1
|
Lee-Riddle GS, Schmidt HJ, Reese PP, Nelson MN, Neergaard R, Barg FK, Serper M. Transplant recipient, care partner, and clinician perceptions of medication adherence monitoring technology: A mixed methods study. Am J Transplant 2024; 24:669-680. [PMID: 37923085 DOI: 10.1016/j.ajt.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
Medication nonadherence is a leading cause of graft loss. Adherence monitoring technologies-reminder texts, smart bottles, video-observed ingestion, and digestion-activated signaling pills-may support adherence. However, patient, care partner, and clinician perceptions of these tools are not well studied. We conducted qualitative individual semistructured interviews and focus groups among 97 participants at a single center: kidney and liver transplant recipients 2 weeks to 18 months posttransplant, their care partners, and transplant clinicians. We assessed adherence practices, reactions to monitoring technologies, and opportunities for care integration. One-size-fits-all approaches were deemed infeasible. Interviewees considered text messages the most acceptable approach; live video checks were the least acceptable and raised the most concerns for inconvenience and invasiveness. Digestion-activated signaling technology produced both excitement and apprehension. Patients and care partners generally aligned in perceptions of adherence monitoring integration into clinical care. Key themes were importance of routine, ease of use, leveraging technology for actionable medication changes, and aversion to surveillance. Transplant clinicians similarly considered text messages most acceptable and video checks least acceptable. Clinicians reported that early posttransplant use and real-time adherence tracking with patient feedback may facilitate successful implementation. The study provides initial insights that may inform future adherence technology implementation.
Collapse
Affiliation(s)
- Grace S Lee-Riddle
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Harald J Schmidt
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria N Nelson
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca Neergaard
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frances K Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
2
|
Chaiyachati KH, Shea JA, Ward M, Nelson MN, Ghosh M, Reilly J, Kelly S, Chisholm DL, Barbati Z, Hemmons JE, Abdel-Rahman D, Ebert JP, Xiong RA, Snider CK, Lee KC, Friedman AB, Meisel ZF, Kilaru AS, Asch DA, Delgado MK, Morgan AU. Patient and clinician perspectives of a remote monitoring program for COVID-19 and lessons for future programs. BMC Health Serv Res 2023; 23:698. [PMID: 37370059 PMCID: PMC10304230 DOI: 10.1186/s12913-023-09684-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
COVID Watch is a remote patient monitoring program implemented during the pandemic to support home dwelling patients with COVID-19. The program conferred a large survival advantage. We conducted semi-structured interviews of 85 patients and clinicians using COVID Watch to understand how to design such programs even better. Patients and clinicians found COVID Watch to be comforting and beneficial, but both groups desired more clarity about the purpose and timing of enrollment and alternatives to text-messages to adapt to patients' preferences as these may have limited engagement and enrollment among marginalized patient populations. Because inclusiveness and equity are important elements of programmatic success, future programs will need flexible and multi-channel human-to-human communication pathways for complex clinical interactions or for patients who do not desire tech-first approaches.
Collapse
Affiliation(s)
- Krisda H Chaiyachati
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA.
| | - Judy A Shea
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Michaela Ward
- Mixed Methods Research Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Maria N Nelson
- Mixed Methods Research Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Medha Ghosh
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julianne Reilly
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sheila Kelly
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Deena L Chisholm
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Zoe Barbati
- Mixed Methods Research Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jessica E Hemmons
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dina Abdel-Rahman
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey P Ebert
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ruiying A Xiong
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- The Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher K Snider
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Kathleen C Lee
- Comcast NBCUniversal in Philadelphia, PA, Philadelphia, USA
| | - Ari B Friedman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- The Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Zachary F Meisel
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Austin S Kilaru
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA
- The Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - M Kit Delgado
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- The Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna U Morgan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA
| |
Collapse
|
3
|
Nelson MN, Akpek E, Margolis DJ, Barg FK, Vittorio CC. A mixed methods study on factors that promote and ameliorate burnout in academic dermatologists. Arch Dermatol Res 2023; 315:859-868. [PMID: 36352151 PMCID: PMC9645749 DOI: 10.1007/s00403-022-02441-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/20/2022] [Indexed: 11/10/2022]
Abstract
The burnout literature is replete with burnout score results from quantitative surveys. There is a paucity of qualitative research that seeks to understand the impact of physician stressors on work-life balance and burnout. This study aimed to identify factors that support and disrupt work-life balance, drivers of burnout, and potential solutions among academic dermatologists. The objective was to better understand factors that promote wellness and ameliorate burnout. Concurrent explanatory mixed methods consisted of scores on the Abbreviated Maslach Burnout Inventory and open-ended semi-structured telephone interviews. The results were that positive factors, such as supportive home life and satisfaction derived from academic endeavors, compete with ongoing feelings of exhaustion, frustration, and apathy. Negative stressors include the electronic medical record, insufficient staffing, administrative and clinical task burden, and perceived lack of interest from mid-level and senior health system leadership in addressing clinicians' needs. This was a single-center academic study. As with all qualitative studies, these results may not be generalizable to all dermatologists. In addition, some participants were concerned about their anonymity. Modifiable root causes of burnout require institutional commitment to sustain the pace required by academic dermatologists.
Collapse
Affiliation(s)
- Maria N Nelson
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Eda Akpek
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
- Division of Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Frances K Barg
- Division of Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, 3600 Spruce Street, 2 Maloney, Philadelphia, PA, 19104, USA
| | - Carmela C Vittorio
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA.
| |
Collapse
|
4
|
Xanthopoulos MS, Nelson MN, Eriksen W, Barg FK, Byars KC, Ishman SL, Esbensen AJ, Meinzen-Derr J, Heubi CH, Gurbani NS, Bradford R, Hicks S, Tapia IE. Caregiver experiences helping children with Down syndrome use positive airway pressure to treat obstructive sleep apnea. Sleep Med 2023; 107:179-186. [PMID: 37196396 DOI: 10.1016/j.sleep.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 04/12/2023] [Accepted: 04/23/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND/OBJECTIVE While positive airway pressure (PAP) is an efficacious intervention for the treatment of obstructive sleep apnea syndrome (OSAS) in children with Down syndrome (DS), implementation and consistent use can be difficult. Caregiver perspectives and experiences using PAP are described with the aim of informing clinical practice. METHODS Qualitative semi-structured phone interviews were conducted with 40 caregivers (i.e., mothers) of children with DS and OSAS treated with PAP for at least 6 months. Content analysis was used to identify themes associated with adherence and non-adherence. RESULTS Respondents indicated variability in caregiver experience with the adoption of PAP and observed benefits of PAP. Varied experiences were attributed to several themes including accessing supplies, interactions with the medical team and equipment company, and patients' unique needs and behaviors, including the child's willingness and ability to adapt to PAP, sensory sensitivities, keeping the mask on all night, and differences in daytime behavior. Many families reported that desensitization with a reward system and trust within the caregiver-patient relationship were helpful. Caregiver suggestions for improving PAP adherence for families of children with DS included improving communication with the medical team and medical equipment company, emphasizing patience, using visual supports, and social support and education for extended family. CONCLUSIONS Although family experiences varied, several actionable strategies by both the medical team and families emerged for improving the experience of and adherence to PAP in children with DS.
Collapse
Affiliation(s)
- Melissa S Xanthopoulos
- Sleep Center, Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Maria N Nelson
- Mixed Methods Research Lab, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Whitney Eriksen
- Mixed Methods Research Lab, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frances K Barg
- Mixed Methods Research Lab, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly C Byars
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Behavioral Medicine and Clinical Psychology/Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stacey L Ishman
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Anna J Esbensen
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jareen Meinzen-Derr
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christine H Heubi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Neepa S Gurbani
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ruth Bradford
- Sleep Center, Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Suzanna Hicks
- Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ignacio E Tapia
- Sleep Center, Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
5
|
Woods-Hill CZ, Nelson MN, Eriksen W, Rendle KA, Beidas RS, Bonafide CP, Brajcich MR, Milstone AM, Shea JA. Determinants of Blood Culture Use in Critically Ill Children: A Multicenter Qualitative Study. Pediatr Qual Saf 2023; 8:e647. [PMID: 37051407 PMCID: PMC10085482 DOI: 10.1097/pq9.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/11/2023] [Indexed: 04/14/2023] Open
Abstract
Blood cultures are fundamental in diagnosing and treating sepsis in the pediatric intensive care unit (PICU), but practices vary widely. Overuse can lead to false positive results and unnecessary antibiotics. Specific factors underlying decisions about blood culture use and overuse are unknown. Therefore, we aimed to identify perceived determinants of blood culture use in the PICU. Methods We conducted semistructured interviews of clinicians (M.D., D.O., R.N., N.P., P.A.) from 6 PICUs who had participated in a quality improvement collaborative about blood culture practices. We developed interview questions by combining elements of the Consolidated Framework for Implementation Research and behavioral economics. We conducted telephone interviews, open-coded the transcripts, and used modified content analysis to determine key themes and mapped themes to elements of Consolidated Framework for Implementation Research and behavioral economics. Results We reached thematic saturation in 24 interviews. Seven core themes emerged across 3 Consolidated Framework for Implementation Research domains: individual characteristics [personal belief in the importance of blood cultures, the perception that blood cultures are a low-risk test]; inner setting [adherence to site-specific usual practices, site-specific overall approach to PICU care (collaborative versus hierarchical), influence of non-PICU clinicians on blood culture decisions]; and outer setting [patient-specific risk factors, sepsis guidelines]. In addition, outcome bias, default bias, and loss aversion emerged as salient behavioral economics concepts. Conclusions Determinants of blood culture use include individual clinician characteristics, inner setting, and outer setting, as well as default bias, outcome bias, and loss aversion. These determinants will now inform the development of candidate strategies to optimize culture practices.
Collapse
Affiliation(s)
- Charlotte Z. Woods-Hill
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia Pa
| | - Maria N. Nelson
- University of Pennsylvania Mixed Methods Research Laboratory
| | | | | | | | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle R. Brajcich
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Judy A. Shea
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| |
Collapse
|
6
|
Klaiman T, Nelson MN, Yan XS, Navathe AS, Patel MS, Refai F, Delgado MK, Pagnotti DR, Liao JM. Clinician Perceptions of Receiving Different Forms of Feedback on their Opioid Prescribing. Am J Med Qual 2023; 38:1-8. [PMID: 36579960 DOI: 10.1097/jmq.0000000000000092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Opioid misuse represents a major public health issue in the United States. One driver is overprescription for acute pain, with the size of initial prescription associated with subsequent long-term use. However, little work has been done to elicit clinician feedback about interventions to reduce opioid prescribing. To address this knowledge gap, qualitative analyses were conducted with clinicians who participated in a randomized controlled trial in which clinicians received monthly emailed feedback notifications about their opioid prescribing behaviors. Semistructured telephone interviews were conducted (N = 12) with urgent care (N = 7) and emergency department (N = 5) clinicians who participated in the trial between November 2020 and April 2021. Clinicians appreciated feedback about their prescribing behavior and found comparative data with peer clinicians to be most useful. Sharing opioid prescribing feedback data with clinicians can be an acceptable way to address opioid prescribing among emergency and urgent care clinicians.
Collapse
Affiliation(s)
- Tamar Klaiman
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Maria N Nelson
- CIO Peer and Practitioner Research and Analytics Department, Gartner, Philadelphia, PA
| | - Xiaowei S Yan
- Sutter Health, Center for Health System Research, Walnut Creek, CA
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Mitesh S Patel
- Department of Clinical Transformation, Ascension, St. Louis, MO
| | - Farah Refai
- Gilead Sciences, Research Department (Virology), Foster City, CA
| | - M Kit Delgado
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - David R Pagnotti
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Joshua M Liao
- School of Medicine, University of Washington, Seattle, WA
| |
Collapse
|
7
|
Parikh RB, Manz CR, Nelson MN, Ferrell W, Belardo Z, Temel JS, Patel MS, Shea JA. Oncologist Perceptions of Algorithm-Based Nudges to Prompt Early Serious Illness Communication: A Qualitative Study. J Palliat Med 2022; 25:1702-1707. [PMID: 35984992 PMCID: PMC9836678 DOI: 10.1089/jpm.2022.0095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2022] [Indexed: 01/22/2023] Open
Abstract
Background: Early serious illness conversations (SICs) about goals of care and prognosis improve mood, quality of life, and end-of-life care quality. Algorithm-based behavioral nudges to oncologists increase the frequency and timeliness of such conversations. However, clinicians' perspectives on such nudges are unknown. Design: Qualitative study consisting of semistructured interviews among medical oncology clinicians who participated in a stepped-wedge cluster randomized trial of Conversation Connect, an algorithm-based intervention consisting of behavioral nudges to promote early SICs in the outpatient oncology setting. Results: Of 79 eligible oncology clinicians, 56 (71%) were approached to participate in interviews and 25 (45%) accepted. Key facilitators to algorithm-based nudges included prompting documentation of conversations, peer comparisons, performance reports, and validating norms around early conversations. Barriers included cancer-specific heterogeneity in algorithm performance and the frequency and tone of text messages. Areas of improvement included utilizing different information channels, identifying patients earlier in the disease trajectory, and incorporating patient-targeted messaging that emphasizes the value of early conversations. Conclusions: Oncology clinicians identified key facilitators and barriers to Conversation Connect. These insights inform future algorithm-based supportive care interventions in oncology. Controlled trial (NCT03984773).
Collapse
Affiliation(s)
- Ravi B. Parikh
- Perelman School of Medicine and University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Christopher R. Manz
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Maria N. Nelson
- Perelman School of Medicine and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William Ferrell
- Perelman School of Medicine and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zoe Belardo
- Perelman School of Medicine and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer S. Temel
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mitesh S. Patel
- Perelman School of Medicine and University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Medicine Nudge Unit, Philadelphia, Pennsylvania, USA
- Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Judy A. Shea
- Perelman School of Medicine and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
8
|
Lau-Min KS, Varughese LA, Nelson MN, Cambareri C, Reddy NJ, Oyer RA, Teitelbaum UR, Tuteja S. Preemptive pharmacogenetic testing to guide chemotherapy dosing in patients with gastrointestinal malignancies: a qualitative study of barriers to implementation. BMC Cancer 2022; 22:47. [PMID: 34996412 PMCID: PMC8742388 DOI: 10.1186/s12885-022-09171-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/28/2021] [Indexed: 12/12/2022] Open
Abstract
Background Pharmacogenetic (PGx) testing for germline variants in the DPYD and UGT1A1 genes can be used to guide fluoropyrimidine and irinotecan dosing, respectively. Despite the known association between PGx variants and chemotherapy toxicity, preemptive testing prior to chemotherapy initiation is rarely performed in routine practice. Methods We conducted a qualitative study of oncology clinicians to identify barriers to using preemptive PGx testing to guide chemotherapy dosing in patients with gastrointestinal malignancies. Each participant completed a semi-structured interview informed by the Consolidated Framework for Implementation Research (CFIR). Interviews were analyzed using an inductive content analysis approach. Results Participants included sixteen medical oncologists and nine oncology pharmacists from one academic medical center and two community hospitals in Pennsylvania. Barriers to the use of preemptive PGx testing to guide chemotherapy dosing mapped to four CFIR domains: intervention characteristics, outer setting, inner setting, and characteristics of individuals. The most prominent themes included 1) a limited evidence base, 2) a cumbersome and lengthy testing process, and 3) a lack of insurance coverage for preemptive PGx testing. Additional barriers included clinician lack of knowledge, difficulty remembering to order PGx testing for eligible patients, challenges with PGx test interpretation, a questionable impact of preemptive PGx testing on clinical care, and a lack of alternative therapeutic options for some patients found to have actionable PGx variants. Conclusions Successful adoption of preemptive PGx-guided chemotherapy dosing in patients with gastrointestinal malignancies will require a multifaceted effort to demonstrate clinical effectiveness while addressing the contextual factors identified in this study. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09171-6.
Collapse
Affiliation(s)
- Kelsey S Lau-Min
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa A Varughese
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, Smilow Center for Translational Research, University of Pennsylvania, 3400 Civic Center Boulevard, Bldg. 421 11th Floor, Room 143, Philadelphia, PA, 19104-5158, USA
| | | | - Christine Cambareri
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nandi J Reddy
- Ann B. Barshinger Cancer Institute, Penn Medicine at Lancaster General Health, Lancaster, PA, USA
| | - Randall A Oyer
- Ann B. Barshinger Cancer Institute, Penn Medicine at Lancaster General Health, Lancaster, PA, USA
| | - Ursina R Teitelbaum
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sony Tuteja
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, Smilow Center for Translational Research, University of Pennsylvania, 3400 Civic Center Boulevard, Bldg. 421 11th Floor, Room 143, Philadelphia, PA, 19104-5158, USA.
| |
Collapse
|
9
|
Fierro J, Herrick H, Fregene N, Khan A, Ferro DF, Nelson MN, Brent CR, Bonafide CP, DeMauro SB. Home pulse oximetry after discharge from a quaternary-care children's hospital: Prescriber patterns and perspectives. Pediatr Pulmonol 2022; 57:209-216. [PMID: 34633759 PMCID: PMC8665108 DOI: 10.1002/ppul.25722] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Pulse oximetry monitoring is prescribed to children receiving home oxygen for chronic medical conditions associated with hypoxemia. Although home pediatric pulse oximetry is supported by national organizations, there is a lack of guidelines outlining indications and prescribing parameters. METHODS A mixed-methods analysis of pediatric home pulse oximetry orders prescribed through the institutional home healthcare provider at a large US children's hospital 6/2018-7/2019 was retrospectively reviewed to determine prescribed alarm parameter limits and recommended interventions. Semi-structured qualitative interviews with pediatric providers managing patients receiving home oxygen and pulse oximetry were conducted to identify opportunities to improve home pulse oximetry prescribing practices. Interviews were analyzed using a modified content analysis approach to identify recurring themes. RESULTS A total of 368 children received home pulse oximetry orders. Orders were most frequently prescribed on noncardiac medical floors (32%). Attending physicians were the most frequent ordering providers (52%). Frequency of use was prescribed in 96% of orders, however, just 70% were provided with specific instructions for interventions when alarms occurred. Provider role and clinical setting were significantly associated with the presence of a care plan. Provider interviews identified opportunities for improvement with the device, management of alarm parameter limits, and access to home monitor data. DISCUSSION This study demonstrated significant variability in home pulse oximetry prescribing practices. Provider interviews highlighted the importance of the provider-patient relationship and areas for improvement. There is an opportunity to create standardized guidelines that optimize the use of home monitoring devices for patients, families, and pulmonary providers.
Collapse
Affiliation(s)
- Julie Fierro
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heidi Herrick
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nicole Fregene
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Amina Khan
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daria F Ferro
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of General Pediatrics, Department of Pediatrics, Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Maria N Nelson
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Canita R Brent
- Division of General Pediatrics, Department of Pediatrics, Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher P Bonafide
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of General Pediatrics, Department of Pediatrics, Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sara B DeMauro
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
10
|
Bleakley A, Maloney EK, Harkins K, Nelson MN, Akpek E, Langbaum JB. An Elicitation Study to Understand Black, Hispanic, and Male Older Adults' Willingness to Participate in Alzheimer's Disease-Focused Research Registries. J Alzheimers Dis 2022; 88:1499-1509. [PMID: 35811525 PMCID: PMC9720734 DOI: 10.3233/jad-220196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a lack of racial, ethnic, and sex diversity in recruitment research registries and Alzheimer's disease (AD) research studies and trials. Theory-based recruitment messages may provide an opportunity to increase study participant diversity in AD research studies and trials. OBJECTIVE To identify behavioral, normative, and control beliefs that are associated with joining an AD-focused recruitment registry among historically underrepresented groups. METHOD Using a Reasoned Action Approach, we conducted 60 semi-structured phone interviews in 2020 among White, Black, and Hispanic adults ages 49-79 years in Philadelphia, PA. Underlying beliefs were elicited for the target behavior of "signing up to be on a registry for brain health research studies in the next month." Percentages based on counts are reported for the overall sample and by race and ethnicity and sex. RESULTS Participants were most concerned that if they were to sign up for a registry, they would be asked to participate in experimental studies. Advancing science to help others was a commonly reported positive belief about signing up. Participants' children and friends/neighbors were important from a normative perspective. Barriers to enrollment focused on logistical concerns and inconvenient sign-up processes, including using a computer. Results show generally few racial and ethnic or sex group differences. CONCLUSION The elicited beliefs from underrepresented groups offer a basis for understanding the behavior of signing up for research registries. However, there were few differences between the groups. Implications for outreach and recruitment are discussed.
Collapse
Affiliation(s)
- Amy Bleakley
- Department of Communication, University of Delaware, 125 Academy Street, Newark, DE 19716
| | - Erin K. Maloney
- Department of Communication, University of Delaware, 125 Academy Street, Newark, DE 19716
| | - Kristin Harkins
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3615 Chestnut St., Philadelphia, PA 19104
| | - Maria N. Nelson
- Mixed Methods Research Lab, Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Andrew Mutch Building - 7th Floor, 51 N 39th Street, Philadelphia, PA 19104
| | - Eda Akpek
- Mixed Methods Research Lab, Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Andrew Mutch Building - 7th Floor, 51 N 39th Street, Philadelphia, PA 19104
| | | |
Collapse
|
11
|
Barbieri JS, Fulton R, Neergaard R, Nelson MN, Barg FK, Margolis DJ. Patient Perspectives on the Lived Experience of Acne and Its Treatment Among Adult Women With Acne: A Qualitative Study. JAMA Dermatol 2021; 157:1040-1046. [PMID: 34319378 DOI: 10.1001/jamadermatol.2021.2185] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction Acne often persists into adulthood in women. However, few studies have specifically explored the lived experience of acne in adult populations. Objective To examine the lived experience of acne and its treatment among a cohort of adult women. Design, Setting, and Participants A qualitative analysis was conducted from free listing and open-ended, semistructured interviews of patients at a large academic health care system (University of Pennsylvania Health System) and a private practice (Dermatologists of Southwest Ohio). Fifty women 18 to 40 years of age with moderate to severe acne participated in interviews conducted between August 30, 2019, and December 31, 2020. Main Outcomes and Measures Free-listing data from interviews were used to calculate the Smith S, a measure of saliency for each list item. Semistructured interviews were examined to detect themes about patient perspectives regarding their acne and its treatment. Results Fifty participants (mean [SD] age, 28 [5.38] years; 24 [48%] White) described acne-related concerns about their appearance that affected their social, professional, and personal lives, with many altering their behavior because of their acne. Depression, anxiety, and social isolation were commonly reported. Participants described successful treatment as having completely clear skin over time or a manageable number of blemishes. Many participants described frustration with finding a dermatologist with whom they were comfortable and with identifying effective treatments for their acne. Conclusions and Relevance The results of this qualitative study suggest that women with acne have strong concerns about appearance and experience mental and emotional health consequences and disruption of their personal and professional lives. In addition, many patients describe challenges finding effective treatments and accessing care. Future trials to understand the optimal treatment approaches for women with acne are needed to improve outcomes in this population.
Collapse
Affiliation(s)
- John S Barbieri
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Rachel Fulton
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Rebecca Neergaard
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Maria N Nelson
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Frances K Barg
- Mixed Methods Research Lab, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| |
Collapse
|
12
|
Hamm RF, Levine LD, Nelson MN, Beidas R. Implementation of a calculator to predict cesarean delivery during labor induction: a qualitative evaluation of the clinician perspective. Am J Obstet Gynecol MFM 2021; 3:100321. [PMID: 33493705 DOI: 10.1016/j.ajogmf.2021.100321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND We previously conducted a prospective cohort study (n=1610) demonstrating that the implementation of a validated calculator to predict likelihood of cesarean delivery during labor induction was associated with reduced maternal morbidity, reduced cesarean delivery rate, and improved birth satisfaction. OBJECTIVE To optimize future implementation, we used qualitative interviews to understand the clinician perspective on: (1) the cesarean delivery risk calculator implementation and (2) the mechanisms by which the use of the calculator resulted in the observed improved outcomes. STUDY DESIGN After completion of the prospective study (June 30, 2019), 20 trainees and attending clinicians (including nurse-midwives, obstetrical physicians, and family medicine physicians) at the study site participated in a single, brief semistructured interview from March 1, 2020, to June 30, 2020. Transcriptions were coded using a systematic approach. RESULTS Overall, clinicians had favorable perspectives regarding the cesarean delivery risk calculator. Clinicians described the calculator as offering "objective data" and a "standardized snapshot of the labor trajectory." Concerns were raised regarding "overreliance" on calculator output. Barriers to use included time for patient counseling and "awkwardness" around the interactions and perceived patient misunderstanding of the calculator result. Although most senior clinicians (n=8) reported that the calculator did not impact patient management, trainee clinicians (n=12) more often felt that the calculator influenced care at the extremes of cesarean delivery risk. Furthermore, more senior clinicians felt "neutral" regarding any impact of counseling patients on cesarean delivery risk compared with trainee clinicians, who felt that the counseling "built [patient-clinician] trust." CONCLUSION This qualitative evaluation characterized the generally positive clinician perspective around the cesarean delivery risk calculator, while identifying specific facilitators and barriers to implementation. In addition, we elucidated potential mechanisms by which the calculator may have been related to clinician decision making and patient-clinician interactions, leading to reduced maternal morbidity and improved patient birth satisfaction. This information is important as widespread implementation of the cesarean delivery risk calculator begins.
Collapse
Affiliation(s)
- Rebecca F Hamm
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Drs Hamm and Levine).
| | - Lisa D Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Drs Hamm and Levine)
| | - Maria N Nelson
- Mixed Methods Research Lab, University of Pennsylvania, Philadelphia, PA (Ms Nelson)
| | - Rinad Beidas
- Departments of Psychiatry, Medical Ethics and Health Policy, and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Dr Beidas); Penn Implementation Science Center (PISCE@LDI), Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Dr Beidas)
| |
Collapse
|
13
|
Lau-Min KS, Varughese LA, Nelson MN, Cambareri C, Reddy NJ, Oyer RA, Teitelbaum UR, Tuteja S. Clinician perspectives on preemptive pharmacogenetic testing to guide chemotherapy dosing in patients with gastrointestinal malignancies. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.3_suppl.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
54 Background: Pharmacogenetic (PGx) testing for germline variants in the DPYD and UGT1A1 genes can be used to guide fluoropyrimidine and irinotecan dosing, respectively. Despite the known association between PGx variants and chemotherapy toxicity, preemptive testing prior to chemotherapy initiation is rarely performed in routine practice. Methods: We conducted a multi-site mixed-methods study to understand clinician attitudes toward PGx testing and to identify facilitators and barriers to using preemptive testing to guide chemotherapy dosing in patients with gastrointestinal malignancies. Each participant completed a demographic survey and semi-structured interview informed by the Consolidated Framework for Implementation Research. Interviews were analyzed using a modified grounded theory approach. Results: A total of 16 medical oncologists and 9 oncology pharmacists from one academic medical center and two community hospitals participated. Fifteen (60%) participants reported feeling comfortable or very comfortable with interpreting PGx test results. While clinicians expressed generally favorable attitudes toward PGx testing, many were hesitant to use it to preemptively guide chemotherapy dosing due to a perceived lack of evidence for this practice. They cited a lack of consensus chemotherapy dosing recommendations in response to PGx test results, as well as concerns about decreased drug efficacy, especially in patients treated with curative intent. Additional barriers included 1) a low prevalence of actionable PGx variants; 2) lengthy PGx test turnaround time; 3) concerns about testing costs and lack of insurance coverage; and 4) burdensome integration of PGx testing into clinical workflows. The electronic health record emerged as a potential tool for the unobtrusive integration of PGx testing into clinical practice–suggested applications included default PGx test orders for eligible patients, discrete reporting of PGx variant results, and clinical decision support to guide subsequent chemotherapy dosing. Conclusions: Successful adoption of preemptive PGx-guided chemotherapy dosing in patients with gastrointestinal malignancies will require a multi-level effort to demonstrate clinical effectiveness while addressing the contextual factors identified in this study. The electronic health record should be explored as a tool to integrate PGx testing into routine practice.
Collapse
Affiliation(s)
- Kelsey S. Lau-Min
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lisa A. Varughese
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Maria N. Nelson
- Mixed Methods Research Lab, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Christine Cambareri
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Nandi J. Reddy
- Ann B. Barshinger Cancer Institute, Penn Medicine at Lancaster General Health, Lancaster, PA
| | - Randall A. Oyer
- Ann B. Barshinger Cancer Institute, Penn Medicine at Lancaster General Health, Lancaster, PA
| | - Ursina R. Teitelbaum
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sony Tuteja
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
14
|
Larkan NJ, Lydiate DJ, Parkin IAP, Nelson MN, Epp DJ, Cowling WA, Rimmer SR, Borhan MH. The Brassica napus blackleg resistance gene LepR3 encodes a receptor-like protein triggered by the Leptosphaeria maculans effector AVRLM1. New Phytol 2013; 197:595-605. [PMID: 23206118 DOI: 10.1111/nph.12043] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 10/05/2012] [Indexed: 05/18/2023]
Abstract
LepR3, found in the Brassica napus cv 'Surpass 400', provides race-specific resistance to the fungal pathogen Leptosphaeria maculans, which was overcome after great devastation in Australia in 2004. We investigated the LepR3 locus to identify the genetic basis of this resistance interaction. We employed a map-based cloning strategy, exploiting collinearity with the Arabidopsis thaliana and Brassica rapa genomes to enrich the map and locate a candidate gene. We also investigated the interaction of LepR3 with the L. maculans avirulence gene AvrLm1 using transgenics. LepR3 was found to encode a receptor-like protein (RLP). We also demonstrated that avirulence towards LepR3 is conferred by AvrLm1, which is responsible for both the Rlm1 and LepR3-dependent resistance responses in B. napus. LepR3 is the first functional B. napus disease resistance gene to be cloned. AvrLm1's interaction with two independent resistance loci, Rlm1 and LepR3, highlights the need to consider redundant phenotypes in 'gene-for-gene' interactions and offers an explanation as to why LepR3 was overcome so rapidly in parts of Australia.
Collapse
Affiliation(s)
- N J Larkan
- Saskatoon Research Centre, Agriculture and Agri-Food Canada, 107 Science Place, Saskatoon, SK, Canada, S7N 0X2
- School of Plant Biology, University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia
| | - D J Lydiate
- Saskatoon Research Centre, Agriculture and Agri-Food Canada, 107 Science Place, Saskatoon, SK, Canada, S7N 0X2
| | - I A P Parkin
- Saskatoon Research Centre, Agriculture and Agri-Food Canada, 107 Science Place, Saskatoon, SK, Canada, S7N 0X2
| | - M N Nelson
- School of Plant Biology, University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia
- The UWA Institute of Agriculture, University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia
| | - D J Epp
- Saskatoon Research Centre, Agriculture and Agri-Food Canada, 107 Science Place, Saskatoon, SK, Canada, S7N 0X2
| | - W A Cowling
- The UWA Institute of Agriculture, University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia
| | - S R Rimmer
- Saskatoon Research Centre, Agriculture and Agri-Food Canada, 107 Science Place, Saskatoon, SK, Canada, S7N 0X2
| | - M H Borhan
- Saskatoon Research Centre, Agriculture and Agri-Food Canada, 107 Science Place, Saskatoon, SK, Canada, S7N 0X2
| |
Collapse
|
15
|
Berger JD, Buirchell BJ, Luckett DJ, Nelson MN. Domestication bottlenecks limit genetic diversity and constrain adaptation in narrow-leafed lupin (Lupinus angustifolius L.). Theor Appl Genet 2012; 124:637-52. [PMID: 22069118 DOI: 10.1007/s00122-011-1736-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 10/14/2011] [Indexed: 05/04/2023]
Abstract
In contrast to most widespread broad-acre crops, the narrow-leafed lupin (Lupinus angustifolius L.) was domesticated very recently, in breeding programmes isolated in both space and time. Whereas domestication was initiated in Central Europe in the early twentieth century, the crop was subsequently industrialized in Australia, which now dominates world production. To investigate the ramifications of these bottlenecks, the genetic diversity of wild (n = 1,248) and domesticated populations (n = 95) was characterized using diversity arrays technology, and adaptation studied using G × E trials (n = 31) comprising all Australian cultivars released from 1967 to 2004 (n = 23). Principal coordinates analysis demonstrates extremely limited genetic diversity in European and Australian breeding material compared to wild stocks. AMMI analysis indicates that G × E interaction is a minor, albeit significant effect, dominated by strong responses to local, Western Australian (WA) optima. Over time Australian cultivars have become increasingly responsive to warm, intermediate rainfall environments in the northern WA grainbelt, but much less so to cool vegetative phase eastern environments, which have considerably more yield potential. G × E interaction is well explained by phenology, and its interaction with seasonal climate, as a result of varying vernalization responses. Yield differences are minimized when vegetative phase temperatures fully satisfy the vernalization requirement (typical of eastern Australia), and maximized when they do not (typical of WA). In breeding for WA optima, the vernalization response has been eliminated and there has been strong selection for terminal drought avoidance through early phenology, which limits yield potential in longer season eastern environments. Conversely, vernalization-responsive cultivars are more yield-responsive in the east, where low temperatures moderately extend the vegetative phase. The confounding of phenology and vernalization response limits adaptation in narrow-leafed lupin, isolates breeding programmes, and should be eliminated by widening the flowering time range in a vernalization-unresponsive background. Concomitantly, breeding strategies that will widen the genetic base of the breeding pool in an ongoing manner should be initiated.
Collapse
Affiliation(s)
- J D Berger
- CSIRO Plant Industry, Private Bag No. 5, Wembley, WA, 6913, Australia.
| | | | | | | |
Collapse
|
16
|
Cousin A, Heel K, Cowling WA, Nelson MN. An efficient high-throughput flow cytometric method for estimating DNA ploidy level in plants. Cytometry A 2010; 75:1015-9. [PMID: 19845019 DOI: 10.1002/cyto.a.20816] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We present an efficient high-throughput flow cytometric method that builds on previously published methods and permits rapid ploidy discrimination in plants. By using Brassica napus L. microspore-derived plants as an example, we describe how 192 leaf tissue samples may be processed and analyzed comfortably by one operator in 6 h from tissue sampling to ploidy determination. The technique involves placing young leaf samples in two 96-well racks, using a bead-beating procedure to release nuclei into a lysis solution, filtering the samples on 96-well filter plates, staining with propidium iodide, and then rapidly estimating DNA ploidy using a plate loader on a BD FACS-Canto II flow cytometer. Throughout the sample preparation process, multichannel pipetting allows faster and less error-prone sample handling. In two 96-well plates of samples, the histogram peaks of DNA content from flow cytometry were wellresolved in 189 of 192 samples tested (98.4%), with CV values ranging from 2.98% to 6.20% with an average CV of 4.35% (SD = 0.68%). This new method is useful in doubled haploid plant breeding programs where early discrimination of haploid and doubled haploid (i.e., diploid) plantlets can confer significantly improved operational efficiencies. We discuss how this method could be further refined including adapting the method to robotic sample processing.
Collapse
Affiliation(s)
- A Cousin
- Canola Breeders Western Australia Pty Ltd, Perth, Australia
| | | | | | | |
Collapse
|
17
|
Chen S, Nelson MN, Ghamkhar K, Fu T, Cowling WA. Divergent patterns of allelic diversity from similar origins: the case of oilseed rape (Brassica napus L.) in China and Australia. Genome 2008; 51:1-10. [PMID: 18356934 DOI: 10.1139/g07-095] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Oilseed rape (Brassica napus) in Australia and China have similar origins, with introductions from Europe, Canada, and Japan in the mid 20th century, and there has been some interchange of germplasm between China and Australia since that time. Allelic diversity of 72 B. napus genotypes representing contemporary germplasm in Australia and China, including samples from India, Europe, and Canada, was characterized by 55 polymorphic simple sequence repeat (SSR) markers spanning the entire B. napus genome. Hierarchical clustering and two-dimensional multidimensional scaling identified a Chinese group (China-1) that was separated from "mixed group" of Australian, Chinese (China-2), European, and Canadian lines. A small group from India was distinctly separated from all other B. napus genotypes. Chinese genotypes, especially in the China-1 group, have inherited unique alleles from interspecific crossing, primarily with B. rapa, and the China-2 group has many alleles in common with Australian genotypes. The concept of "private alleles" is introduced to describe both the greater genetic diversity and the genetic distinctiveness of Chinese germplasm, compared with Australian germplasm, after 50 years of breeding from similar origins.
Collapse
Affiliation(s)
- S Chen
- School of Plant Biology, Faculty of Natural and Agricultural Sciences, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia.
| | | | | | | | | |
Collapse
|
18
|
Abstract
Dihydroorotate dehydrogenases (DHODs) oxidize dihydroorotate (DHO) to orotate using the FMN prosthetic group to abstract a hydride equivalent from C6 and a protein residue (Ser for Class 2 DHODs) to deprotonate C5. The fundamental question of whether the scission of the two DHO C-H bonds is concerted or stepwise was addressed for two Class 2 enzymes, those from Escherichia coli and Homo sapiens, by determining kinetic isotope effects on flavin reduction in anaerobic stopped-flow experiments. Isotope effects were determined for the E. coli enzyme at two pH values below a previously reported pKa controlling reduction [Palfey, B. A., Björnberg, O., and Jensen K. F. (2001) Biochemistry 40, 4381-4390] and were about 3-fold for DHO labeled at the 5-position, about 4-fold for DHO labeled at the 6-position, and about 6-7-fold for DHO labeled at both the 5- and 6-positions. These isotope effects are consistent with either a stepwise oxidation of DHO or a concerted mechanism with significant quantum mechanical tunneling. At a pH value above the pKa controlling reduction, no isotope effect was observed in E. coli DHOD for DHO deuterated at the 5-position (the proton donor in the reaction). This is consistent with a stepwise reaction; above the (kinetic) pKa, the deprotonation of C5 is fast enough that it does not contribute to the observed rate constant and, therefore, is not isotopically sensitive. All available information points to Ser acting as a component in a proton relay network which allows its transient deprotonation. The H. sapiens DHOD also appears to have a pKa near 9.4 controlling reduction, similar to that previously reported for the E. coli enzyme. Similar KIEs were obtained with the H. sapiens enzyme at a pH value below the pKa.
Collapse
Affiliation(s)
- Rebecca L Fagan
- Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, Michigan 48109-0606, USA
| | | | | | | |
Collapse
|
19
|
Nelson MN, White-Traut RC, Vasan U, Silvestri J, Comiskey E, Meleedy-Rey P, Littau S, Gu G, Patel M. One-year outcome of auditory-tactile-visual-vestibular intervention in the neonatal intensive care unit: effects of severe prematurity and central nervous system injury. J Child Neurol 2001; 16:493-8. [PMID: 11453445 DOI: 10.1177/088307380101600706] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thirty-seven infants with severe central nervous system injury or extreme prematurity were randomly assigned to a multisensory (auditory-tactile-visual-vestibular) intervention or control group. Intervention began in the hospital at 33 weeks' postconceptional age and continued twice daily in the home until 2 months' corrected age. Mother-infant interactions during feedings were videotaped, and the Bayley Scales of Infant Development were administered. Control mothers stimulated their infants more during feeding, but these significant differences dissipated by 4 months. The presence of periventricular leukomalacia was associated with significantly poorer mental development, regardless of group assignment. Experimental infants tended to exhibit better motor and mental performance and had 23% fewer cerebral palsy diagnoses at 1 year, but these trends were not statistically significant. The type of brain injury was more important in determining 1-year developmental outcome than type of postnatal experience, suggesting that periventricular leukomalacia presents a major challenge for infant development.
Collapse
Affiliation(s)
- M N Nelson
- Department of Pediatrics, Rush-Presbyterian-St. Luke's Medical Center, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Sandler RH, Finegold SM, Bolte ER, Buchanan CP, Maxwell AP, Väisänen ML, Nelson MN, Wexler HM. Short-term benefit from oral vancomycin treatment of regressive-onset autism. J Child Neurol 2000; 15:429-35. [PMID: 10921511 DOI: 10.1177/088307380001500701] [Citation(s) in RCA: 375] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In most cases symptoms of autism begin in early infancy. However, a subset of children appears to develop normally until a clear deterioration is observed. Many parents of children with "regressive"-onset autism have noted antecedent antibiotic exposure followed by chronic diarrhea. We speculated that, in a subgroup of children, disruption of indigenous gut flora might promote colonization by one or more neurotoxin-producing bacteria, contributing, at least in part, to their autistic symptomatology. To help test this hypothesis, 11 children with regressive-onset autism were recruited for an intervention trial using a minimally absorbed oral antibiotic. Entry criteria included antecedent broad-spectrum antimicrobial exposure followed by chronic persistent diarrhea, deterioration of previously acquired skills, and then autistic features. Short-term improvement was noted using multiple pre- and post-therapy evaluations. These included coded, paired videotapes scored by a clinical psychologist blinded to treatment status; these noted improvement in 8 of 10 children studied. Unfortunately, these gains had largely waned at follow-up. Although the protocol used is not suggested as useful therapy, these results indicate that a possible gut flora-brain connection warrants further investigation, as it might lead to greater pathophysiologic insight and meaningful prevention or treatment in a subset of children with autism.
Collapse
Affiliation(s)
- R H Sandler
- Section of Pediatric Gastroenterology and Nutrition, Rush Children's Hospital, Rush Medical College, Chicago, IL 60612, USA.
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Hanna BD, Nelson MN, White-Traut RC, Silvestri JM, Vasan U, Rey PM, Patel MK, Comiskey E. Heart rate variability in preterm brain-injured and very-low-birth-weight infants. Biol Neonate 2000; 77:147-55. [PMID: 10729717 DOI: 10.1159/000014209] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Heart rate variability (HRV) reflects the complex interplay of the sympathetic and parasympathetic innervation of the heart. Developmental maturation of the fetus and newborn results in predictable alterations in the neural cardiac control of heart rate. Furthermore, patterns of HRV are closely correlated to clinical outcome in several pathologic situations. The first aim of this study was to characterize the maturational patterns of HRV in a group of developmentally at-risk newborns (those with severe hemorrhagic or ischemic brain injury and extremely immature, low-birth-weight infants). Secondly, we sought to determine whether a correlation exists between HRV and length of hospital stay, diagnosis of cerebral palsy, and neurodevelopmental test scores at 1-year corrected age. Time domain indices of HRV were computed longitudinally from 32 to 37 weeks of corrected gestational age in 19 very low birth weight, preterm infants. Among the 19 infants studied, 7 infants had no evidence of brain injury, 7 infants had periventricular leukomalacia (PVL), 3 infants had grade III/IV intraventricular hemorrhage (IVH), and 2 infants had both IVH and PVL. Neurologic injuries were documented using ultrasound and neurodevelopmental progress was followed through 1 year of corrected gestational age. A multivariate repeated measures analysis was performed to determine the relationship between the type of perinatal brain injury and neurodevelopmental status at 1 year of corrected gestational age. The type of perinatal brain injury was highly correlated to specific patterns of HRV with multivariate regression models producing adjusted r(2) values ranging from 0.63 to 0.99. The type of perinatal brain injury was highly correlated to the developmental outcome measures (p < 0.0000) with PVL patients having the lowest neurodevelopmental scores, IVH patients having the highest scores, and noninjured infants having midrange, grossly normal values. Using ANOVA, HRV was correlated to outcome, but individual comparisons revealed statistical significance only for the noninjured group (p < 0.04). However, multivariate models, which characterized outcome within each brain injury group, were highly significant (adjusted r (2) ranged from 0.23 to 0.89). In summary, the type of perinatal brain injury determined the pattern of HRV and HRV was highly correlated to length of hospital stay and neurodevelopmental function assessed at 1 year of corrected gestational age.
Collapse
Affiliation(s)
- B D Hanna
- University of Illinois at Chicago, College of Nursing and Rush Children's Hospital at Rush-Presbyterian-St. Luke's Medical Center, The Rush Children's Heart Center,60612, USA
| | | | | | | | | | | | | | | |
Collapse
|
22
|
White-Traut RC, Nelson MN, Silvestri JM, Patel M, Vasan U, Han BK, Cunningham N, Burns K, Kopischke K, Bradford L. Developmental intervention for preterm infants diagnosed with periventricular leukomalacia. Res Nurs Health 1999; 22:131-43. [PMID: 10094298 DOI: 10.1002/(sici)1098-240x(199904)22:2<131::aid-nur5>3.0.co;2-e] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Preterm infants with periventricular leukomalacia (PVL) were evaluated to determine whether multi-sensory stimulation is safe and to assess whether it improved neurobehavior and neurodevelopment. Thirty preterm infants with documented PVL were randomly assigned to control (n= 15) or experimental (Group E) (n= 15) groups at 33 weeks post-conceptional age. Group E infants received 15 minutes of auditory, tactile, visual, and vestibular (ATVV) intervention twice a day, five days a week, for four weeks during hospitalization. Repeated measures ANOVA demonstrated that Group E infants experienced significant increases in heart and respiratory rate and a 0.72% drop in hemoglobin saturation, coinciding with a significant behavioral state shift from sleep to alertness during intervention. No differences were identified in neurobehavioral function and neurodevelopment, indicating that Group E suffered no injury. Group E had an average hospital stay nine days shorter than that of controls, with the associated cost savings of $213,840. The earlier hospital discharge indicates that ATVV intervention promotes alertness without compromising physiologic status in vulnerable infants.
Collapse
Affiliation(s)
- R C White-Traut
- University of Illinois at Chicago, College of Nursing, 60612, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
White-Traut RC, Nelson MN, Silvestri JM, Cunningham N, Patel M. Responses of preterm infants to unimodal and multimodal sensory intervention. Pediatr Nurs 1997; 23:169-75, 193. [PMID: 9165933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To examine the immediate responses of preterm infants to two forms of unimodal [auditory only (A) and tactile only (T)] and two forms of multimodal sensory stimulation [auditory, tactile and visual (ATV); auditory, tactile, visual and vestibular (ATVV)]. METHOD A convenience sample of 54 clinically stable preterm infants (33-34 postconceptional weeks) was randomly assigned to 1 of 5 experimental groups [Control (C); (A); (T); (ATV); and (ATVV)]. Stimulation was applied for 15 minutes once daily for 4 consecutive days. RESULTS Outcome measures included pulse (PR) and respiratory rate (RR), oxygen saturation, behavioral state (BS), and body temperature. Repeated measures ANOVA identified significant differences among the groups during intervention for PR (p < .001), RR (p = .01), and BS (p < .02). Infants receiving any intervention with a tactile component showed increasing arousal (change in BS), and increased PR and RR during stimulation. Group T infants had higher proportions of PR > 180 while Group ATVV had higher proportions of PR < 140 (p = .0001). Group ATVV showed increased alertness following stimulation (24%) in contrast to having the least alertness during stimulation (11%). CONCLUSIONS Tactile stimulation alone may be too arousing for these infants while the addition of vestibular stimulation may modulate arousal and facilitate optimal arousal prior to feeding.
Collapse
Affiliation(s)
- R C White-Traut
- Graduate Pediatric and Perinatal Programs, University of Illinois at Chicago, USA
| | | | | | | | | |
Collapse
|
24
|
Burns K, Cunningham N, White-Traut R, Silvestri J, Nelson MN. Infant stimulation: modification of an intervention based on physiologic and behavioral cues. J Obstet Gynecol Neonatal Nurs 1994; 23:581-9. [PMID: 7996309 DOI: 10.1111/j.1552-6909.1994.tb01924.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Research involving developmental intervention with premature infants in the hospital has traditionally taken two paths: application of a sensory stimulation protocol and individualized assessment and treatment. This article describes a new method that combines some of the philosophical strengths of these two approaches. A decision tree is presented to standardize the modifications of a developmental intervention based on physiologic and behavioral cues.
Collapse
Affiliation(s)
- K Burns
- College of Nursing, Department of Maternal-Child Nursing, University of Illinois at Chicago 60612
| | | | | | | | | |
Collapse
|
25
|
White-Traut RC, Nelson MN, Burns K, Cunningham N. Environmental influences on the developing premature infant: theoretical issues and applications to practice. J Obstet Gynecol Neonatal Nurs 1994; 23:393-401. [PMID: 8083780 DOI: 10.1111/j.1552-6909.1994.tb01896.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
The neonatal intensive-care unit (NICU) environment may interfere with the maturation and organization of premature infants' central nervous systems and may fail to meet these infants' developmental needs. In particular, immature distance receptors (i.e., hearing and vision) may receive overwhelming stimulation, whereas more mature tactile and vestibular pathways receive little stimulation. Furthermore, research on fetal learning suggests that the NICU environment should sensitively address requirements for learning by providing contingent experience. Nurses are ideally suited to reorganize the NICU and intervene to optimize infants' growth and development.
Collapse
|
26
|
White-Traut RC, Nelson MN, Silvestri JM, Patel MK, Kilgallon D. Patterns of physiologic and behavioral response of intermediate care preterm infants to intervention. Pediatr Nurs 1993; 19:625-9. [PMID: 8278239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE To determine the safety of a developmental intervention for use with preterm infants and feasibility of a time sampling procedure. METHODOLOGY An experimental design was used to test an intervention with clinically stable 33-34-week postconceptional age infants over a 4-day period. Repeated outcome measures included pulse rate, oxygen saturation levels, and infant behavioral state. FINDINGS The intervention resulted in significant differences in infant behavioral state with the experimental group achieving more alertness. Physiologic parameters remained within normal limits both during and after the intervention. CONCLUSIONS The protocol was found to be safe for implementation with clinically stable preterm infants. Behavioral state findings suggest the potential for the intervention to promote alertness. Results suggest that changes in oxygen saturation and pulse rate were dependent upon changes in behavioral state.
Collapse
|
27
|
Abstract
We hypothesized that intellectual, neurodevelopmental, and visual-motor tests would be able to characterize the scope and nature of central nervous system involvement in children with congenital central hypoventilation syndrome. Age-appropriate intellectual (Brazelton Neonatal Behavioral Assessment, Bayley Scales of Infant Development, Wechsler Preschool and Primary Scale of Intelligence-Revised and Wechsler Intelligence Scale for Children--Revised), neurodevelopmental (Halsted-Reitan neuropsychologic battery), and visual-motor (Beery visual-motor integration test) tests were given to 17 children with congenital central hypoventilation syndrome (age 0.1 to 14.3 years). We found a broad range in IQ and developmental quotient, from greater than the 85th percentile to less than the 5th percentile, with discrepancies noted between verbal and performance measures. Multiple asymmetries and deficiencies of motor performance, not consistently related to handedness, were also found. Significant eye-hand coordination deficits were uncommon, but general performance was well below average. Full, verbal, and performance IQs and developmental quotients greater than or equal to 70 and less than 70 were compared by chi-square analysis with other associated conditions, including hours of ventilatory support, duration of initial hospitalization, growth, pulmonary hypertension, seizures, brain atrophy, central and peripheral hearing deficits, and ophthalmologic abnormalities; no statistically significant associations were found. These results lend support to the hypothesis that congenital central hypoventilation syndrome is a diffuse central nervous system process. However, the effects of transient hypoxia and associated conditions on neurodevelopmental test results cannot be excluded with certainty.
Collapse
Affiliation(s)
- J M Silvestri
- Department of Pediatrics, Rush-Presbyterian-St. Luke's Medical Center, Rush Medical College, Rush University, Chicago 60612
| | | | | |
Collapse
|
28
|
Abstract
Bronchopulmonary dysplasia (BPD) may adversely affect the postnatal growth of the extremely premature infant; however, most studies have not controlled for birth weight. We studied 90 Black premature infants (mean birth weight 989 +/- 148 g). Weight was recorded biweekly until discharge and at 4, 8, and 12 months of age corrected for prematurity. Infants with BPD (N = 23) were contrasted with infants without BPD (N = 67). Data were modeled using the Count model: Stage I birth to term and Stage II term to 12 months. Birth weight was considered part of growth beginning in utero and multivariate analyses were used to control for BPD, gestational age, duration of hospitalization and socioeconomic status. After adjustment for birth weight, BPD did not explain the growth pattern. A lower gestational age was associated with a slower establishment of steady growth (P less than 0.01), while an increased duration of hospitalization was associated with a lower growth rate (P less than 0.05). Growth in stage II was not explained by study variables. 'Catch-up' growth was seen in both infants with and without BPD. We conclude that differences in growth among infants with BPD are mainly attributable to birth weight. We speculate that poorer growth may be seen in a sub-group of infants with severe BPD.
Collapse
Affiliation(s)
- M E Bozynski
- University of Michigan Medical Center, Department of Pediatrics, Ann Arbor 48109/0254
| | | | | | | | | | | |
Collapse
|
29
|
|
30
|
Bozynski ME, Nelson MN, Genaze D, Rosati-Skertich C, Matalon TA, Vasan U, Naughton PM. Cranial ultrasonography and the prediction of cerebral palsy in infants weighing less than or equal to 1200 grams at birth. Dev Med Child Neurol 1988; 30:342-8. [PMID: 3042496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The rôle of serial cranial ultrasonography in the prediction of cerebral palsy was examined in 116 surviving infants with birthweights less than or equal to 1200 g. All underwent serial real-time sonographic examinations of the brain on days one, five and 21, then monthly, until term corrected age. Intraventricular hemorrhage (IVH) was diagnosed in 48 infants, and three had periventricular leukomalacia. Of the 116 infants, 31 had ultrasound abnormalities at term. At 12 to 18 months corrected age 12 infants had cerebral palsy and 38 were classified as suspect; the other 66 were normal. There was a clear association between risk group, based on sonographic findings at term, and outcome. Infants with IVH whose cranial ultrasounds failed to become normal by term corrected age were at higher risk for cerebral palsy than those with normal examinations at term, regardless of the severity of IVH. Thus an abnormal ultrasound at term corrected age was highly predictive of cerebral palsy, especially among survivors of IVH. It remained the best predictor of cerebral palsy, even when other perinatal and neonatal variables were considered. In contrast, duration of mechanical ventilation, rather than sonographic findings, was the best predictor of suspect neuromotor status.
Collapse
Affiliation(s)
- M E Bozynski
- Section of Newborn Services, Women's Hospital, Ann Arbor, MI 48109-0254
| | | | | | | | | | | | | |
Collapse
|
31
|
White-Traut RC, Nelson MN. Maternally administered tactile, auditory, visual, and vestibular stimulation: relationship to later interactions between mothers and premature infants. Res Nurs Health 1988; 11:31-9. [PMID: 3347763 DOI: 10.1002/nur.4770110106] [Citation(s) in RCA: 68] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Thirty-three mother-infant pairs were randomly assigned to one of three groups: control, talking, or interactive (RISS). The later treatment included massage, talking, eye contact and rocking. The intervention (RISS) was administered to determine whether mothers and their preterm infants who actively interacted with each other would differ on later maternal and infant behaviors. The talking and RISS treatments were administered at specified time intervals 24 hours after delivery. Prior to hospital discharge, mother-infant interaction was assessed during a feeding. Significant differences were identified among the three groups for maternal (p less than .03) and infant (p less than .05) behaviors. These results suggest that active maternal interaction with the premature infant may enhance specific components of mother-infant interaction.
Collapse
|
32
|
Bozynski ME, Nelson MN, Matalon TA, O'Donnell KJ, Naughton PM, Vasan U, Meier WA, Ploughman L. Prolonged mechanical ventilation and intracranial hemorrhage: impact on developmental progress through 18 months in infants weighing 1,200 grams or less at birth. Pediatrics 1987; 79:670-6. [PMID: 3575020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In this prospective, longitudinal study, the relative impact of intracranial hemorrhage and prolonged mechanical ventilation on developmental progress during the first 18 months of life of infants weighing 1,200 g or less at birth was examined. A total of 159 surviving infants were divided into two groups: infants with and those without intracranial hemorrhage. These groups were then subdivided into groups of infants receiving prolonged mechanical ventilation (greater than 21 days) and those mechanically ventilated for 21 days or less, thus creating four subgroups. Group 1 (intracranial hemorrhage and prolonged mechanical ventilation) and group 3 (intracranial hemorrhage and no prolonged mechanical ventilation) showed no statistically significant differences for severity of intracranial hemorrhage, persistence of ventriculomegaly, or presence of periventricular leukomalacia. A repeated-measures analysis of variance demonstrated a main effect for prolonged mechanical ventilation on outcome as measured by the Bayley Mental Development Index and Bayley Psychomotor Development Index at 4, 8, 12, and 18 months of age (corrected for prematurity). Forward stepwise regression revealed prolonged mechanical ventilation to the best predictor of Bayley indexes at all ages except 4 months of age, for which the Psychomotor Development Index was best predicted by length of hospitalization. No main effect for intracranial hemorrhage was demonstrated, but the motor performance of infants with intracranial hemorrhage declined significantly with age. By contrast prolonged mechanical ventilation was associated with uniformly poor performance at every age and serves as a powerful marker for poor developmental progress during the first 18 months of life in infants weighing 1,200 g or less at birth.
Collapse
|
33
|
Bozynski ME, Nelson MN, Matalon TA, Genaze DR, Rosati-Skertich C, Naughton PM, Meier WA. Cavitary periventricular leukomalacia: incidence and short-term outcome in infants weighing less than or equal to 1200 grams at birth. Dev Med Child Neurol 1985; 27:572-7. [PMID: 3905465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
One hundred surviving infants with birthweights less than or equal to 1200 g were examined longitudinally, using real-time ultrasonography of the brain. Five infants were diagnosed as having cavitary periventricular leukomalacia (PVL). One infant expired within a month following discharge; the remaining four entered a follow-up program and received developmental assessments. Three infants had moderate-severe spastic diplegia and the fourth had spastic quadriplegia. Cavitary PVL can be diagnosed in vivo and predicts future motor delay or cerebral palsy. Since the typical site of PVL involves the optic radiations, and the incidence of visual-perceptual disturbances is high in premature infants, further research is needed to explore the possible relationship between these two abnormalities.
Collapse
|
34
|
Bozynski ME, Nelson MN, Rosati-Skertich C, Genaze D, O'Donnell K, Naughton P. Two year longitudinal followup of premature infants weighing less than or equal to 1,200 grams at birth: sequelae of intracranial hemorrhage. J Dev Behav Pediatr 1984; 5:346-52. [PMID: 6210308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Intracranial hemorrhage (ICH) is a major problem for the premature infant, occurring in more than one-third of surviving infants weighing less than or equal to 1,500 g at birth. The literature on perinatal ICH, as it relates to neurodevelopment outcome, is briefly reviewed, and preliminary results from our two-year followup of 75 less than or equal to 1,200-g infants are summarized. An analysis of pathophysiology, diagnosis, classification, and followup indicates that risk for ICH and its sequelae increases as gestational age and birth weight decrease. Hydrocephalus apparently no longer presents significant risk beyond that conveyed by the original hemorrhage. However, persistent posthemorrhagic ventriculomegaly and/or periventricular abnormalities serve as significant "markers" of risk for neuromotor delay through two years of age. In contrast, recovery of normal ventricular morphology by term gestational age apparently indexes a degree of recovery from ICH and predicts a more normal developmental outcome through the first two postnatal years.
Collapse
|
35
|
Bozynski ME, Nelson MN, Genaze D, Rosati-Skertich C, Chilcote WS, Ramsey RG, O'Donnell KJ, Meier WA. Intracranial hemorrhage and neurodevelopmental outcome at one year in infants weighing 1200 grams or less. Prognostic significance of ventriculomegaly at term gestational age. Am J Perinatol 1984; 1:325-30. [PMID: 6394021 DOI: 10.1055/s-2007-1000032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Seventy-five surviving infants weighting 1200 g or less at birth were followed up longitudinally, employing real-time ultrasonographic examination of the brain from birth to term corrected gestational age. Evaluations using the Milani-Comparetti Motor Developmental Screening Test and developmental testing using the Bayley Scales of Infant Development were performed at 4, 8, and 12 months corrected age. Thirty-five (46.7%) of the infants were diagnosed to have intracranial hemorrhage (ICH). These infants were significantly smaller and lighter and were mechanically ventilated close to five times longer than infants without ICH. ICH was predictive of poorer developmental outcome through the first postnatal year. ICH infants had significantly lower Bayley motor scores at both 4 and 12 months. Sixteen of the 20 who scored less than 84 on one or both of the Bayley Scales at one year had a history of ICH. When infants with hemorrhage and normal ventricles at term (ICH-no VM) were compared to infants with hemorrhage and ventriculomegaly at term (ICH-VM), the poorest motor outcome was seen in the ICH-VM group. Only the ICH-VM group showed motor performance significantly poorer than the non-ICH group at 12 months of age. Regardless of severity of hemorrhage, the data suggested an added risk for poorer developmental outcome in ICH survivors who had ventriculomegaly or abnormal periventricular morphology at term. Thus, intracranial hemorrhage per se indicates significantly greater risk of short-term motor sequelae continuing through the first four postnatal months, but persistently abnormal ventricles serve as a more significant "marker" of risk for longer term neuromotor delays at one year corrected age.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
|
36
|
|
37
|
Nelson MN, Ross LE. Effects of masking tasks on differential eyelid conditioning: a distinction between knowledge of stimulus contingencies and attentional or cognitive activities involving them. J Exp Psychol 1974; 102:1-9. [PMID: 4809655 DOI: 10.1037/h0035682] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
38
|
|
39
|
|