of the number of deaths to the number of person-years at risk, presented as rates per 1000 person-years. Person-years at risk was calculated for each patient as the time between the start of the observation period (January 1, 2010 or date of birth for patients who are born later) and the end of the observation period (date of death, loss-to follow-up or December 31, 2018). Patients who were deceased or lost to follow-up before January 1, 2010 were not included in the analysis. Inhibitor person-years at risk for inhibitor patients was calculated from January 1, 2010 if the first positive inhibitor test occurred prior to January 1, 2010 or from the date of the first positive inhibitor test that occurred during the observation period until the end of the observation period. Inhibitor-related death was attributed to all patients who had a positive inhibitor history. Mortality rates were compared between inhibitor and non-inhibitor patients using z- test. Results: Between 1/1/2010 and 12/31/2018, the ATHNdataset included 6,606 NSHA patients who were born between 1920 and 2018. Patients were observed for a total of 56,064 person-years. 85.57% (n = 5,653) of these patients were observed for the full nine years. The average follow-up time per patient was almost 8.5 years. Inhibitors developed in 171 (2.59%) NSHA patients. The median age for inhibitor development was 13 years (IQR, 6 - 37 years) and the mean age was 22 years. Demographics characteristics of the patients are listed in Table 1. All-cause mortality At the end of follow-up, there was a total of 136 deaths in the NSHA population, occurring at a median age of 63 years (IQR, 51 - 75 years). The overall all-cause mortality rate was 2.43 per 1,000 person-years (95% CI: 2.02 - 2.83). The most common primary cause of death was cancer (n=27, 19.9%) (Table 2). Inhibitor-related mortality Three deaths were associated with inhibitors. Inhibitor-related mortality rate was 2.40 per 1,000 person-years, whereas among the never inhibitor group, the mortality rate was 2.44 per 1,000 person-years (p = 0.790). Mortality risk ratio between inhibitor and never inhibitor was 0.98 (95% CI: 0.31 - 3.08). Conclusion: In NSHA patients, the development of inhibitors occurred at a relatively early age and was not associated with increased mortality. Disclosures Kempton: Novo Nordisk: Research Funding; Octapharma: Honoraria; Genentech: Honoraria; Spark Therapeutics: Honoraria. Key:Uniqure BV: Research Funding.

scholarly journals Natural History and Evolution of Anti-Interferon-γ Autoantibody-Associated Immunodeficiency Syndrome in Thailand and the United States

2019 ◽  
Vol 71 (1) ◽  
pp. 53-62 ◽  
Author(s):  
Gloria H Hong ◽  
Ana M Ortega-Villa ◽  
Sally Hunsberger ◽  
Ploenchan Chetchotisakd ◽  
Siriluck Anunnatsiri ◽  
...  
Keyword(s):  
United States ◽  
Natural History ◽  
The United States ◽  
Interferon Γ ◽  
Mycobacterium Abscessus ◽  
Annual Data ◽  
Persistent Infections ◽  
Ifn Γ ◽  
Immunodeficiency Syndrome

Abstract Background The natural history of anti-interferon-γ (IFN-γ) autoantibody-associated immunodeficiency syndrome is not well understood. Methods Data of 74 patients with anti-IFN-γ autoantibodies at Srinagarind Hospital, Thailand, were collected annually (median follow-up duration, 7.5 years). Annual data for 19 patients and initial data for 4 patients with anti-IFN-γ autoantibodies at the US National Institutes of Health were collected (median follow-up duration, 4.5 years). Anti-IFN-γ autoantibody levels were measured in plasma samples. Results Ninety-one percent of US patients were of Southeast Asian descent; there was a stronger female predominance (91%) in US than Thai (64%) patients. Mycobacterium abscessus (34%) and Mycobacterium avium complex (83%) were the most common nontuberculous mycobacteria in Thailand and the United States, respectively. Skin infections were more common in Thailand (P = .001), whereas bone (P < .0001), lung (P = .002), and central nervous system (P = .03) infections were more common in the United States. Twenty-four percent of Thai patients died, most from infections. None of the 19 US patients with follow-up data died. Anti-IFN-γ autoantibody levels decreased over time in Thailand (P < .001) and the United States (P = .017), with either cyclophosphamide (P = .01) or rituximab therapy (P = .001). Conclusions Patients with anti-IFN-γ autoantibodies in Thailand and the United States had distinct demographic and clinical features. While titers generally decreased with time, anti-IFN-γ autoantibody disease had a chronic clinical course with persistent infections and death. Close long-term surveillance for new infections is recommended.

scholarly journals Co-Designing and Evaluating a Self-Care Curriculum of an App for Chinese Immigrant Caregivers

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 507-508
Author(s):  
Ying Wang ◽  
Mandong Liu ◽  
Iris Chi
Keyword(s):  
Mental Health ◽  
United States ◽  
Physical Health ◽  
Self Care ◽  
The United States ◽  
The Self ◽  
Community Resources ◽  
Chinese Immigrant ◽  
Knowledge And Skills ◽  
Support Resources

Abstract Chinese immigrant caregivers face unique self-care difficulties in the United States due to language barriers, cultural isolation, and occupational stress. This study aimed to conduct a formative evaluation on a caregiver self-care curriculum of an app designed for Chinese immigrants in the United States. Using a co-design approach in 2019, 22 Chinese immigrant caregivers in Los Angeles county were recruited through purposive sampling method. The directed content analysis was adopted to analyze the qualitative data using NVivo 12.1.0 software. We organized the findings under two main contents: self-care and caregiving. Three categories were identified under the self-care content: physical health, emotional and mental health, and support resources. Sixteen subcategories under physical health (e.g., dietary supplements), five subcategories under emotional and mental health (e.g., depression) and eight subcategories under support resources (e.g., support and networking group, senior center) are suggested. Two categories were identified under the caregiving content: caregiving knowledge and skills, and community resources. Fourteen subcategories under caregiving knowledge and skills (e.g., care assessment) and six subcategories under community resources (e.g., medical emergency call) were mentioned. With this useful information, we could further refine the self-care curriculum to be more linguistically, culturally and occupationally sensitive for Chinese immigrant caregivers. Empowerment approach for enhancing the ability to caregiving and self-care should be emphasized in content design for immigrant caregivers. The co-design approach is crucial for planning of the program and intervention curriculum to improve understanding of the users’ needs and better cater them.

scholarly journals SAT0172 UTILIZATION OF HYDROXYCHLOROQUINE AND CORTICOSTEROIDS AMONG LUPUS PATIENTS WITH INCIDENT END-STAGE RENAL DISEASE (ESRD) ONSET: A LONGITUDINAL STUDY USING USRDS REGISTRY

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1027.2-1027
Author(s):  
A. R. Broder ◽  
W. Mowrey ◽  
A. Valle ◽  
B. Goilav ◽  
K. Yoshida ◽  
...  
Keyword(s):  
United States ◽  
Lupus Nephritis ◽  
Renal Disease ◽  
International Classification Of Diseases ◽  
The United States ◽  
Diagnostic Code ◽  
Prescribing Practices ◽  
Part D ◽  
Stage Renal Disease

Background:The development of ESRD due to lupus nephritis is one of the most common and serious complications of SLE. Mortality among SLE ESRD patients is 4-fold higher compared to lupus nephritis patients with preserved renal function1Mortality in SLE ESRD is also twice as high compared with non-SLE ESRD, even though SLE patients develop ESRD at a significantly younger age. In the absence of ESRD specific guidelines, medication utilization in SLE ESRD is unknown.Objectives:The objective of this study was to investigate the real-world current US-wide patterns of medication prescribing among lupus nephritis patients with new onset ESRD enrolled in the United States Renal Disease Systems (USRDS) registry. We specifically focused on HCQ and corticosteroids (CS) as the most used medications to treat SLE.Methods:Inclusion: USRDS patients 18 years and above with SLE as a primary cause of ESRD (International Classification of Diseases, 9thRevision (ICD9) diagnostic code 710.0, previously validated2). who developed ESRD between January 1st, 2006 and July 31, 2011 (to ensure at least 6 months of follow-up in the USRDS). Patients had to be enrolled in Medicare Part D (to capture pharmacy claims). The last follow-up date was defined as either the last date of continuous part D coverage or the end of the study period, Dec 31, 2013.Results:Of the 2579 patients included, 1708 (66%) were HCQ- at baseline, and 871 (34%) were HCQ+ at baseline. HCQ+ patients at baseline had a slightly lower duration of follow-up compared to HCQ- patients at baseline, median (IQR) of 2.32 (1.33, 3.97) years and 2.55 (1.44, 4.25) years, respectively, p= 0.02. During follow-up period, only 778 (30%) continued HCQ either intermittently or continuously to the last follow-up date, 1306 (51%) were never prescribed HCQ after baseline, and 495 (19%) discontinued HCQ before the last follow-up date. Of the 1801 patients who were either never prescribed or discontinued HCQ early after ESRD onset, 713 (40%) were prescribed CS to the end of the follow-up period: 55% were receiving a low dose <10mg/daily, and 43 were receiving moderate dose (10-20mg daily)Conclusion:HCQ may be underprescribed and CS may be overprescribed in SLE ESRD. Changing the current prescribing practices may improve outcomes in SLE ESRDReferences:[1]Yap DY et al., NDT 2012.[2]Broder A et al., AC&R 2016.Acknowledgments :The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S. government.Funding: :NIH/NIAMS K23 AR068441 (A Broder), NIH/NIAMS R01 AR 057327 and K24 AR 066109 (KH Costenbader)Disclosure of Interests: :Anna R. Broder: None declared, Wenzhu Mowrey: None declared, Anna Valle: None declared, Beatrice Goilav: None declared, Kazuki Yoshida: None declared, Karen Costenbader Grant/research support from: Merck, Consultant of: Astra-Zeneca

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