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Bharadwaj AG, Okura GC, Woods JW, Allen EA, Miller VA, Kempster E, Hancock MA, Gujar S, Slibinskas R, Waisman DM. Identification and characterization of calreticulin as a novel plasminogen receptor. J Biol Chem 2024; 300:105465. [PMID: 37979915 PMCID: PMC10770727 DOI: 10.1016/j.jbc.2023.105465] [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: 09/18/2023] [Revised: 10/22/2023] [Accepted: 11/06/2023] [Indexed: 11/20/2023] Open
Abstract
Calreticulin (CRT) was originally identified as a key calcium-binding protein of the endoplasmic reticulum. Subsequently, CRT was shown to possess multiple intracellular functions, including roles in calcium homeostasis and protein folding. Recently, several extracellular functions have been identified for CRT, including roles in cancer cell invasion and phagocytosis of apoptotic and cancer cells by macrophages. In the current report, we uncover a novel function for extracellular CRT and report that CRT functions as a plasminogen-binding receptor that regulates the conversion of plasminogen to plasmin. We show that human recombinant or bovine tissue-derived CRT dramatically stimulated the conversion of plasminogen to plasmin by tissue plasminogen activator or urokinase-type plasminogen activator. Surface plasmon resonance analysis revealed that CRT-bound plasminogen (KD = 1.8 μM) with moderate affinity. Plasminogen binding and activation by CRT were inhibited by ε-aminocaproic acid, suggesting that an internal lysine residue of CRT interacts with plasminogen. We subsequently show that clinically relevant CRT variants (lacking four or eight lysines in carboxyl-terminal region) exhibited decreased plasminogen activation. Furthermore, CRT-deficient fibroblasts generated 90% less plasmin and CRT-depleted MDA MB 231 cells also demonstrated a significant reduction in plasmin generation. Moreover, treatment of fibroblasts with mitoxantrone dramatically stimulated plasmin generation by WT but not CRT-deficient fibroblasts. Our results suggest that CRT is an important cellular plasminogen regulatory protein. Given that CRT can empower cells with plasmin proteolytic activity, this discovery may provide new mechanistic insight into the established role of CRT in cancer.
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Affiliation(s)
- Alamelu G Bharadwaj
- Departments of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada; Biochemistry and Molecular Biology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gillian C Okura
- Departments of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John W Woods
- Biochemistry and Molecular Biology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Erica A Allen
- Departments of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Victoria A Miller
- Departments of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Emma Kempster
- Departments of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mark A Hancock
- McGill SPR-MS Facility, McGill University, Montréal, Québec, Canada
| | - Shashi Gujar
- Departments of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Rimantas Slibinskas
- Life Sciences Center, Institute of Biotechnology, Vilnius University, Vilnius, Lithuania
| | - David M Waisman
- Departments of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada; Biochemistry and Molecular Biology, Dalhousie University, Halifax, Nova Scotia, Canada.
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Miller VA, Miller C, Davis SM, Nokoff NJ, Buchanan C, Friedrich EA, Carl A, Strine S, Vogiatzi MG. Information needs and health status in adolescents and young adults with differences of sex development or sex chromosome aneuploidies. J Pediatr Urol 2023; 19:586-595. [PMID: 37308330 DOI: 10.1016/j.jpurol.2023.05.012] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION When and how to provide condition-related information to adolescents and young adults (AYAs) with differences of sex development or sex chromosome aneuploidies (DSDs or SCAs) is largely based on anecdotal experience and lacks informed guidance. For AYAs with a DSD or SCA, having accurate information is critical for attaining optimal adjustment and well-being, participating in decision making related to treatment options, and transitioning successfully to adult health care, yet prior studies have focused exclusively on parental perspectives and not on the views of adolescents themselves. OBJECTIVE The objective of this study was to describe unmet information needs in AYAs with a DSD or SCA and examine associations with perceived global health. METHODS Participants were recruited from specialty clinics at Children's Hospital of Philadelphia (n = 20) and Children's Hospital Colorado (n = 60). AYAs ages 12-21 years with a DSD or SCA and a parent completed a survey assessing perceived information needs across 20 topics, importance of those topics, and global health using the PROMIS Pediatric Global Health questionnaire (PGH-7). RESULTS AYAs had diagnoses of Klinefelter syndrome (41%), Turner syndrome (25%), and DSD (26%) and were 16.7 years (SD = 2.56) and 44% female. Parent participants were primarily mothers (81%). AYAs perceived that 48.09% of their information needs were unmet (SD = 25.18, range: 0-100). Parents perceived that 55.31% of AYAs' information needs were unmet (SD = 27.46 range: 5-100). AYAs and parents across conditions reported unmet needs related to information about transition to adult health care, financial support for medical care, and how the condition might affect the AYA's health in the future. While AYA-reported PGH-7 scores were not associated with percentage of AYA unmet information needs, parent-reported PGH-7 scores were (r = -.46, p < .001), such that lower parent-reported global health was associated with higher percentage of AYA unmet information needs. DISCUSSION/CONCLUSION On average, parents and AYAs perceived that half of AYAs' information needs were unmet, and a higher percentage of AYA unmet information needs was associated with lower perceived global health. The frequency of unmet needs in this sample of AYAs reflects an opportunity for improvement in clinical care. Future research is needed to understand how education to children and AYAs unfolds as they mature and to develop strategies to address the information needs of AYAs with a DSD or SCA, promote well-being, and facilitate AYA engagement in their own health care.
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Affiliation(s)
- Victoria A Miller
- Division of Adolescent Medicine, HUB, 3500 Civic Center Blvd., Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Christina Miller
- Graduate Program in Genetic Counseling, University of Colorado Anschutz Medical Campus, 13001 East 17th Place, W5107, Aurora, CO, 80045, USA
| | - Shanlee M Davis
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO, 80045, USA
| | - Natalie J Nokoff
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO, 80045, USA
| | - Cindy Buchanan
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO, 80045, USA
| | - Elizabeth A Friedrich
- Division of Adolescent Medicine, HUB, 3500 Civic Center Blvd., Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Alexandra Carl
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO, 80045, USA
| | - Sophia Strine
- Division of Endocrinology and Diabetes, HUB, 3500 Civic Center Blvd., Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Maria G Vogiatzi
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Endocrinology and Diabetes, HUB, 3500 Civic Center Blvd., Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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Grimberg A, Friedrich EA, Faig W, Kamoun C, Fremont ER, Xiao R, Miller VA. Patient and Parent Characteristics Related to Quality of Life and Self-Esteem in Healthy Youth Undergoing Provocative Growth Hormone Testing. J Pediatr 2023; 260:113460. [PMID: 37172805 DOI: 10.1016/j.jpeds.2023.113460] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/24/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To examine how height and youth as well as parenting characteristics associate with quality of life (QoL) and self-esteem among healthy youth undergoing growth evaluation with growth hormone (GH) testing. STUDY DESIGN Healthy youth, aged 8-14 years, undergoing provocative GH testing, and a parent completed surveys at or around the time of testing. Surveys collected demographic data; youth and parent reports of youth health-related QoL; youth reports of self-esteem, coping skills, social support, and parental autonomy support; and parent reports of perceived environmental threats and achievement goals for their child. Clinical data were extracted from electronic health records. Univariate models and multivariable linear regressions were used to identify factors associated with QoL and self-esteem. RESULTS Sixty youth (mean height z score -2.18 ± 0.61) and their parents participated. On multivariable modeling, youth perceptions of their physical QoL associated with higher grade in school, greater friend and classmate support, and older parent age; youth psychosocial QoL with greater friend and classmate support, and with less disengaged coping; and youth height-related QoL and parental perceptions of youth psychosocial QoL with greater classmate support. Youth self-esteem associated with greater classmate support and taller mid-parental height. Youth height was not associated with QoL or self-esteem outcomes in multivariable regression. CONCLUSIONS Perceived social support and coping skills, rather than height, were related to QoL and self-esteem in healthy short youth and may serve as an important potential area for clinical intervention.
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Affiliation(s)
- Adda Grimberg
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Elizabeth A Friedrich
- Craig Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Walter Faig
- Department of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Camilia Kamoun
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Endocrinology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Ettya R Fremont
- Craig Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rui Xiao
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Victoria A Miller
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Craig Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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Miller VA, Ibarra Toro A, Friedrich EA, Snyder M, Stevens E, Fremont ER. Adolescent, Parent, and Clinician Perspectives on Increasing Adolescent Involvement in Decision-Making During Clinic Visits. J Pediatr Health Care 2023; 37:528-536. [PMID: 37204373 PMCID: PMC10524528 DOI: 10.1016/j.pedhc.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/05/2023] [Accepted: 04/28/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION This study aimed to describe adolescent, parent, and clinician ideas for enhancing adolescent decision-making involvement (DMI) during clinic visits for chronic illness. METHOD Adolescents who recently attended a follow-up visit for a chronic illness, their parents, and clinicians were interviewed. Participants completed semistructured interviews; transcripts were coded and analyzed in NVivo. Responses to questions about ideas to increase adolescent DMI were reviewed and sorted into categories and themes. RESULTS There were five themes: (1) adolescents need to understand their condition and regimen, (2) adolescents and parents should prepare before the visit, (3) clinicians and adolescents should have one-on-one time, (4) opportunities for condition-specific peer support would be helpful, and (5) clinicians and parents should engage in specific communication behaviors. DISCUSSION Findings from this study highlight potential clinician-, parent-, and adolescent-focused strategies for enhancing adolescent DMI. Clinicians, parents, and adolescents may need specific guidance on how to enact new behaviors.
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Cousino MK, Miller VA, Smith C, Lim HM, Yu S, Lowery R, Uzark K, Fredericks EM, Wolfe J, Blume ED, Schumacher KR. Medical and End-of-Life Decision-Making Preferences in Adolescents and Young Adults with Advanced Heart Disease and Their Parents. JAMA Netw Open 2023; 6:e2311957. [PMID: 37145598 PMCID: PMC10163392 DOI: 10.1001/jamanetworkopen.2023.11957] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
Importance Despite high disease morbidity and mortality and complex treatment decisions, little is known about the medical and end-of-life decision-making preferences of adolescents and young adults (AYA) with advanced heart disease. AYA decision-making involvement is associated with important outcomes in other chronic illness groups. Objective To characterize decision-making preferences of AYAs with advanced heart disease and their parents and determine factors associated with these preferences. Design, Setting, and Participants Cross-sectional survey between July 2018 and April 2021 at a single-center heart failure/transplant service at a Midwestern US children's hospital. Participants were AYAs aged 12 to 24 years with heart failure, listed for heart transplantation, or posttransplant with life-limiting complications and a parent/caregiver. Data were analyzed from May 2021 to June 2022. Main Outcomes and Measures Single-item measure of medical decision-making preferences, MyCHATT, and Lyon Family-Centered Advance Care Planning Survey. Results Fifty-six of 63 eligible patients enrolled in the study (88.9%) with 53 AYA-parent dyads. Median (IQR) patient age was 17.8 (15.8-19.0) years; 34 (64.2%) patients were male, and 40 patients (75.5%) identified as White and 13 patients (24.5%) identified as members of a racial or ethnic minority group or multiracial. The greatest proportion of AYA participants (24 of 53 participants [45.3%]) indicated a preference for active, patient-led decision-making specific to heart disease management, while the greatest proportion of parents (18 of 51 participants [35.3%]) preferred they and physician(s) make shared medical decisions on behalf of their AYA, representing AYA-parent decision-making discordance (χ2 = 11.7; P = .01). Most AYA participants stated a preference to discuss adverse effects or risks of treatment (46 of 53 participants [86.8%]), procedural and/or surgical details (45 of 53 participants [84.9%]), impact of condition on daily activities (48 of 53 participants [90.6%]), and their prognosis (42 of 53 participants [79.2%]). More than half of AYAs preferred to be involved in end-of-life decisions if very ill (30 of 53 participants [56.6%]). Longer time since cardiac diagnosis (r = 0.32; P = .02) and worse functional status (mean [SD] 4.3 [1.4] in New York Heart Association class III or IV vs 2.8 [1.8] in New York Heart Association class I or II; t-value = 2.7; P = .01) were associated with a preference for more active, patient-led decision-making. Conclusions and Relevance In this survey study, most AYAs with advanced heart disease favored active roles in medical decision-making. Interventions and educational efforts targeting clinicians, AYAs with heart disease, and their caregivers are needed to ensure they are meeting the decision-making and communication preferences of this patient population with complex disease and treatment courses.
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Affiliation(s)
- Melissa K Cousino
- Department of Pediatrics, Michigan Medicine, Ann Arbor
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor
| | - Victoria A Miller
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia Smith
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Heang M Lim
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Sunkyung Yu
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Ray Lowery
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Karen Uzark
- Department of Pediatrics, Michigan Medicine, Ann Arbor
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor
| | | | - Joanne Wolfe
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Elizabeth D Blume
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
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Kamoun C, Miller VA, Feudtner C, Friedrich EA, Grimberg A. Views on Short Stature of Female Versus Male Endocrine Pediatric Patients Undergoing Provocative Growth Hormone Testing and Their Parents. Endocr Pract 2023:S1530-891X(23)00381-6. [PMID: 37088146 PMCID: PMC10330208 DOI: 10.1016/j.eprac.2023.04.004] [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: 02/08/2023] [Revised: 04/08/2023] [Accepted: 04/14/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE Boys outnumber girls in short stature evaluations and growth hormone treatment despite absence of gender differences in short stature prevalence. Family views on short stature influence medical management, but gender-based analysis of these views is lacking. This study explored endocrine patients' and their parents' perceptions of short stature and its impact on quality of life by patient gender. METHODS Patients aged 8-14 years undergoing provocative growth hormone testing and one parent each completed semi-structured interviews. Clinical data were extracted by chart review. RESULTS 24 patient-parent dyads (6 female patients, 22 mothers; predominantly non-Hispanic White) participated. Six major themes emerged: 1) patients' perceptions of their short stature were similar by gender, 2) physical experiences of short stature were similar by gender, 3) social experiences of short stature were both similar and different by gender, 4) parental perceptions of short stature as a factor limiting their child's functionality were similar by gender, 5) concern about societal stigma related to short stature arose for both genders, and 6) patients' perceptions of parental messaging about the import of their short stature were similar by gender. CONCLUSION Our data reveal more similarities than differences between genders in patient perceptions and patient and parent-reported experiences of short stature. Worry about stature-related stigma was noted for patients of both genders. Parental messaging about short stature emerged as an important area to explore further by patient gender. Our findings suggest that clinicians should be wary of making gender or stigma-based assumptions when evaluating children with short stature.
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Affiliation(s)
- Camilia Kamoun
- Division of Endocrinology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA.
| | - Victoria A Miller
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Feudtner
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medical Ethics, Children's Hospital of Philadelphia & Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth A Friedrich
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Adda Grimberg
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Fremont ER, Friedrich EA, Grimberg A, Miller VA. Youth and Parent Perceptions of Youth Decision-Making Roles Regarding Evaluation for Short Stature. Child Health Care 2023; 53:148-162. [PMID: 38646614 PMCID: PMC11028966 DOI: 10.1080/02739615.2022.2163491] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Youth decision-making involvement (DMI) in medical treatment associates with greater adherence and feelings of self-efficacy. However, little is known about youth DMI regarding medical evaluation and diagnostic procedures. Using thematic analysis of semi-structured interviews, we explored parent (n=24) and youth (n=24) perceptions of youth roles in the decision to undergo evaluation for short stature. Five themes emerged about evaluation decisions including: parents/providers were gatekeepers, some parents sought youth agreement, conversations focused on logistics, some parents gave limited information, and youth expressed anxiety. Results suggest that including youth in discussions about evaluation may alleviate anxiety and uncertainty about upcoming procedures.
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Affiliation(s)
- Ettya R. Fremont
- Division of Adolescent Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth A. Friedrich
- Division of Adolescent Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adda Grimberg
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria A. Miller
- Division of Adolescent Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Fremont ER, Friedrich EA, Feudtner C, Grimberg A, Miller VA. Perceptions of Youth and Parent Decision-Making Roles Regarding Recombinant Human Growth Hormone Treatment. Endocrines 2022; 3:590-600. [PMID: 37152718 PMCID: PMC10162591 DOI: 10.3390/endocrines3040050] [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] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
Recombinant human growth hormone (rhGH) is prescribed to youth with growth hormone deficiency (GHD) to support normal growth and ensure healthy physical development, and to youth without GHD to address height concerns. Perceptions of youth involvement in rhGH treatment decisions have not been explored. This study aimed to examine perceptions of youth and parent roles in decisions around rhGH treatment. Youth (n = 22, 11.5 ± 2.0 years) who had undergone evaluation for short stature and their parents (n = 22) participated in semi-structured interviews after stimulation test results had been received. Interviews revealed the following themes: 1) parent provided youth with support; 2) parent facilitated youth's decision-making involvement; 3) youth had no role or did not remember their role; and 4) youth did not remember conversations with their parents or providers. Parents facilitated their children's involvement by sharing information and seeking their opinions. Whereas some participants described youth as having a substantial decision-making role, not all youth felt they were involved, and some youth could not recall conversations about rhGH. Parents can bolster youth involvement by having conversations using developmentally appropriate language, which is critical to youth feeling empowered and developing efficacy over their own care.
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Affiliation(s)
- Ettya R. Fremont
- Division of Adolescent Medicine, Children’s Hospital of Philadelphia
| | | | - Chris Feudtner
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania
| | - Adda Grimberg
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia
| | - Victoria A. Miller
- Division of Adolescent Medicine, Children’s Hospital of Philadelphia
- Correspondence:
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Barber FD, Campbell E, Yamamura Y, Patterson CJ, Hartnett AC, Kinahan H, Miller VA, Brink AL, Poullard A, Urschel GE, Brantley A, Cepeda IG, Goswami P, Charles S, Philip S, Bresser S, Musekiwa-Adjei S, Perez N, Le H, Phillips P, Subbiah V, Meric-Bernstam F, Dumbrava EE. Management of Adverse Events in Early Clinical Trials by Advanced Practice Providers in the Outpatient Setting: The University of Texas MD Anderson Cancer Center Experience. J Adv Pract Oncol 2022; 13:664-672. [PMID: 36199491 PMCID: PMC9514129 DOI: 10.6004/jadpro.2022.13.7.2] [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] [Indexed: 11/17/2022] Open
Abstract
Background Advanced practice providers (APPs) play important roles in enrolling, educating, and caring for patients in clinical trials. However, much remains unknown about the role of APPs in managing adverse events (AEs) in early (phase I to II) clinical trials. In this study, we assessed the outpatient management of grade 3 to 4 AEs by APPs in early trials and characterized the workflow of our APP Phase I to II Fast Track (FT) Clinic. Patients and Methods We retrospectively reviewed records of patients with advanced or metastatic solid tumors enrolled in phase I to II clinical trials who were seen by APPs from September 2017 to August 2018 in the APP phase I to II FT clinic in the Department of Investigational Cancer Therapeutics. Results A total of 808 patients enrolled in 159 clinical trials were seen in 2,697 visits (median 3 visits per patient; range 1-28) by 10 APPs. Treatment was interrupted in 6.9% of visits, and grade 3 to 4 AEs were seen in 5.4% of visits; however, patients from 1.4% of visits were sent to the emergency center (EC) and/or admitted. Patients referred to the EC and/or admitted were more likely to have baseline hypoalbuminemia, high lactate dehydrogenase, and poor Eastern Cooperative Oncology Group performance status (i.e., ECOG > 1; p < .001). There were no associations between EC referral and gender, APP years of experience, or type of treatment. Conclusions The APP Phase I to II FT Clinic has an important role in the management of AEs by APPs in early clinical trials in the outpatient setting, potentially avoiding EC visits and admissions.
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Affiliation(s)
- Fedricker D. Barber
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Erick Campbell
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yuko Yamamura
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Clover J. Patterson
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Audrey C. Hartnett
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Holly Kinahan
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Victoria A. Miller
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amanda L. Brink
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anna Poullard
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gabriele E. Urschel
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andre Brantley
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Isabel G. Cepeda
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Poonam Goswami
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sheena Charles
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shincy Philip
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sara Bresser
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sandra Musekiwa-Adjei
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nageli Perez
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hung Le
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Penny Phillips
- Clinical Center for Targeted Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Vivek Subbiah
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Funda Meric-Bernstam
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Sheikh Khalifa Bin Zayed Al Nahyan Institute for Personalized Cancer Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ecaterina E. Dumbrava
- From Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Kenyon CC, Flaherty C, Floyd GC, Jenssen BP, Miller VA. Promoting Healthy Childhood Behaviors With Financial Incentives: A Narrative Review of Key Considerations and Design Features for Future Research. Acad Pediatr 2022; 22:203-209. [PMID: 34403802 PMCID: PMC8844312 DOI: 10.1016/j.acap.2021.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 03/16/2021] [Revised: 07/15/2021] [Accepted: 08/10/2021] [Indexed: 11/24/2022]
Abstract
In the last decade, there has been a robust increase in research using financial incentives to promote healthy behaviors as behavioral economics and new monitoring technologies have been applied to health behaviors. Most studies of financial incentives on health behaviors have focused on adults, yet many unhealthy adult behaviors have roots in childhood and adolescence. The use of financial incentives is an attractive but controversial strategy in childhood. In this review, we first propose 5 general considerations in designing and applying incentive interventions to children. These include: 1) the potential impact of incentives on intrinsic motivation, 2) ethical concerns about incentives promoting undue influence, 3) the importance of child neurodevelopmental stage, 4) how incentive interventions may influence health disparities, and 5) how to finance effective programs. We then highlight empirical findings from randomized trials investigating key design features of financial incentive interventions, including framing (loss vs gain), timing (immediate vs delayed), and magnitude (incentive size) effects on a range of childhood behaviors from healthy eating to adherence to glycemic control in type 1 diabetes. Though the current research base on these subjects in children is limited, we found no evidence suggesting that loss-framed incentives perform better than gain-framed incentives in children and isolated studies from healthy food choice experiments support the use of immediate, small incentives versus delayed, larger incentives. Future research on childhood incentives should compare the effectiveness of gain versus loss-framing and focus on which intervention characteristics lead to sustained behavior change and habit formation.
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Affiliation(s)
- Chén C. Kenyon
- PolicyLab and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia,Division of General Pediatrics, Children’s Hospital of Philadelphia,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania
| | - Carina Flaherty
- PolicyLab and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia
| | - G. Chandler Floyd
- PolicyLab and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia
| | - Brian P. Jenssen
- PolicyLab and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia,Division of General Pediatrics, Children’s Hospital of Philadelphia,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania
| | - Victoria A. Miller
- Division of Adolescent Medicine, Children’s Hospital of Philadelphia,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania
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Nickerson JL, Baghalabadi V, Dang Z, Miller VA, Little SL, Doucette AA. Organic Solvent-Based Protein Precipitation for Robust Proteome Purification Ahead of Mass Spectrometry. J Vis Exp 2022. [DOI: 10.3791/63503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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12
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Agarwal S, Crespo-Ramos G, Long JA, Miller VA. "I Didn't Really Have a Choice": Qualitative Analysis of Racial-Ethnic Disparities in Diabetes Technology Use Among Young Adults with Type 1 Diabetes. Diabetes Technol Ther 2021; 23:616-622. [PMID: 33761284 PMCID: PMC8501459 DOI: 10.1089/dia.2021.0075] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: Racial-ethnic disparities in diabetes technology use are well documented in young adults (YA) with type 1 diabetes (T1D), but modifiable targets for intervention still need to be identified. Our objective was to explore YA perspectives on technology access and support in routine clinical care. Materials and Methods: Participants were YA with T1D of Hispanic or non-Hispanic Black race-ethnicity from pediatric and adult endocrinology clinics in the Bronx, NY. We conducted semistructured individual interviews to explore how health care and personal experiences affected technology use. Interviews were audio-recorded and transcribed for analysis. We used a modified inductive coding approach with two independent coders and iterative coding processes to improve data reliability and validity. Results: We interviewed 40 YA with T1D: mean age 22 years; 62% female; 72% Medicaid insured; 72% Hispanic; 28% non-Hispanic Black; and mean hemoglobin A1C 10.3%. Themes were categorized into potentially exacerbating and alleviating factors of racial-ethnic disparities in technology use. Exacerbating factors included perceptions that providers were gatekeepers of information and prescription access to technology, providers did not employ shared decision making for use, and YA biases against technology were left unaddressed. Alleviating factors included provider optimism and tailoring of technology benefits to YA needs, and adequate Medicaid insurance coverage. Conclusions: Our results reveal potential intervention targets at the provider level to increase technology uptake among underrepresented YA with T1D. Diabetes health care providers need to be aware of inadvertent withholding of information and prescription access to technology. Provider approaches that address YA technology concerns and promote shared decision making help to mitigate racial/ethnic disparities in technology use.
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Affiliation(s)
- Shivani Agarwal
- Fleischer Institute for Diabetes and Metabolism, Montefiore Medical Center, Bronx, New York, USA
- NY-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, New York, USA
- Address correspondence to: Shivani Agarwal, MD, MPH, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, 1180 Morris Park Avenue, Bronx, NY 10461, USA
| | - Gladys Crespo-Ramos
- Fleischer Institute for Diabetes and Metabolism, Montefiore Medical Center, Bronx, New York, USA
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Judith A. Long
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Victoria A. Miller
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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13
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Fremont ER, Slick N, Willi SM, Miller VA. "I Think Parents Shouldn't Be Too Pushy": A Qualitative Exploration of Parent and Youth Perspectives of Youth Decision-Making Involvement in Starting Continuous Glucose Monitoring. Sci Diabetes Self Manag Care 2021; 47:355-366. [PMID: 34448420 DOI: 10.1177/26350106211040424] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this qualitative study was to explore parent and youth perspectives of the decision-making process to start continuous glucose monitoring (CGM). METHODS Youth with type 1 diabetes and their parents were assessed with semistructured interviews before adding CGM to their regimen and 2 months after device initiation. Interviews focused on parent, youth, and provider decision-making roles and suggestions for enhancing youth decision-making involvement (DMI). Data were coded and analyzed using thematic analysis. RESULTS Youth (N = 41; 13.7 ± 2.9 years) were categorized into decision-making roles: (1) youth primary decision maker (54.8%), (2) youth primary decision maker with parental influence (14.3%), (3) parent primary decision maker with youth agreement (26.2%), and (4) parent primary decision maker without youth agreement (4.8%). Participants described that clinicians provided information, recommended CGM, and gave support. Recommendations to enhance youth DMI included that youth should ask questions, express opinions, and do their own research. Providers should give unbiased information and use visual aids (eg, show the device and videos) to engage youth. CONCLUSIONS Participants agreed that whereas youth should have a primary role in the decision about CGM, parental and provider support is critical. Parents and providers can facilitate dialogue by directly engaging with youth about their thoughts, feelings, and concerns. Provider use of visual aids may enhance youth engagement and expectations.
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Affiliation(s)
- Ettya R Fremont
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nathalie Slick
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven M Willi
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria A Miller
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Miller VA, Xiao R, Willi SM. Correlates of Continuous Glucose Monitoring Use Trajectories in Children and Adolescents with Type 1 Diabetes. Diabetes Technol Ther 2021; 23:590-594. [PMID: 33605786 PMCID: PMC8377507 DOI: 10.1089/dia.2020.0668] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The goal of this study was to characterize trajectories of continuous glucose monitoring (CGM) use in youth 5-12 weeks after starting CGM and examine what factors differentiate between the trajectory groups. Parent-youth dyads completed assessments before starting CGM. Days of CGM use between weeks 5 and 12 were accessed through cloud-based data repository. Three patterns of use were observed among 96 youth (mean age 13.4 ± 2.75 years; 75% white): sustained high, declining, and sustained low. Youth in the sustained low and declining groups were more likely than those in the sustained high group to use a receiver (versus smart phone). There were no differences between the trajectory groups with respect to age, race, ethnicity, income, or insulin regimen. Future research should examine trajectory groups for a longer follow-up period and identify baseline factors that reliably predict which youth will have low or declining CGM use over time.
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Affiliation(s)
- Victoria A. Miller
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Address correspondence to, Victoria A. Miller, PhD, Division of Adolescent Medicine, Children's Hospital of Philadelphia, Buerger Room 12-219, Philadelphia, PA 19104-4399, USA
| | - Rui Xiao
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven M. Willi
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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15
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Fremont ER, Miller VA. Perspectives on Remote Glucose Monitoring in Youth With Type 1 Diabetes. J Pediatr Psychol 2021; 46:1276-1285. [PMID: 34333655 DOI: 10.1093/jpepsy/jsab068] [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: 01/08/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Continuous glucose monitoring (CGM) has become increasingly popular among youth with type 1 diabetes (T1D). Used with CGM, remote monitoring (RM) gives caregivers real-time access to patients' glucose values. Whereas RM may safeguard against hypo- and hyperglycemic events, little is known about how older children and adolescents, who are striving for independence, and their parents view the RM aspect of CGM. The goal of this study was to describe and explore parent and youth perceptions of RM. METHODS Youth with T1D and their parents participated separately in semi-structured interviews 2 months after starting CGM. Questions focused on decisions to use and experiences with RM. RESULTS Analysis of 43 parents and 41 youth (13.79 years ± 2.82) interviews revealed four themes, with 10 subthemes. Seven subthemes emerged in parent and youth interviews, and three emerged exclusively in parent interviews. The overarching themes included the impact of RM on (1) peace-of-mind, (2) parental anxiety, (3) communication; and addressed (4) technological limitations that prevented some from using RM. Regardless of youth age, youth and parents found comfort in parental knowledge of glucose values and parental abilities to assist youth (e.g., giving reminders to eat). Whereas RM could lead to conflicts due to excessive communication (e.g., texting), conflicts could be resolved through iterative parent-youth conversations. CONCLUSION RM may facilitate youth independence by providing a way for them to stay connected to their support system while acquiring developmentally appropriate skills. However, families should have iterative discussions about boundaries to mitigate parental over-involvement.
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Affiliation(s)
| | - Victoria A Miller
- Children's Hospital of Philadelphia.,Perelman School of Medicine at the University of Pennsylvania
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Lee T, Rosario H, Cifuentes E, Cui J, Lin EC, Miller VA, Lin HC. Review of interruptions in a pediatric subspecialty outpatient clinic. PLoS One 2021; 16:e0254528. [PMID: 34324552 PMCID: PMC8320932 DOI: 10.1371/journal.pone.0254528] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 06/29/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction The objective of this study was to describe interruptions in the pediatric ambulatory setting and to assess their impact on perceived physician communication, patient satisfaction and recall of provided physician instructions. Methods An observational study was performed at the Children’s Hospital of Philadelphia, Pediatric Gastroenterology clinic. Participation consisted of video recording the clinic visit and the caregiver completed post-visit surveys on communication and satisfaction. Video recordings were coded for interruptions, which were divided into 3 main categories: Visit Associated, Pediatric Associated, and Unanticipated. An interruption rate was calculated and correlated with the following outcome variables to assess the impact of interruptions: caregiver satisfaction, caregiver perception on the quality of physician communication, and caregiver instruction recall. Results There were 675 interruptions noted in the 81 clinic visits, with an average of 7.96 (σ = 7.68) interruptions per visit. Six visits had no interruptions. The Patient was the most frequent interrupter. Significantly higher interruption rates occurred in clinic visits with younger patients (<7 years old) with most of the interruptions being Pediatric Associated interruptions. There was minimal correlation between the clinic visit interruption rate and caregiver satisfaction with the communication, caregiver perception of quality of communication, or caregiver instruction recall rate. Conclusion The effect of interruptions on the pediatric visit remains unclear. Interruptions may be part of the communication process to ensure alignment of the patient’s agenda. Additional studies are needed to help determine the impact of interruptions and guide medical education on patient communication.
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Affiliation(s)
- Tyler Lee
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Hinette Rosario
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Elizabeth Cifuentes
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Jiawei Cui
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Emery C. Lin
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Victoria A. Miller
- Division of Adolescent Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Henry C. Lin
- Division of Pediatric Gastroenterology, Doernbecher Children’s Hospital, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, United States of America
- * E-mail:
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17
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Friedrich E, Robles R, Silva K, Fisher Thiel M, Ford CA, Miller VA. Feasibility and Acceptability of a Novel Primary Care-Based Intervention to Promote Parent-Teen Communication About Teen Strengths. J Prim Prev 2021; 42:163-181. [PMID: 33709224 DOI: 10.1007/s10935-021-00626-3] [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] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 10/21/2022]
Abstract
Strength-based approaches to youth development have been tested in community settings and are related to improvements in social, health, and academic realms. However, little is known about similar approaches to enhance parent-teen communication (PTC) in pediatric primary care. The goal of this study was to test the feasibility and acceptability of an intervention to facilitate parent-teen communication about teen strengths. Intervention materials were developed based on a literature review, expert consultation, and feedback from stakeholders. The final intervention was a parent-directed booklet and a parent-teen discussion activity. At the well-adolescent visit (WAV), dyads received an orientation to the materials and were instructed to complete the discussion activity within 2 weeks of the WAV. Health Care Providers verbally endorsed the materials and instructed parents to read the booklet and complete the discussion activity with their teens. Acceptability was assessed at 2-week and 2-month follow-ups. Parent-adolescent dyads from an urban, pediatric primary care practice were enrolled with half assigned to the treatment group. Those in the treatment group (60 dyads) are the focus of this paper. Youth were 13-15 years old, 55% female, and 66% Black. Most participating parents (97%) were female. Fidelity was ≥ 88% for delivery of each of the intervention components. Fifty-four of the 60 parents in the intervention group completed the 2-week call. Of those 54 parents, 96% read the booklet and 62% found the booklet either extremely or very helpful. The majority of parents (67%) and teens (72%) reported that the discussion activity was excellent or very good. Analysis of qualitative data also provided rich insight into the participants' experiences with the intervention materials. Overall results suggest that an intervention to promote PTC about teen strengths is feasible and acceptable to parents and teens within primary care.
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Affiliation(s)
- Elizabeth Friedrich
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Buerger Building, Room 12-219, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.,Center for Parent and Teen Communication, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Reyneris Robles
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Buerger Building, Room 12-219, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.,Center for Parent and Teen Communication, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Karol Silva
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Buerger Building, Room 12-219, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Megan Fisher Thiel
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Buerger Building, Room 12-219, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Carol A Ford
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Buerger Building, Room 12-219, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.,Division of Adolescent Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.,Center for Parent and Teen Communication, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Victoria A Miller
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Buerger Building, Room 12-219, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA. .,Division of Adolescent Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA. .,Center for Parent and Teen Communication, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA.
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18
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Dalembert G, Samba I, Miller VA, Ford CA, Fiks AG. Perspectives of Urban Adolescent Black Males and Their Parents on Well Care. Acad Pediatr 2021; 21:336-343. [PMID: 32861804 DOI: 10.1016/j.acap.2020.08.018] [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: 02/11/2020] [Revised: 07/13/2020] [Accepted: 08/26/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Adolescents have fewer well-care visits than all other age groups. Males and ethnic minorities are seen least often. We elicited from Black adolescent males and their parents key drivers of teen well-care seeking. METHODS We conducted separate semistructured interviews with Black adolescent males and their parents. We recruited parent-teen dyads from West Philadelphia. Eligible teens were age 13 to 18, with no complex chronic health conditions. We purposively sampled teens who had not received preventive care in at least 2 years, some of whom had since returned to care and some not. Interviews were recorded, transcribed, and coded by 2 coders using the constant comparative method, resolving discrepancies by consensus. Interviews continued until thematic saturation. RESULTS We interviewed 23 Black adolescent males (mean age 15) and 22 parents (20 mothers). Participants understood that teens should routinely receive preventive care. Four themes emerged: receiving preventive care is important to knowing teens are mentally and physically well; remembering to schedule/attend visits is challenging - participants find appointment reminders helpful; mothers noted that males of all ages are generally disengaged from health care; teens and parents felt that a "good" parent ensures teens receive preventive care. CONCLUSIONS Black adolescent males and their parents value regular preventive care as an opportunity to ensure the teen is physically and mentally well, but competing priorities interfere with care receipt. Results support testing the impact of reminders on receipt of care in this population. These reminders may be most effective if directed at mothers and focused on "good parenting."
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Affiliation(s)
- George Dalembert
- Department of Pediatrics, Children's Hospital of Philadelphia (G Dalembert, I Samba, VA Miller, CA Ford, and AG Fiks), Philadelphia, Pa; University of Pennsylvania Perelman School of Medicine (G Dalembert, VA Miller, CA Ford, and AG Fiks), Philadelphia, Pa.
| | - Ima Samba
- Department of Pediatrics, Children's Hospital of Philadelphia (G Dalembert, I Samba, VA Miller, CA Ford, and AG Fiks), Philadelphia, Pa
| | - Victoria A Miller
- Department of Pediatrics, Children's Hospital of Philadelphia (G Dalembert, I Samba, VA Miller, CA Ford, and AG Fiks), Philadelphia, Pa; University of Pennsylvania Perelman School of Medicine (G Dalembert, VA Miller, CA Ford, and AG Fiks), Philadelphia, Pa
| | - Carol A Ford
- Department of Pediatrics, Children's Hospital of Philadelphia (G Dalembert, I Samba, VA Miller, CA Ford, and AG Fiks), Philadelphia, Pa; University of Pennsylvania Perelman School of Medicine (G Dalembert, VA Miller, CA Ford, and AG Fiks), Philadelphia, Pa
| | - Alexander G Fiks
- Department of Pediatrics, Children's Hospital of Philadelphia (G Dalembert, I Samba, VA Miller, CA Ford, and AG Fiks), Philadelphia, Pa; University of Pennsylvania Perelman School of Medicine (G Dalembert, VA Miller, CA Ford, and AG Fiks), Philadelphia, Pa
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Safa A, Lau AR, Aten S, Schilling K, Bales KL, Miller VA, Fitzgerald J, Chen M, Hill K, Dzwigalski K, Obrietan K, Phelps MA, Sadee W, Oberdick J. Pharmacological Prevention of Neonatal Opioid Withdrawal in a Pregnant Guinea Pig Model. Front Pharmacol 2021; 11:613328. [PMID: 33716726 PMCID: PMC7953910 DOI: 10.3389/fphar.2020.613328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/15/2020] [Indexed: 11/19/2022] Open
Abstract
Newborns exposed to prenatal opioids often experience intense postnatal withdrawal after cessation of the opioid, called neonatal opioid withdrawal syndrome (NOWS), with limited pre- and postnatal therapeutic options available. In a prior study in pregnant mice we demonstrated that the peripherally selective opioid antagonist, 6β-naltrexol (6BN), is a promising drug candidate for preventive prenatal treatment of NOWS, and a therapeutic mechanism was proposed based on preferential delivery of 6BN to fetal brain with relative exclusion from maternal brain. Here, we have developed methadone (MTD) treated pregnant guinea pigs as a physiologically more suitable model, enabling detection of robust spontaneous neonatal withdrawal. Prenatal MTD significantly aggravates two classic maternal separation stress behaviors in newborn guinea pigs: calling (vocalizing) and searching (locomotion) - natural attachment behaviors thought to be controlled by the endogenous opioid system. In addition, prenatal MTD significantly increases the levels of plasma cortisol in newborns, showing that cessation of MTD at birth engages the hypothalamic-pituitary-adrenal (HPA) axis. We find that co-administration of 6BN with MTD prevents these withdrawal symptoms in newborn pups with extreme potency (ID50 ∼0.02 mg/kg), at doses unlikely to induce maternal or fetal withdrawal or to interfere with opioid antinociception based on many prior studies in rodents and non-human primates. Furthermore, we demonstrate a similarly high potency of 6BN in preventing opioid withdrawal in adult guinea pigs (ID50 = 0.01 mg/kg). This high potency appears to run counter to our pharmacokinetic studies showing slow 6BN transit of both the placenta and maternal blood brain barrier in guinea pigs, and calls into question the preferential delivery mechanism. Rather, it suggests a novel receptor mechanism to account for the selectively high potency of 6BN to suppress opioid dependence at all developmental stages, even in adults, as compared to its well-established low potency as a classical opioid antagonist. In conclusion, 6BN is an attractive compound for development of a preventive therapy for NOWS.
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Affiliation(s)
- Alireza Safa
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Allison R. Lau
- Department of Psychology, California National Primate Research Center, Animal Behavior Graduate Group, University of California, Davis, CA, United States
| | - Sydney Aten
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Karl Schilling
- Anatomisches Institute, Anatomie und Zellbiologie, Rheinische Friedrich-Wilhelms-Universität, Bonn, Germany
| | - Karen L. Bales
- Department of Psychology, California National Primate Research Center, Animal Behavior Graduate Group, University of California, Davis, CA, United States
| | - Victoria A. Miller
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Julie Fitzgerald
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Min Chen
- Division of Pharmaceutics and Pharmaceutical Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH, United States
| | - Kasey Hill
- Division of Pharmaceutics and Pharmaceutical Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH, United States
| | - Kyle Dzwigalski
- Division of Pharmaceutics and Pharmaceutical Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH, United States
| | - Karl Obrietan
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Mitch A. Phelps
- Division of Pharmaceutics and Pharmaceutical Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH, United States
| | - Wolfgang Sadee
- Department of Cancer Biology and Genetics, Ohio State University Wexner Medical Center, Columbus, OH, United States
- Aether Therapeutics Inc., Austin, TX, United States
| | - John Oberdick
- Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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20
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Miller VA, Xiao R, Slick N, Feudtner C, Willi SM. Youth Involvement in the Decision to Start CGM Predicts Subsequent CGM Use. Diabetes Care 2020; 43:2355-2361. [PMID: 32703764 PMCID: PMC7510031 DOI: 10.2337/dc20-0348] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/25/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The ability of continuous glucose monitoring (CGM) to improve diabetes outcomes depends upon consistent use. To identify factors that facilitate long-term use of CGM, this study tested the hypothesis that youth involvement in the decision to initiate this therapy would influence subsequent CGM use and that CGM self-efficacy and satisfaction mediate this relationship. RESEARCH DESIGN AND METHODS Before initiating CGM, parent-youth dyads (i.e., pairs) from an academic endocrinology clinic completed assessments, including a measure of the child's involvement in the decision to start CGM. Two months into CGM use, youth completed measures of CGM self-efficacy and satisfaction. Fidelity of CGM use between weeks 5 and 12 was accessed via a cloud-based data repository. Hypotheses were tested with linear mixed-effects models, accounting for patients clustered within provider and repeated measures within patients. RESULTS CGM use in 108 dyads (youth mean age 13.4 ± 2.7 years; 73% White) was positively predicted by baseline parent report of youth involvement in the CGM decision (P < 0.0001), and this relationship was mediated by youth's perceptions of CGM self-efficacy (P < 0.0001) and hassle (P = 0.014). So, when the youth shared their opinions about CGM with parents and participated in the decision to start, they perceived higher self-efficacy and lower hassle at 2-month follow-up, which predicted more days of use. This pattern held in models adjusting for youth race and sex and family income. CONCLUSIONS To achieve maximum clinical benefit from CGM use, providers should facilitate youth involvement in the decision to initiate the device.
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Affiliation(s)
- Victoria A Miller
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rui Xiao
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nathalie Slick
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Chris Feudtner
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Steven M Willi
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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21
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Henderson BR, Flaherty CM, Floyd GC, You J, Xiao R, Bryant-Stephens TC, Miller VA, Feudtner C, Kenyon CC. Tailored Medication Adherence Incentives Using mHealth for Children With High-Risk Asthma (TAICAM): Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e16711. [PMID: 32459653 PMCID: PMC7459431 DOI: 10.2196/16711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 01/24/2023] Open
Abstract
Background Poor adherence to inhaled corticosteroid medications for children with high-risk asthma is both well documented and poorly understood. It has a disproportionate prevalence and impact on children of minority demographics in urban settings. Financial incentives have been shown to be a compelling method to engage those in a high-risk asthma population, but whether adherence can be maintained by offering financial incentives and how these incentives can be used to sustain high adherence are unknown. Objective The aim of this study is to determine the marginal effects of a financial incentive–based intervention on inhaled corticosteroid adherence, health care system use, and costs. Methods Participants include children aged 5 to 12 years who have had either at least two hospitalizations or one hospitalization and one emergency department visit for asthma in the year prior to their enrollment (and their caregivers). Participants are given an electronic inhaler sensor in order to track their medication use over a period of 7 months. After a 1-month period of observation, participants are randomized to 1 of 3 arms for a 3-month period. Participants in arm 1 receive daily text message reminders, feedback, and gain–framed, nominal financial incentives; participants in arm 2 receive daily text message reminders and feedback only, and participants in arm 3 receive no reminders, feedback, or incentives. All participants are subsequently observed for an additional 3-month period with no reminders, feedback, or incentives to assess whether any sustained effects are apparent. Results Study enrollment began in September 2019 with a target sample size of N=125 children. As of June 2020, 61 children have been enrolled. Data collection is estimated to be completed in June 2022, and analyses will be completed by June 2023. Conclusions This study will provide data that will help to determine whether a financial incentive–based mobile health intervention for promoting inhaled corticosteroid use can be effective in patients with high-risk asthma over longer periods. Trial Registration Clinicaltrial.gov NCT03907410; https://clinicaltrials.gov/ct2/show/NCT03907410 International Registered Report Identifier (IRRID) DERR1-10.2196/16711
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Affiliation(s)
- Brittney R Henderson
- Roberts Center for Pediatric Research, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Carina M Flaherty
- Roberts Center for Pediatric Research, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - G Chandler Floyd
- Roberts Center for Pediatric Research, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jack You
- Roberts Center for Pediatric Research, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Rui Xiao
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Tyra C Bryant-Stephens
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Victoria A Miller
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Chris Feudtner
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Chén Collin Kenyon
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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22
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Murphy C, Miller VA. Concurrent and Longitudinal Associations among Parenting Style, Responsibility, and Adherence in Youth with Cystic Fibrosis. Child Health Care 2020; 49:153-167. [PMID: 32742054 DOI: 10.1080/02739615.2019.1616295] [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] [Indexed: 10/26/2022]
Abstract
In an effort to identify pathways for improvements in clinical monitoring and intervention, the current study investigated the role that parenting style plays in treatment adherence and responsibility for youth with CF. Participants (n = 50) completed questionnaires related to treatment adherence, treatment responsibility, and parenting style at baseline and at a two year follow up visit. Aspects of parenting style (e.g., warmth, autonomy support) were related to youth adherence and responsibility in cross-sectional and prospective analyses. These data suggest that aspects of parenting may be important targets of interventions to promote treatment adherence in youth with CF.
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Affiliation(s)
- Christina Murphy
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA
| | - Victoria A Miller
- Children's Hospital of Philadelphia, Philadelphia, PA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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23
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Miller VA, Silva K, Friedrich E, Robles R, Ford CA. Efficacy of a Primary Care-Based Intervention to Promote Parent-Teen Communication and Well-Being: A Randomized Controlled Trial. J Pediatr 2020; 222:200-206.e2. [PMID: 32444221 DOI: 10.1016/j.jpeds.2020.03.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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] [Received: 10/07/2019] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the impact of a primary care-based, parent-directed intervention on changes in parent-teen communication, parental beliefs about adolescents, parent and adolescent well-being, adolescent distress, and adolescent positive affect from baseline to 2-month follow-up. STUDY DESIGN In this randomized controlled trial, 120 adolescents (13-15 years of age) scheduled for well visits and their parents were randomized to the strength intervention or control group. The intervention included a booklet highlighting 3 key messages about adolescence, instructions to have a discussion with their teen about each other's strengths, and clinician endorsement. Outcomes were assessed before the well visit and 2 months later. RESULTS Adolescents were 61% female and 65% black. Parents were primarily female (97%); 72% had a 4-year degree or higher. The intervention had a positive impact on adolescent-reported open communication among adolescents with baseline low open communication scores (B = 3.55; P = .005; 95% CI, 1.07-6.03). Adolescents in the intervention group reported a decrease in distress (-1.54 vs 3.78; P = .05; partial eta squared [η2] = 0.038) and increase in positive affect (1.30 vs -3.64; P = .05; η2 = 0.04) compared with control group adolescents. The intervention did not affect parent-reported communication, parental beliefs, or adolescent well-being. Control parents demonstrated a marginal increase in well-being, whereas intervention parents did not (0.82 vs -0.18; P = .07; η2 = 0.029). CONCLUSIONS This study highlights the potential impact of primary care-based, universal, low-intensity interventions targeting parents of adolescents on parent-teen communication and important adolescent health outcomes. TRIAL REGISTRATION Clinicaltrials.gov: NCT03496155.
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Affiliation(s)
- Victoria A Miller
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Adolescent Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Parent and Teen Communication, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Karol Silva
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth Friedrich
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Center for Parent and Teen Communication, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Reyneris Robles
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Center for Parent and Teen Communication, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Carol A Ford
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Adolescent Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Parent and Teen Communication, Children's Hospital of Philadelphia, Philadelphia, PA
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24
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Silva K, Ford CA, Miller VA. Daily Parent-Teen Conflict and Parent and Adolescent Well-Being: The Moderating Role of Daily and Person-Level Warmth. J Youth Adolesc 2020; 49:1601-1616. [PMID: 32472471 DOI: 10.1007/s10964-020-01251-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 02/04/2020] [Accepted: 04/29/2020] [Indexed: 01/20/2023]
Abstract
In early-mid adolescence, parent-teen conflicts become more intense and parents' displays of warmth tend to decline temporarily. Daily increases of parent-teen conflict have been linked to concurrent increases in adolescent emotional distress, yet greater average levels of parental warmth are known to buffer adolescents' response to daily stressors such as interpersonal conflict. It is unclear whether daily increases in parental warmth may also function as a protective buffer that attenuates the daily association between parent-teen conflict and individuals' well-being. The present study aimed to fill an important gap in the literature by examining daily (within-person) fluctuations, and average between-person differences, in parental warmth as potential moderators of the daily association between parent-teen conflict intensity (defined here by the degree of negative emotions in parent-teen interactions) and well-being (distress, positive affect, and self-esteem) of both parents and adolescents. Data are based on daily reports from 120 parents-adolescents dyads recruited from a primary care practice in the Northeastern U.S. Almost all parents were mothers (Mage = 44.55, SD = 6.36), 61% of adolescents were female (Mage = 14.36, SD = 0.88), and 66% of dyads were African American. Multilevel modeling was used to assess the daily association between parent-teen conflict and well-being and examine daily and person-level (across-days) warmth as moderators of that association. Examining daily parental warmth as a moderator addressed whether the daily association between conflict and well-being varied as a function of when parental warmth increased or decreased within individuals (relative to individuals' own daily average). In contrast, examining person-level mean warmth as a moderator addressed whether the daily association between conflict and well-being varied as a function of who, on average, reported higher vs. lower levels of parental warmth. As expected, both parents and adolescents reported significantly lower well-being on days they experienced more conflict than usual. Daily fluctuations in parental warmth did not moderate the daily associations between conflict and well-being in parents or adolescents, indicating that the daily association did not change when parents were warmer than usual. In adolescents, the daily associations between conflict and distress, as well as conflict and positive affect, were moderated by person-mean levels of parental warmth, such that daily increases in conflict were associated with higher distress and lower positive affect (on the same day) primarily among adolescents with average or below average levels of parental warmth. Daily conflict was not associated with lower well-being among adolescents with higher-than-average levels of parental warmth. In parents, neither daily nor person-level warmth moderated the daily association between conflict and well-being, suggesting that the negative, daily association between conflict and well-being did not change as a function of parents' daily or average perceptions of warmth. These findings suggest that isolated, day-specific increases in warmth may be less protective than high, stable levels of parental warmth in mitigating the daily association between parent-teen conflict and adolescent well-being.
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Affiliation(s)
- Karol Silva
- Department of Pediatrics, Division of Adolescent Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Carol A Ford
- Department of Pediatrics, Division of Adolescent Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria A Miller
- Department of Pediatrics, Division of Adolescent Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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25
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Lee T, Cui J, Rosario H, Hilmara D, Samuelson K, Lin EC, Miller VA, Lin HC. Assessment of caregiver expectations of physician communication in a pediatric setting. BMC Health Serv Res 2020; 20:408. [PMID: 32393244 PMCID: PMC7212563 DOI: 10.1186/s12913-020-05262-x] [Citation(s) in RCA: 6] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 04/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In pediatrics, communication often occurs through an intermediary such as a caregiver. The goal of this study is to assess caregiver communication expectations and determine if meeting expectations influences caregiver satisfaction or instruction retention. METHODS A survey study was performed at the Children's Hospital of Philadelphia. Before the visit, caregivers completed a survey on communication expectations, Caregiver Expected Kalamazoo Essential Elements Communication Checklist (Caregiver Expected KEECC). After the visit, caregivers were surveyed on their perception of physician communication (Caregiver Perceived KEECC) and satisfaction. Caregivers were contacted 1 week after the clinic visit to assess instruction retention. Meeting of caregiver expectation was calculated by the difference between Caregiver Expected and Caregiver Perceived KEECC scores. RESULTS 112 caregivers participated in the study. There was no significant difference in Caregiver Expected KEECC versus Caregiver Perceived KEECC score (4.39 vs 4.56). Caregiver communication expectations were exceeded in 51.5% of the visits. Communication expectations were exceeded more among caregivers with at a college education (p < 0.01) and more among White caregivers (p < 0.01). The average caregiver satisfaction score with the clinic visit was 4.67. Higher satisfaction scores were observed in caregivers who had their communication expectations met or exceeded (p < 0.01). Caregivers with communication expectations exceeded had higher percentage recall of physician instructions (p < 0.01). CONCLUSIONS Caregiver communication expectations may be influenced by demographic factors. Communication expectation affects visit outcomes including caregiver satisfaction and instruction retention. Therefore, physicians need to be cognizant of caregiver communication expectations, which can impact quality of the healthcare experience.
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Affiliation(s)
- Tyler Lee
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Julie Cui
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Hinette Rosario
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Didja Hilmara
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Kate Samuelson
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Emery C. Lin
- Department of Medicine, College of Medicine Drexel University, Philadelphia, PA USA
| | - Victoria A. Miller
- Division of Adolescent Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Henry C. Lin
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
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26
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Silva K, Miller VA. Does Self-Efficacy Mediate the Link Between Impulse Control and Diabetes Adherence? J Pediatr Psychol 2020; 45:445-453. [PMID: 32106299 DOI: 10.1093/jpepsy/jsaa007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 09/13/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The goal of this study was to test the hypothesis that diabetes self-efficacy mediates the relationship between impulse control and type 1 diabetes (T1D) management from ages 8 to 18 years, using multilevel modeling. METHODS Participants included 117 youth with T1D and their parents. Youth (aged 8-16 years at baseline) and parents were assessed 5 times over 2 years. Using a cohort sequential design, we first estimated the growth trajectory of adherence from age 8 to 18 years, then specified a multilevel mediation model using impulse control as the main predictor, diabetes self-efficacy as the mediator, and changes in adherence (both within- and between-individuals) as the outcome. RESULTS According to youth-reported adherence only, self-efficacy partially mediated the within-person effect of impulse control on adherence. On occasions when youth reported increases in impulse control, they tended to report higher adherence, and this was, in part, due to increases in youths' perceived self-efficacy. Self-efficacy accounted for approximately 21% of the within-person relationship between impulse control and youth-reported adherence. There was no association between impulse control and adherence between-individuals. Impulse control and self-efficacy were not related to parent-reported adherence. CONCLUSION Environments that enrich youth with confidence in their own diabetes-related abilities may benefit self-care behaviors in youth with T1D, but such increases in youths' perceived competence do not fully account for, or override, the behavioral benefits of impulse control. Efforts to improve adherence in youth with T1D will benefit from consideration of both impulse control and self-efficacy.
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Affiliation(s)
- Karol Silva
- Department of Pediatrics, Children's Hospital of Philadelphia
| | - Victoria A Miller
- Department of Pediatrics, Children's Hospital of Philadelphia.,Perelman School of Medicine, University of Pennsylvania
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27
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Miller VA, Jawad AF. Decision-Making Involvement and Prediction of Adherence in Youth With Type 1 Diabetes: A Cohort Sequential Study. J Pediatr Psychol 2020; 44:61-71. [PMID: 29788441 DOI: 10.1093/jpepsy/jsy032] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 04/26/2018] [Indexed: 11/12/2022] Open
Abstract
Objective To assess developmental trajectories of decision-making involvement (DMI), defined as the ways in which parents and children engage each other in decision-making about illness management, in youth with type 1 diabetes (T1D) and examine the effects of DMI on levels of and changes in adherence with age. Methods Participants included 117 youth with T1D, enrolled at ages 8-16 years and assessed five times over 2 years. The cohort sequential design allowed for the approximation of the longitudinal curve from age 8 to 19 from overlapping cohort segments. Children and parents completed the Decision-Making Involvement Scale, which yields subscales for different aspects of DMI, and a self-report adherence questionnaire. Mixed-effects growth curve modeling was used for analysis, with longitudinal measures nested within participant and participants nested within cohort. Results Most aspects of DMI (Parent Express, Parent Seek, Child Express, and Joint) increased with child age; scores on some child report subscales (Parent Express, Child Seek, and Joint) decreased after age 12-14 years. After accounting for age, Child Seek, Child Express, and Joint were associated with overall higher levels of adherence in both child (estimates = 0.08-0.13, p < .001) and parent (estimates = 0.07- 0.13, p < .01) report models, but they did not predict changes in adherence with age. Conclusion These data suggest that helping children to be more proactive in T1D discussions, by encouraging them to express their opinions, share information, and solicit guidance from parents, is a potential target for interventions to enhance effective self-management.
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Affiliation(s)
- Victoria A Miller
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania
| | - Abbas F Jawad
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania
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28
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Cousino MK, Miller VA, Smith C, Uzark K, Lowery R, Rottach N, Blume ED, Schumacher KR. Medical and end-of-life decision making in adolescents' pre-heart transplant: A descriptive pilot study. Palliat Med 2020; 34:272-280. [PMID: 31647374 PMCID: PMC8063635 DOI: 10.1177/0269216319874689] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adolescents and young adults undergoing heart transplantation experience risks of morbidity and mortality both pre- and post-transplant. To improve end-of-life care for this population, it is necessary to understand their medical and end-of-life decision-making preferences. AIM (1) To examine adolescent/young adult decision-making involvement specific to heart transplant listing, and (2) to characterize their preferences specific to medical and end-of-life decision making. DESIGN This cross-sectional research study utilized survey methods. Data were collected from October 2016 to March 2018. SETTING/PARTICIPANTS Twelve adolescent and young adult patients listed for heart transplant (ages = 12-19 years) and one parent for each were enrolled at a single-center, US children's hospital. RESULTS Consistent with their preferences, the majority of adolescent/young adult participants (82%) perceived a high level of involvement in the decision to be listed for transplant. Patient involvement in this decision was primarily by way of seeking advice or information from their parents and being asked to express their opinion from parents. Despite a preference among patients to discuss their prognosis and be involved in end-of-life decision making if seriously ill, only 42% of patients had discussed their end-of-life wishes with anyone. Few parents recounted having such discussions. Preferences regarding the timing and nature of end-of-life decision-making discussions varied. CONCLUSIONS Although young people are involved in the decision to pursue heart transplantation, little attention is paid to involving them in discussions regarding end-of-life decision making in a manner that is consistent with individual preferences.
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Affiliation(s)
- Melissa K Cousino
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Transplant Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Victoria A Miller
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cynthia Smith
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Karen Uzark
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Nichole Rottach
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Kurt R Schumacher
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Transplant Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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29
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Silva K, Miller VA. Parenting and the development of impulse control in youth with type 1 diabetes: the mediating role of negative affect. Applied Developmental Science 2019; 26:94-108. [DOI: 10.1080/10888691.2019.1700797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Karol Silva
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Victoria A. Miller
- Children’s Hospital of Philadelphia, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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30
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Boyden JY, Hill DL, Carroll KW, Morrison WE, Miller VA, Feudtner C. The Association of Perceived Social Support with Anxiety over Time in Parents of Children with Serious Illnesses. J Palliat Med 2019; 23:527-534. [PMID: 31697175 DOI: 10.1089/jpm.2019.0387] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background: Parenting a child with a serious life-threatening illness (SLTI) may impact parents' mental health. The protective association of social support with anxiety over time following an acute medical event has not been empirically tested in a sample of parents of children with oncologic and nononcologic serious illnesses. Objective: To test the potential association of perceived social support with anxiety in parents of children with SLTIs over time. Design: Prospective cohort study. Setting/Subjects: Two hundred parents of 158 children in the Decision Making in Serious Pediatric Illness study, conducted at the Children's Hospital of Philadelphia. Measurements: Parental anxiety and perceived social support were assessed using the Hospital Anxiety and Depression Scale (HADS) and the Social Provisions Scale (SPS). We performed bivariate linear regressions to test cross-sectional and longitudinal associations between the SPS and anxiety scores at baseline, 12 months, and 24 months. Results: The average SPS total and subscale scores decreased significantly from baseline to 12 months, and increased from 12 to 24 months. The average HADS-Anxiety scores decreased significantly from baseline to 12 months, and remained stable at 24 months. Cross-sectionally, total SPS scores were negatively associated with anxiety scores at each time point. Longitudinally, SPS scores were associated with anxiety scores, although this association weakened in adjusted modeling. Conclusions: Over a two-year period, higher levels of perceived social support were associated with lower levels of anxiety in parents of seriously ill children. Clinicians and researchers should work to optimize social support for families to improve parental mental health outcomes.
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Affiliation(s)
- Jackelyn Y Boyden
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas L Hill
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Karen W Carroll
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Wynne E Morrison
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria A Miller
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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31
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Kenyon CC, Sundar KG, Gruschow SM, Quarshie WO, Feudtner C, Bryant-Stephens TC, Miller VA. Tailored medication adherence incentives for high-risk children with asthma: a pilot study. J Asthma 2019; 57:1372-1378. [PMID: 31389724 DOI: 10.1080/02770903.2019.1648503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: While reminder-based electronic monitoring systems have shown promise in enhancing inhaled corticosteroid (ICS) adherence in select populations, more engaging strategies may be needed in families of children with high-risk asthma. This study assesses the acceptability and feasibility of gain-framed ICS adherence incentives in families of urban, minority children with frequent asthma hospitalization.Methods: We enrolled children aged 5-11 years with multiple yearly asthma hospitalizations in a 2-month, mixed methods, ICS adherence incentive pilot study. All participants received inhaler sensors and a smartphone app to track ICS use. During month 1, families received daily adherence reminders and weekly feedback, and children earned up to $1/day for complete adherence. No reminders, feedback, or incentives were provided in month 2. We assessed feasibility and acceptability using caregiver surveys and semi-structured interviews and ICS adherence using electronic monitoring data.Results: Of the 29 families approached, 20 enrolled (69%). Participants were primarily Black (95%), publicly insured (75%), and averaged 2.9 asthma hospitalizations in the prior year. Fifteen of the 16 caregivers (94%) surveyed at month 2 liked the idea of receiving adherence incentives. Mean adherence was significantly higher in month 1 compared with month 2 (80% vs. 33%, mean difference = 47%; 95% CI [33, 61], p < 0.001). Caregivers reported that their competing priorities often limited adherence, while incentives helped motivate child adherence.Conclusions: ICS adherence incentives were acceptable and feasible in a high-risk cohort of children with asthma. Future studies should assess the efficacy of adherence incentives in enhancing ICS adherence in high-risk children.
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Affiliation(s)
- Chén C Kenyon
- PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kavya G Sundar
- PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Siobhan M Gruschow
- PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William O Quarshie
- Healthcare Analytics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Chris Feudtner
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tyra C Bryant-Stephens
- PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria A Miller
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Hill DL, Faerber JA, Li Y, Miller VA, Carroll KW, Morrison W, Hinds PS, Feudtner C. Changes Over Time in Good-Parent Beliefs Among Parents of Children With Serious Illness: A Two-Year Cohort Study. J Pain Symptom Manage 2019; 58:190-197. [PMID: 31026508 PMCID: PMC6679776 DOI: 10.1016/j.jpainsymman.2019.04.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 11/20/2022]
Abstract
CONTEXT Parents of seriously ill children hold personal beliefs about what they should do to be good parents. How these beliefs change over time is unknown. OBJECTIVES The objectives of this study were to describe the pattern of Good-Parent Beliefs over time, and determine whether parents' hopeful patterns of thinking, affect, and perceived child's health are associated with changes in beliefs at 12 and 24 months. METHODS Our longitudinal sample included 124 parents of 100 children hospitalized with serious illness. We used latent transition models to classify parents into groups with similar Good-Parent Beliefs during the baseline and follow-up periods and modeled the change in good-parent beliefs over time as a function of covariates using generalized linear mixed models. RESULTS Two parent belief profiles emerged from the latent transition model: Loved ("Making sure my child feels loved," n = 61 at baseline) and Informed ("Making informed decisions," n = 63 at baseline). At 12 months, 21 parents (20.4%) had moved into the Loved group and no parents transitioned to the Informed group. By 24 months, eight parents transitioned to the Loved group and four to the Informed group (13.04%). Transition into the Loved group was associated with parents' baseline degree of hopeful thinking and positive perceptions of child's health at baseline. CONCLUSION Some parents change their parenting priorities over time. Hopeful patterns of thinking and perception of child health appear to predict change. Clinicians should regularly reevaluate Good-Parent Beliefs over time to promote priority-congruent dialogue.
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Affiliation(s)
- Douglas L Hill
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer A Faerber
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yimei Li
- Departments of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Victoria A Miller
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Karen W Carroll
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Wynne Morrison
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pamela S Hinds
- Department of Nursing Science, Professional Practice, and Quality, Children's National Health System, Washington, DC, USA; Department of Pediatrics, School of Medicine and the Health Sciences, George Washington University, Washington, DC, USA
| | - Chris Feudtner
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Schrock AB, Ouyang C, Sandhu J, Sokol E, Jin D, Ross JS, Miller VA, Lim D, Amanam I, Chao J, Catenacci D, Cho M, Braiteh F, Klempner SJ, Ali SM, Fakih M. Tumor mutational burden is predictive of response to immune checkpoint inhibitors in MSI-high metastatic colorectal cancer. Ann Oncol 2019; 30:1096-1103. [PMID: 31038663 DOI: 10.1093/annonc/mdz134] [Citation(s) in RCA: 382] [Impact Index Per Article: 76.4] [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] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Microsatellite instability (MSI) is a biomarker for response to immune checkpoint inhibitors (ICPIs). PD-1 inhibitors in metastatic colorectal carcinoma (mCRC) with MSI-high (MSI-H) have demonstrated a high disease control rate and favorable progression-free survival (PFS); however, reported response rates to pembrolizumab and nivolumab are variable and often <50%, suggesting that additional predictive biomarkers are needed. METHODS Clinicopathologic data were collected from patients with MSI-H mCRC confirmed by hybrid capture-based next-generation sequencing (NGS) treated with PD-1/L1 inhibitors at five institutes. Tumor mutational burden (TMB) was determined on 0.8-1.1 Mb of sequenced DNA and reported as mutations/Mb. Potential biomarkers of response and time to progression were analyzed by univariate and multivariate analyses. Once TMB was confirmed as a predictive biomarker, a larger dataset of 18 140 unique CRC patients was analyzed to define the relevance of the identified TMB cut-point. RESULTS A total of 22 patients were treated with PD-1/L1 inhibitors including 19 with pembrolizumab monotherapy. Among tested variables, TMB showed the strongest association with objective response (OR; P < 0.001) and PFS, by univariate (P < 0.001) and multivariate analysis (P < 0.01). Using log-rank statistics, the optimal predictive cut-point for TMB was estimated between 37 and 41 mutations/Mb. All 13 TMBhigh cases responded, while 6/9 TMBlow cases had progressive disease. The median PFS for TMBhigh has not been reached (median follow-up >18 months) while the median PFS for TMBlow was 2 months. A TMB of 37.4 mutations/Mb in a large MSI-H mCRC population (821/18, 140 cases; 4.5%) evaluated by NGS corresponded to the 35th percentile cut-point. CONCLUSIONS TMB appears to be an important independent biomarker within MSI-H mCRC to stratify patients for likelihood of response to ICPIs. If validated in prospective studies, TMB may play an important role in guiding the sequencing and/or combinations of ICPIs in MSI-H mCRC.
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Affiliation(s)
| | - C Ouyang
- Center for Informatics, City of Hope National Medical Center, Duarte; Department of Computational and Quantitative Medicine, Beckman Research Institute of the City of Hope, Duarte
| | - J Sandhu
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte
| | - E Sokol
- Foundation Medicine, Inc., Cambridge
| | - D Jin
- Foundation Medicine, Inc., Cambridge
| | - J S Ross
- Foundation Medicine, Inc., Cambridge; Department of Pathology, SUNY Upstate Medical University, Syracuse
| | | | - D Lim
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte
| | - I Amanam
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte
| | - J Chao
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte
| | - D Catenacci
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medical Center and Biological Sciences, Chicago
| | - M Cho
- Division of Hematology and Oncology, Department of Internal Medicine, UC Davis Comprehensive Cancer Center, Sacramento
| | - F Braiteh
- Department of Hematology/Oncology, Comprehensive Cancer Centers of Nevada, Las Vegas
| | - S J Klempner
- The Angeles Clinic and Research Institute, Los Angeles, USA
| | - S M Ali
- Foundation Medicine, Inc., Cambridge
| | - M Fakih
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte.
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Walter JK, Sachs E, Schall TE, Dewitt AG, Miller VA, Arnold RM, Feudtner C. Interprofessional Teamwork During Family Meetings in the Pediatric Cardiac Intensive Care Unit. J Pain Symptom Manage 2019; 57:1089-1098. [PMID: 30876957 PMCID: PMC6800054 DOI: 10.1016/j.jpainsymman.2019.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 03/05/2019] [Accepted: 03/05/2019] [Indexed: 01/12/2023]
Abstract
CONTEXT Parents of children in the pediatric cardiac intensive care unit (CICU) report inadequate communication and a lack of empathy during conversations with their clinicians. OBJECTIVE To assess quantitatively and qualitatively the contributions made by team members of different professions in communicating with parents during family meetings. METHODS Prospective observational study. The study was conducted in the pediatric CICU at the Children's Hospital of Philadelphia. Subjects were members of the interprofessional team attending family meetings for patients admitted to the CICU longer than two weeks. We used quantitative conversation attribution and coding to compare durations of attendee contributions and contribution type by professional role. The SCOPE codebook and other quantitative codes drawn from best practices in family meetings were used to measure communication behaviors. A qualitative analysis of nurses' and social workers' contributions was used to identify themes not otherwise captured. RESULTS Across 10 meetings, physicians spoke for an average of 78.1% (SD 10.7%) of each meeting, nonphysicians 9.6% (SD 7.8%), and parents 17.4% (SD 12.2%). Parental understanding was assessed an average of 0.2 (SD 0.4) times per meeting. Parents expressed emotion an average of 4.2 times per meeting (SD 7.1), and the clinical team responded empathetically 2.2 times per meeting (SD 4.3). All clinician empathic responses were a minority of their overall contributions. Conversation was almost exclusively between physicians and families until physicians indicated other team members could contribute. CONCLUSIONS Coordination of team members' roles in the meetings may improve parental engagement necessary for decision-making and empathic responses that are often missed.
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Affiliation(s)
- Jennifer K Walter
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Emily Sachs
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theodore E Schall
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aaron G Dewitt
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Victoria A Miller
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robert M Arnold
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Silva K, Miller VA. The Role of Cognitive and Psychosocial Maturity in Type 1 Diabetes Management. J Adolesc Health 2019; 64:622-630. [PMID: 30655120 PMCID: PMC6478514 DOI: 10.1016/j.jadohealth.2018.10.294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 07/25/2018] [Revised: 10/17/2018] [Accepted: 10/17/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of the article was to explore the longitudinal relationship between treatment responsibility and type 1 diabetes management (i.e., adherence and glycemic control) in adolescence and to examine whether indicators of cognitive and psychosocial maturity moderate the link between youth responsibility and diabetes outcomes. METHODS Participants included 117 youth with type 1 diabetes and their parents. Youth (aged 8-16 years) and parents were assessed five times over 2 years. Using a cohort sequential design, we estimated the growth trajectory of adherence and glycemic control (i.e., hemoglobin A1c [HbA1c]) from age 8 to 18 years. Treatment responsibility, verbal ability, and impulse control were used as predictors of within-person variability and between-person differences in the growth parameters (i.e., intercept and slope). RESULTS Adherence and HbA1c declined linearly from ages 8 to 18 years. Significant within-person interactions between impulse control and responsibility revealed that on occasions when youth experienced increases in both responsibility and impulse control, adherence and HbA1c were higher than would be predicted by the age-related trajectory. For adherence only, when youth acquired more responsibility, without experiencing contemporaneous gains in impulse control, adherence worsened. For glycemic control only, a significant within-person interaction indicated that time-specific increases in both youth responsibility and verbal capacity were associated with a concurrent decline in HbA1c. CONCLUSIONS The present findings underscore that the associations between treatment responsibility and diabetes management depend on youths' maturational context. Intervention efforts to enhance impulse control skills in youth with diabetes may prevent the decline in diabetes management that tends to occur as youth acquire more responsibility for diabetes-related tasks.
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Affiliation(s)
- Karol Silva
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Victoria A. Miller
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Goodman ES, Ford CA, Friedrich EA, Ginsburg KR, Miller VA, Mirman JH. Frequency of communication about adolescents’ strengths and weaknesses and the parent–adolescent relationship. Applied Developmental Science 2019. [DOI: 10.1080/10888691.2019.1594813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Emma S. Goodman
- Department of Psychology, The University of Alabama at Birmingham
| | - Carol A. Ford
- Division of Adolescent Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia
| | - Elizabeth A. Friedrich
- Division of Adolescent Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia
| | - Kenneth R. Ginsburg
- Division of Adolescent Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia
| | - Victoria A. Miller
- Division of Adolescent Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia
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Hanker AB, Koch JP, Ye D, Sliwoski G, Sheehan J, Kinch LN, Red Brewer M, He J, Miller VA, Lalani AS, Cutler RE, Croessmann S, Zabransky DJ, Meiler J, Arteaga CL. Abstract PD3-05: Co-occurring gain-of-function mutations in HER2 and HER3 cooperate to enhance HER2/HER3 binding, HER-dependent signaling, and breast cancer growth. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-pd3-05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
ERBB2, the gene encoding HER2, is mutated in 2-4% of breast cancers. The HER2 tyrosine kinase inhibitor neratinib has shown clinical activity against breast cancers harboring HER2 activating mutations, suggesting these tumors depend on HER2 signaling. Co-occurring HER2 and HER3 (ERBB3) mutations have been reported in patients who respond to neratinib (Hanker et al., Cancer Discov. 2017) suggesting the possibility of cooperativity of both oncogenes. Co-expression of the mutant intracellular domains of HER2 and HER3 in HEK293 cells enhanced phosphorylation of HER3 and ERK compared to expression of either mutant alone, which was blocked by 100 nM neratinib. Interrogation of TCGA, METABRIC, Project GENIE, and Foundation Medicine datasets revealed that gain-of-function mutations in ERBB2 and ERBB3 co-occur with a statistically significant frequency. For example, in GENIE, ERBB2 mutations co-occur with mutations in ERBB3 (8.3% of ERBB2-mutant vs 2.3% of ERBB2 WT; q=1.37x10-10).
We hypothesized that co-occurring mutations in HER2 and HER3 cooperate to enhance HER2 signaling and dependence and breast cancer progression.
Thirty-four unique breast cancers were found to harbor co-occurring mutations in HER2 and HER3, the most common of which were ERBB2L755S/ERBB3E928G (n=10), ERBB2V777L/ERBB3E928G(n=6), and ERBB2L869R/Q/ERBB3E928G (n=4). Using co-immunoprecipitation assays with HER2 and HER3 antibodies in transfected HEK293 cells, we found that co-expression of HER3E928G with wild type (WT) HER2, or co-expression of HER2L755S or HER2L869R with HER3WT, slightly increased HER2-HER3 dimerization. However, binding was strongest between double mutants. This was accompanied by the highest levels of Y1289 p-HER3 in cells expressing both HER3E928G and each HER2L755S, HER2V777L, or HER2L869R compared to cells expressing each HER2 or HER3 mutant with a respective WT heterodimer partner. Structural modeling of the HER2L869R/HER3E928G double-mutant predicted that the HER3 mutation, located at the dimer interface, may enhance heterodimerization of the kinase domains through decreased bulk and electrostatic repulsion. We also noted that the HER2L755S mutation is predicted to be in close proximity to HER3E928G (<4 Å) and may impact binding affinity. Investigation of the structural basis for the enhanced binding of other double mutants is in progress.
MCF7 “knock-in” cells incorporating HER2L755S, HER2V777L, or HER2L869R (or HER2WT) were stably transduced with HER3E928G or HER3WT. Co-expression of double mutants strongly enhanced estrogen-independent growth in 3D Matrigel over cells expressing either mutant alone. We are currently testing inhibitors of HER2/HER3 signaling, including neratinib ± trastuzumab, trastuzumab + pertuzumab, and the ERBB1-3 antibody mixture Sym013, to determine therapeutic strategies to block the cooperative growth induced by co-occurring HER2 and HER2 mutations.
Conclusions: Co-expression of mutant HER2 and mutant HER3 promotes HER2/HER binding, HER3 phosphorylation, and breast tumor cell proliferation. We aim to identify therapeutic vulnerabilities for patients with co-occurring HER2 and HER3 mutations.
Citation Format: Hanker AB, Koch JP, Ye D, Sliwoski G, Sheehan J, Kinch LN, Red Brewer M, He J, Miller VA, Lalani AS, Cutler, Jr. RE, Croessmann S, Zabransky DJ, Meiler J, Arteaga CL. Co-occurring gain-of-function mutations in HER2 and HER3 cooperate to enhance HER2/HER3 binding, HER-dependent signaling, and breast cancer growth [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD3-05.
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Affiliation(s)
- AB Hanker
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - JP Koch
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - D Ye
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - G Sliwoski
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - J Sheehan
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - LN Kinch
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - M Red Brewer
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - J He
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - VA Miller
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - AS Lalani
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - RE Cutler
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - S Croessmann
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - DJ Zabransky
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - J Meiler
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
| | - CL Arteaga
- UT Southwestern Medical Center, Nashville, TN; Vanderbilt University Medical Center, Nashville, TN; Vanderbilt University, Nashville, TN; Foundation Medicine, Cambridge, MA; Puma Biotechnology, Los Angeles, CA; Johns Hopkins University, Baltimore, MD
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Gay LM, Elvin JA, Vergilio JA, Killian JK, Ramkissoon S, Severson E, Daniel S, Hammerich A, Sokol E, Frampton G, Chung J, Trabucco S, Ali S, Reddy P, Schrock AB, Miller VA, Ross JS. Abstract P3-06-18: Comprehensive genomic profiling of carcinosarcomas of the breast. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p3-06-18] [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: 11/16/2022]
Abstract
Abstract
Background:
Carcinosarcomas of the breast (BCSC) are exceptionally rare and the underlying genomic drivers are still being elucidated. Comprehensive genomic profiling (CGP) determines the tumor mutation burden (TMB) and identifies all four classes of genomic alterations (GA) that have potential to direct personalized treatment strategies.
Methods:
CGP by hybridization capture of exons from up to 315 cancer-related genes and select introns of 28 genes commonly rearranged in cancer was applied to ≥ 50ng of DNA extracted from 9 consecutive BCSC and sequenced to high, uniform median coverage (>500X). Tumor mutational burden (TMB) was determined on 1.1 Mbp of sequenced DNA and microsatellite instability (MSI) was determined by principal components analysis of optimized loci.
Results:
The 9 BCSC patients had a median age of 57 yrs (range 49-78 yrs). CGP was performed on the primary BCSC in 4 cases and on metastasis biopsies in 5 cases (4 lung and 1 lymph node). The mean GA/tumor was 6.6 and clinically relevant GA (CRGA)/tumor was 1.3. The most frequent non-CRGA were in TP53 (89%), MYC (56%) and LYN (40%). The most frequent CRGA were in PIK3CA (33%), and NF1, BRCA1, PTEN, RICTOR, FGFR1, AKT2 and STK11 (all at 11%). The median TMB for all BCSC was 2.4 mut/Mb with 1 (11%) tumor with a TMB > 20 mut/Mb and 8 BCSC (88%) with TMB < 5 mut/Mb. Five of 5 BCSC (100%) that were available for MSI status testing were microsatellite stable.
Conclusions:
On CGP, BCSC feature a high frequency of GA, but only a modest frequency of CRGA and high TMB. However, when the CRGA and TMB positive cases are combined (77.8% overall in this series), the opportunity for personalized targeted and immunotherapies are significant. Thus, further investigation of precision therapies for BCSC in the clinical trial setting appear warranted.
Citation Format: Gay LM, Elvin JA, Vergilio J-A, Killian JK, Ramkissoon S, Severson E, Daniel S, Hammerich A, Sokol E, Frampton G, Chung J, Trabucco S, Ali S, Reddy P, Schrock AB, Miller VA, Ross JS. Comprehensive genomic profiling of carcinosarcomas of the breast [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-06-18.
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Affiliation(s)
- LM Gay
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - JA Elvin
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - J-A Vergilio
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - JK Killian
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - S Ramkissoon
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - E Severson
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - S Daniel
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - A Hammerich
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - E Sokol
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - G Frampton
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - J Chung
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - S Trabucco
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - S Ali
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - P Reddy
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - AB Schrock
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - VA Miller
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
| | - JS Ross
- Foundation Medicine, Inc., Cambridge, MA; Upstate Medical University, Syracuse, NY
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Abstract
Decision-making is important in the context of pediatric chronic illness because children and families need to make decisions about burdensome and complex treatments on a regular basis, and children must eventually learn how to make such decisions independently. Research related to children's decision-making in medical settings has been focused primarily on cognitive aspects of decision-making, such as understanding and capacity. The concept of decision-making involvement (DMI) recognizes that children can be involved in decision-making in multiple ways, regardless of capacity, and that parents and health care providers play a critical role in supporting children as they learn to make decisions on their own. Providers can facilitate DMI during medical encounters by asking for the children's opinions and concerns, encouraging turn-taking, soliciting questions, asking for information directly from the children, and checking that the children understand what has been said. Efforts to involve children send the message that the youth perspective is important and set the expectation for increased participation over time. Providers can also support parent-child decision-making about illness management at home by guiding parents as to how best to involve children in decisions about illness management, identifying areas in which more or less parental guidance and support are needed, and assisting youth in planning ahead for decision-making about illness management in high-risk situations. Additional research is needed to identify why children's DMI in medical settings remains low, develop and evaluate strategies to enhance DMI, and test the effects of DMI on health-related behaviors and outcomes over time.
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Affiliation(s)
- Victoria A. Miller
- Division of Adolescent Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Miller VA, Friedrich E, García-España JF, Mirman JH, Ford CA. Adolescents Spending Time Alone With Pediatricians During Routine Visits: Perspectives of Parents in a Primary Care Clinic. J Adolesc Health 2018; 63:280-285. [PMID: 29887486 DOI: 10.1016/j.jadohealth.2018.01.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 05/25/2017] [Revised: 01/05/2018] [Accepted: 01/17/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To increase understanding of parental perspectives on time alone and of factors that influence adolescent communication with physicians in a pediatric clinic. METHODS The sample consisted of 91 parents of adolescents aged 14-17 years who attended a well child visit at one primary care pediatric practice and completed a 2-week follow-up phone call as part of a larger study on adolescent health and communication. Parents reported whether their child met alone with the pediatrician, rated the importance of him or her having time alone with the physician, and responded to open-ended questions regarding barriers and facilitators of adolescent-physician communication. Bivariate and multivariate analyses tested associations of parent and adolescent characteristics with perceived parental importance of time alone. We conducted content analyses of responses to open-ended questions. RESULTS Slightly more than half of parents (n = 53, 58%) indicated that it was "a lot" important for their adolescents to meet alone with the pediatrician; parents of males were more likely than parents of females to select this highest rating (73% vs. 43%, χ2(1) = 8.34, p = .004; adjusted odds ratio 4.88, 95% confidence interval 1.84-12.96). Responses to open-ended questions identified numerous adolescent, parent, and provider factors that parents perceived to influence adolescent-physician communication during well child visits, such as preparation for visit, rapport and familiarity with the pediatrician, privacy concerns, time alone with the pediatrician, emotional comfort, trust, and support. CONCLUSIONS Most parents thought time alone was highly important for their own adolescent in a primary care setting, and parents described additional strategies to facilitate adolescent communication.
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Affiliation(s)
- Victoria A Miller
- Division of Adolescent Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Friedrich
- Division of Adolescent Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - J Felipe García-España
- Division of Adolescent Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jessica H Mirman
- Department of Psychology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Carol A Ford
- Division of Adolescent Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Hill DL, Nathanson PG, Carroll KW, Schall TE, Miller VA, Feudtner C. Changes in Parental Hopes for Seriously Ill Children. Pediatrics 2018; 141:peds.2017-3549. [PMID: 29567813 PMCID: PMC5869332 DOI: 10.1542/peds.2017-3549] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hopes of parents of children with serious illness play an important role in decision-making and coping. Little is known about how parent hopes change over time. We describe the changes in parent hopes across multiple domains and time intervals, examine hopes in a subgroup of parents whose child died, and explore the maintenance of domains over time. METHODS In a mixed-methods prospective cohort study on decision-making, parents of seriously ill children reported demographic characteristics and hopes at baseline and reported any changes in hopes at 4-, 8-, 12-, 16-, and 20-month follow-up visits. Hopes were coded into 9 domains. Hope changes and domain changes were identified for each parent at each visit. RESULTS One hundred and ninety-nine parents of 158 patients most often reported hopes in the domains of quality of life (75%), physical body (69%), future well-being (47%), and medical care (34%). Hope percentages increased over time for quality of life (84%), future well-being (64%), and broader meaning (21%). The hope domains reported by parents of children who died were similar to the rest of the sample. The majority of parents who completed 5 to 6 follow-up visits changed at least 1 domain. At the individual parent level, some domains revealed considerable change over time, whereas other domains were stable among a subset of parents. CONCLUSIONS The specific hopes and overall areas of hope of parents of seriously ill children vary over time, although most hopes fall within 4 major areas. Accordingly, clinicians should regularly check with parents about their current hopes.
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Affiliation(s)
| | | | | | | | | | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Affiliation(s)
- Victoria A Miller
- a Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
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Ross JS, Chung J, Elvin JE, Vergilio JA, Ramkissoon S, Suh J, Severson E, Daniel S, Frampton GM, Fabrizio D, Hartmaier RJ, Albacker LA, Ali SM, Schrock AB, Miller VA, Stephens PJ, Gay LM. Abstract PD8-01: CDH1 mutated classic and pleomorphic invasive lobular breast carcinomas differ in genomic signatures and opportunities for targeted and immunotherapies. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-pd8-01] [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: 11/16/2022]
Abstract
Abstract
Background: Typically defined by negative IHC staining for E-cadherin, classic (CILC) and pleomorphic (PILC) are often combined as a single breast cancer subtype. We queried whether patients with relapsed metastatic disease, mCILC and mPILC, would harbor contrasting genomic alterations (GA)and that molecular information could further differentiate the 2 tumor types and thereby influence therapy selection.
Methods: DNA was extracted from 40 µm of FFPE sections of 10,784 invasive breast carcinomas. 454 (4%) CDH1 mutated mILC were selected including 428 classic mCILC (94%) and 26 mPLIC (6%) subtypes. Comprehensive genomic profiling (CGP) was performed on hybridization-captured, adaptor ligation-based libraries to a mean coverage depth >600X for up to 315 cancer-related genes. Tumor mutational burden (TMB) was determined on 1.1 Mbp of sequenced DNA.
Results: mCILC and mPILC patients featured a median age of 63 years (Table). Slide based ER+ status and HER2+ status was significantly different in both groups (P<0.0001). The frequency of base substitutions in ESR1 was significantly higher in mCILC, and this difference was also significantly higher in mCILC metastasis biopsies exposed to hormonal therapy than in pre-treatment primary tumors (P<0.0001). ERBB2 (HER2) GA (amp + non-amp) detected by CGP were higher in mPILC than mCILC in both pre-and post-treatment samples (P<0.0001 for both). The ERBB2 GA frequency was nearly twice as high after hormonal therapy in both mCILC and mPILC. ESR1 and ERBB2 GA were mutually exclusive overall and especially in the mCILC group. PIK3CA GA were the most frequent GA in both mCILC and mPILC. TP53 GA were significantly more frequent in mPILC than mCILC. At 19%, the frequency of TMB > 15 mutations/MB in mPILC was more than twice as frequent than in mCILC (P=0.046). All (100%) of both the CILC and PILC groups were negative for mis-match repair deficiency or MSI high status. mCILC and mPILC patients with post primary therapy associated ESR1 and ERBB2 GA responding to targeted and immunotherapies will be presented.
Contrasting Clinical and Genomic Features of CILC and PILC Classic CILC (428 cases)Pleomorphic PILC (26 cases)Median Age6363*ER+98%74%*HER2 IHC/FISH+12 (3%)6 (22%)ESR1 GA Primary Pre-Rx6%0%ESR1 GA Metastatic Post-Rx17%0%ERBB2 GA Primary Pre-Rx7%18%ERBB2 GA Metastatic Post-Rx12%34%Other Significant GAPIK3CA (55%), CCND1 (21%), TP53 (17%), ARID1A, AKT3, MDM4, PTEN (all 11%)PIK3CA (58%), TP53 (30%), AKT1 22%), FGFR4, CCND1, PTEN (all 17%)TMB median (mut/Mb)2.73.6TMB > 15%8%19%*when clinical status available
Conclusions: CGP of mCILC and mPILC reveals significant differences in the panorama of GA both in pre-treatment primary and metastatic disease lesions especially in therapy-impacting GA in ESR1 and ERBB2. mCILC is more often driven by ESR1 GA and mPILC by ERBB2 GA. Although both mCILC and mPILC feature subsets of tumors with high TMB, this is more frequent for mPILC likely indicating different potentials for immunotherapies to benefit these patients.
Citation Format: Ross JS, Chung J, Elvin JE, Vergilio J-A, Ramkissoon S, Suh J, Severson E, Daniel S, Frampton GM, Fabrizio D, Hartmaier RJ, Albacker LA, Ali SM, Schrock AB, Miller VA, Stephens PJ, Gay LM. CDH1 mutated classic and pleomorphic invasive lobular breast carcinomas differ in genomic signatures and opportunities for targeted and immunotherapies [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD8-01.
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Affiliation(s)
- JS Ross
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - J Chung
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - JE Elvin
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - J-A Vergilio
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - S Ramkissoon
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - J Suh
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - E Severson
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - S Daniel
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - GM Frampton
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - D Fabrizio
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - RJ Hartmaier
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - LA Albacker
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - SM Ali
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - AB Schrock
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - VA Miller
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - PJ Stephens
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
| | - LM Gay
- Albany Medical College, Albany, NY; Foundation Medicine, Cambridge, MA
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Kenyon CC, Gruschow SM, Quarshie WO, Griffis H, Leach MC, Zorc JJ, Bryant-Stephens TC, Miller VA, Feudtner C. Controller adherence following hospital discharge in high risk children: A pilot randomized trial of text message reminders. J Asthma 2018; 56:95-103. [PMID: 29437489 DOI: 10.1080/02770903.2018.1424195] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To assess the feasibility of a mobile health, inhaled corticosteroid (ICS) adherence reminder intervention and to characterize adherence trajectories immediately following severe asthma exacerbation in high-risk urban children with persistent asthma. METHODS Children aged 2-13 with persistent asthma were enrolled in this pilot randomized controlled trial during an asthma emergency department (ED) visit or hospitalization. Intervention arm participants received daily text message reminders for 30 days, and both arms received electronic sensors to measure ICS use. Primary outcomes were feasibility of sensor use and text message acceptability. Secondary outcomes included adherence to prescribed ICS regimen and 30-day adherence trajectories. Group-based trajectory modeling was used to examine adherence trajectories. RESULTS Forty-one participants (mean age 5.9) were randomized to intervention (n = 21) or control (n = 20). Overall, 85% were Black, 88% had public insurance, and 51% of the caregivers had a high school education or less. Thirty-two participant families (78%) transmitted medication adherence data; of caregivers who completed the acceptability survey, 25 (96%) chose to receive daily reminders beyond that study interval. Secondary outcome analyses demonstrated similar average daily adherence between groups (intervention = 36%; control = 32%, P = 0.73). Three adherence trajectories were identified with none ever exceeding 80% adherence. CONCLUSIONS Within a high-risk pediatric cohort, electronic monitoring of ICS use and adherence reminders delivered via text message were feasible for most participants, but there was no signal of effect. Adherence trajectories following severe exacerbation were suboptimal, demonstrating an important opportunity for asthma care improvement.
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Affiliation(s)
- Chén C Kenyon
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania.,b Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Siobhan M Gruschow
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania
| | - William O Quarshie
- c Healthcare Analytics Unit , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania
| | - Heather Griffis
- c Healthcare Analytics Unit , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania
| | - Michelle C Leach
- d Sidney Kimmel Medical College , Thomas Jefferson University , Philadelphia , Pennsylvania
| | - Joseph J Zorc
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania.,b Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Tyra C Bryant-Stephens
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania
| | - Victoria A Miller
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania.,b Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Chris Feudtner
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania.,b Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
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Becker TD, Lin HC, Miller VA. A pilot study of observed physician-parent-child communication and child satisfaction in a gastroenterology clinic. Patient Prefer Adherence 2018; 12:1327-1335. [PMID: 30100709 PMCID: PMC6065589 DOI: 10.2147/ppa.s171620] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Child participation in pediatric medical visits is low. In this pilot study, we sought to better understand relationships between observed communication and child-reported perceptions of communication in a clinical setting. MATERIALS AND METHODS For this cross-sectional observational study, pediatric gastroenterology appointments (n=39) were videotaped and coded to quantify various adult affective (eg, chit-chat, empathy) and facilitative (eg, asking questions, encouraging responses) behaviors toward the child, interference with child participation (eg, interrupting or ignoring child), and child verbal participation. Post-visit surveys assessed child perceptions of having voice in the clinical encounter, ease of understanding, and satisfaction with communication. RESULTS Parent and provider chit-chat was associated with child-reported ease of understanding. Provider facilitation was positively associated with child participation, but affective communication strategies were not. Physician interference was negatively associated with ease of understanding but positively associated with perception of voice. CONCLUSION Facilitative communication may improve outcomes by enhancing child participation and thus exchange of medical information, whereas chit-chat appears to positively impact children's perceptions of communication.
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Affiliation(s)
- Timothy D Becker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Henry C Lin
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria A Miller
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,
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Dhar CP, Kaflay D, Dowshen N, Miller VA, Ginsburg KR, Barg FK, Yun K. Attitudes and Beliefs Pertaining to Sexual and Reproductive Health Among Unmarried, Female Bhutanese Refugee Youth in Philadelphia. J Adolesc Health 2017; 61:791-794. [PMID: 28935387 PMCID: PMC5931208 DOI: 10.1016/j.jadohealth.2017.06.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/22/2017] [Accepted: 06/05/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE We explored attitudes and beliefs pertaining to sexual and reproductive health (SRH) among unmarried, female, resettled Bhutanese refugees 16-20 years. METHODS Fourteen interviews were analyzed using the constant comparison method, and major themes were identified. RESULTS SRH was stigmatized for unmarried youth, making seeking information about SRH or accessing family planning difficult. There were many misconceptions about access to SRH. CONCLUSIONS Universal, culturally, and linguistically appropriate comprehensive SRH education is recommended for female Bhutanese refugee youth. Terminology used should take into account differences in conceptualization of concepts like dating. Educators and health care providers should clearly describe consent and confidentiality laws regarding adolescent SRH services.
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Affiliation(s)
- Cherie Priya Dhar
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Pediatrics, The Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Dilu Kaflay
- Bhutanese American Organization-Philadelphia, Philadelphia, Pennsylvania
| | - Nadia Dowshen
- Craig-Dalsimer Division of Adolescent Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria A Miller
- Craig-Dalsimer Division of Adolescent Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kenneth R Ginsburg
- Craig-Dalsimer Division of Adolescent Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frances K Barg
- Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Anthropology, University of Pennsylvania School of Arts and Sciences, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katherine Yun
- PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Wong CA, Miller VA, Murphy K, Small D, Ford CA, Willi SM, Feingold J, Morris A, Ha YP, Zhu J, Wang W, Patel MS. Effect of Financial Incentives on Glucose Monitoring Adherence and Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes: A Randomized Clinical Trial. JAMA Pediatr 2017; 171:1176-1183. [PMID: 29059263 PMCID: PMC6583649 DOI: 10.1001/jamapediatrics.2017.3233] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Glycemic control often deteriorates during adolescence and the transition to young adulthood for patients with type 1 diabetes. The inability to manage type 1 diabetes effectively during these years is associated with poor glycemic control and complications from diabetes in adult life. OBJECTIVE To determine the effect of daily financial incentives on glucose monitoring adherence and glycemic control in adolescents and young adults with type 1 diabetes. DESIGN, SETTING, AND PARTICIPANTS The Behavioral Economic Incentives to Improve Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes (BE IN CONTROL) study was an investigator-blinded, 6-month, 2-arm randomized clinical trial conducted between January 22 and November 2, 2016, with 3-month intervention and follow-up periods. Ninety participants (aged 14-20) with suboptimally controlled type 1 diabetes (hemoglobin A1c [HbA1c] >8.0%) were recruited from the Diabetes Center for Children at the Children's Hospital of Philadelphia. INTERVENTIONS All participants were given daily blood glucose monitoring goals of 4 or more checks per day with 1 or more level within the goal range (70-180 mg/dL) collected with a wireless glucometer. The 3-month intervention consisted of a $60 monthly incentive in a virtual account, from which $2 was subtracted for every day of nonadherence to the monitoring goals. During a 3-month follow-up period, the intervention was discontinued. MAIN OUTCOMES AND MEASURES The primary outcome was change in HbA1c levels at 3 months. Secondary outcomes included adherence to glucose monitoring and change in HbA1c levels at 6 months. All analyses were by intention to treat. RESULTS Of the 181 participants screened, 90 (52 [57.8%] girls) were randomized to the intervention (n = 45) or control (n = 45) arms. The mean (SD) age was 16.3 (1.9) years. The intervention group had significantly greater adherence to glucose monitoring goals in the incentive period (50.0% vs 18.9%; adjusted difference, 27.2%; 95% CI, 9.5% to 45.0%; P = .003) but not in the follow-up period (15.3% vs 8.7%; adjusted difference, 3.9%; 95% CI, -2.0% to 9.9%; P = .20). The change in HbA1c levels from baseline did not differ significantly between groups at 3 months (adjusted difference, -0.08%; 95% CI, -0.69% to 0.54%; P = .80) or 6 months (adjusted difference, 0.03%; 95% CI, -0.55% to 0.60%; P = .93). CONCLUSIONS AND RELEVANCE Among adolescents and young adults with type 1 diabetes, daily financial incentives improved glucose monitoring adherence during the incentive period but did not significantly improve glycemic control. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02568501.
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Affiliation(s)
- Charlene A. Wong
- Department of Pediatrics, Duke Clinical Research Institute, Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina,Leonard Davis Institute of Health Economics, Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, Philadelphia
| | - Victoria A. Miller
- Division of Adolescent Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine and University of Pennsylvania, Philadelphia
| | - Kathryn Murphy
- Division of Pediatric Endocrinology, The Children’s Hospital of Philadelphia, Philadelphia
| | - Dylan Small
- Leonard Davis Institute of Health Economics, Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, Philadelphia,Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia
| | - Carol A. Ford
- Division of Adolescent Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine and University of Pennsylvania, Philadelphia
| | - Steven M. Willi
- Division of Pediatric Endocrinology, The Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Jordyn Feingold
- medical student, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexander Morris
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Yoonhee P. Ha
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Leonard Davis Institute of Health Economics, Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, Philadelphia,Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Wenli Wang
- Leonard Davis Institute of Health Economics, Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, Philadelphia,Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Mitesh S. Patel
- Leonard Davis Institute of Health Economics, Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, Philadelphia,Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Department of Medicine, Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania,Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia
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Chung JH, Pavlick D, Hartmaier R, Schrock AB, Young L, Forcier B, Ye P, Levin MK, Goldberg M, Burris H, Gay LM, Hoffman AD, Stephens PJ, Frampton GM, Lipson DM, Nguyen DM, Ganesan S, Park BH, Vahdat LT, Leyland-Jones B, Mughal TI, Pusztai L, O'Shaughnessy J, Miller VA, Ross JS, Ali SM. Hybrid capture-based genomic profiling of circulating tumor DNA from patients with estrogen receptor-positive metastatic breast cancer. Ann Oncol 2017; 28:2866-2873. [PMID: 28945887 PMCID: PMC5834148 DOI: 10.1093/annonc/mdx490] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Genomic changes that occur in breast cancer during the course of disease have been informed by sequencing of primary and metastatic tumor tissue. For patients with relapsed and metastatic disease, evolution of the breast cancer genome highlights the importance of using a recent sample for genomic profiling to guide clinical decision-making. Obtaining a metastatic tissue biopsy can be challenging, and analysis of circulating tumor DNA (ctDNA) from blood may provide a minimally invasive alternative. PATIENTS AND METHODS Hybrid capture-based genomic profiling was carried out on ctDNA from 254 female patients with estrogen receptor-positive breast cancer. Peripheral blood samples were submitted by clinicians in the course of routine clinical care between May 2016 and March 2017. Sequencing of 62 genes was carried out to a median unique coverage depth of 7503×. Genomic alterations (GAs) in ctDNA were evaluated and compared with matched tissue samples and genomic datasets of tissue from breast cancer. RESULTS At least 1 GA was reported in 78% of samples. Frequently altered genes were TP53 (38%), ESR1 (31%) and PIK3CA (31%). Temporally matched ctDNA and tissue samples were available for 14 patients; 89% of mutations detected in tissue were also detected in ctDNA. Diverse ESR1 GAs including mutation, rearrangement and amplification, were observed. Multiple concurrent ESR1 GAs were observed in 40% of ESR1-altered cases, suggesting polyclonal origin; ESR1 compound mutations were also observed in two cases. ESR1-altered cases harbored co-occurring GAs in PIK3CA (35%), FGFR1 (16%), ERBB2 (8%), BRCA1/2 (5%), and AKT1 (4%). CONCLUSIONS GAs relevant to relapsed/metastatic breast cancer management were identified, including diverse ESR1 GAs. Genomic profiling of ctDNA demonstrated sensitive detection of mutations found in tissue. Detection of amplifications was associated with ctDNA fraction. Genomic profiling of ctDNA may provide a complementary and possibly alternative approach to tissue-based genomic testing for patients with estrogen receptor-positive metastatic breast cancer.
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Affiliation(s)
- J H Chung
- Foundation Medicine, Inc., Cambridge.
| | - D Pavlick
- Foundation Medicine, Inc., Cambridge
| | | | | | - L Young
- Foundation Medicine, Inc., Cambridge
| | - B Forcier
- Foundation Medicine, Inc., Cambridge
| | - P Ye
- Avera Cancer Institute, Sioux Falls
| | - M K Levin
- Baylor University Medical Center, Texas Oncology, US Oncology, Dallas
| | | | - H Burris
- Sarah Cannon Research Institute, Nashville
| | - L M Gay
- Foundation Medicine, Inc., Cambridge
| | | | | | | | | | - D M Nguyen
- Sutter Medical Group of the Redwoods, Santa Rosa
| | - S Ganesan
- Division of Medical Oncology, Department of Medicine, Rutgers Cancer Institute of New Jersey, New Brunswick
| | - B H Park
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore
| | - L T Vahdat
- Weill Cornell Breast Center, Weill Cornell Medicine, New York
| | | | - T I Mughal
- Foundation Medicine, Inc., Cambridge; Tufts University Medical Center, Boston
| | - L Pusztai
- Department of Breast Medical Oncology, Yale University, Yale Cancer Center, New Haven
| | - J O'Shaughnessy
- Baylor University Medical Center, Texas Oncology, US Oncology, Dallas
| | | | - J S Ross
- Foundation Medicine, Inc., Cambridge; Department of Pathology and Laboratory Medicine, Albany Medical College, Albany, USA. mailto:
| | - S M Ali
- Foundation Medicine, Inc., Cambridge
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Walser SA, Werner-Lin A, Mueller R, Miller VA, Biswas S, Bernhardt BA. How do providers discuss the results of pediatric exome sequencing with families? Per Med 2017; 14:409-422. [PMID: 28966657 DOI: 10.2217/pme-2017-0015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
AIM This study provides preliminary data on the process and content of returning results from exome sequencing offered to children through one of the Clinical Sequencing Exploratory Research (CSER) projects. MATERIALS & METHODS We recorded 25 sessions where providers returned diagnostic and secondary sequencing results to families. Data interpretation utilized inductive thematic analysis. RESULTS Typically, providers followed a results report and discussed diagnostic findings using technical genomic and sequencing concepts. We identified four provider processes for returning results: teaching genetic concepts; assessing family response; personalizing findings; and strengthening patient-provider relationships. CONCLUSION Sessions should reflect family interest in medical management and next steps, and minimize detailed genomic concepts. As the scope and complexity of sequencing increase, the traditional information-laden counseling model requires revision.
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Affiliation(s)
- Sarah A Walser
- Translational Medicine & Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Allison Werner-Lin
- School of Social Policy & Practice, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Rebecca Mueller
- Department of History & Sociology of Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Victoria A Miller
- Division of Adolescent Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia & Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 9104, USA
| | - Sawona Biswas
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Barbara A Bernhardt
- Translational Medicine & Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
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Heilmann AM, Schrock AB, He J, Nahas M, Curran K, Shukla N, Cramer S, Draper L, Verma A, Erlich R, Ross J, Stephens P, Miller VA, Ali SM, Verglio JA, Tallman MS, Mughal TI. Novel PDGFRB fusions in childhood B- and T-acute lymphoblastic leukemia. Leukemia 2017; 31:1989-1992. [PMID: 28552906 DOI: 10.1038/leu.2017.161] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - A B Schrock
- Foundation Medicine Inc., Cambridge, MA, USA
| | - J He
- Foundation Medicine Inc., Cambridge, MA, USA
| | - M Nahas
- Foundation Medicine Inc., Cambridge, MA, USA
| | - K Curran
- Memorial Sloane Kettering Cancer Center, New York, NY, USA
| | - N Shukla
- Memorial Sloane Kettering Cancer Center, New York, NY, USA
| | - S Cramer
- University of Alabama, Birmingham, MS, USA
| | - L Draper
- University of Utah, Salt Lake City, UT, USA
| | - A Verma
- University of Utah, Salt Lake City, UT, USA
| | - R Erlich
- Foundation Medicine Inc., Cambridge, MA, USA
| | - J Ross
- Foundation Medicine Inc., Cambridge, MA, USA.,Albany College of Medicine, Albany, NY, USA
| | - P Stephens
- Foundation Medicine Inc., Cambridge, MA, USA
| | - V A Miller
- Foundation Medicine Inc., Cambridge, MA, USA
| | - S M Ali
- Foundation Medicine Inc., Cambridge, MA, USA
| | - J-A Verglio
- Foundation Medicine Inc., Cambridge, MA, USA
| | - M S Tallman
- Memorial Sloane Kettering Cancer Center, New York, NY, USA
| | - T I Mughal
- Foundation Medicine Inc., Cambridge, MA, USA.,Tufts University Medical Center, Boston, MA, USA
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