Educational attainment in long-term survivors of childhood cancer: A report from the Childhood Cancer Survivor Study (CCSS)

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Background: Diagnosis and treatment of childhood cancer place survivors at risk for lower educational attainment, the increased burden of chronic conditions on attainment has not been examined. Methods: Participants included 16724 survivors (48% female; mean diagnosis age 9.1 years, current age 36.2 years, time since diagnosis 26.6 years) and 4098 siblings (mean current age 39.3 years) Educational attainment was categorized as college graduation (yes/no) among survivors ≥ age 25 years. Chronic conditions occurring before age 25 years of age were graded using Common Terminology for Adverse Events 4.3. Modified Poisson regression models estimated relative risks (RR) and 95% confidence intervals (CI) of treatment exposures and chronic conditions on education attainment, adjusting for age at diagnosis and sex. Results: College graduation was reported by 8391 (51%) survivors and 2410 (59%) siblings. Survivors of all diagnoses were more likely to not graduate compared to siblings (all p’s < 0.05), with survivors of CNS tumor (RR1.36, CI 1.25-1.49), leukemia (RR 1.17, CI 1.07-1.28), and Hodgkin lymphoma (RR 1.17, CI 1.07-1.29) being at higher risk than survivors of neuroblastoma. Compared to survivors with no history of cranial radiation therapy (CRT), higher risk of not graduating college was seen in those who received 20-30Gy (RR 1.16, CI 1.09-1.25), 30-50Gy (RR 1.37, CI 1.26-1.49) and ≥50Gy (RR 1.35, CI 1.28-1.42). Among survivors not exposed to CRT, dexamethasone had a protective effect on college education (RR 0.88, CI 0.80-0.97) compared to no corticosteroid exposure. Male sex and older age (≥ 5 years) at diagnosis were associated with being more likely to not graduate college. survivors reporting any serious/life threatening chronic condition prior to age 25 years (grades 3-4) were more likely to not graduate college (RR 1.14, 95% CI 1.10-1.18) compared to no or mild/moderate conditions (grades < 3). Conclusions: Survivors reporting chronic conditions are less likely to complete a college education by age 25 years and may need additional early educational or vocational resources.

Patient, Provider, and System Factors Associated With Failure to Follow-Up Elevated Glucose Results in Patients Without Diagnosed Diabetes

Background:

Although elevated glucose values are strongly associated with undiagnosed diabetes, they are frequently overlooked. Patient, provider, and system factors associated with failure to follow-up elevated glucose values in electronic medical records (EMRs) are not well described.

Methods:

We conducted a chart review in a comprehensive EMR with a patient portal and results management features. Established primary care patients with no known diagnosis of diabetes and ≥ 1 glucose value >125 mg/dL were included. Follow-up failure was defined as (1) no documented comment on the glucose value or result communication to the patient within 30 days or (2) no hemoglobin A_1c (HbA_1c) ordered within 30 days or resulted within 12 months. Associations were examined using Wilcoxon and χ² tests.

Results:

Of 150 charts reviewed, 97 met inclusion criteria. The median glucose was 133 mg/dL, and 20% of patients had multiple values >125 mg/dL. Only 36% of elevated glucose values were followed up. No associations were observed between patient characteristics, diabetes risk factors, or provider characteristics and follow-up failures. Automated flagging of glucose values ≥140 mg/dL by highlighting them red in the EMR was not associated with improved follow-up (46% vs 32%; P = .19). Even when follow-up occurred (n = 35), only 31% completed gold standard diabetes testing (HbA_1c) within 12 months. Of the resulted HbA_1c tests (n = 11), 55% were in the prediabetes range (5.7%-6.4%).

Conclusions:

Two-thirds of elevated glucose values were not followed up, despite EMR features facilitating results management. Greater understanding of the results management process and improved EMR functionalities to support results management are needed.

Reasons for Lack of Diagnostic Colonoscopy After Positive Result on Fecal Immunochemical Test in a Safety-Net Health System

BACKGROUND

Effective colorectal cancer screening depends on timely diagnostic evaluation in patients with abnormal results on fecal immunochemical tests (FITs). Although prior studies suggest low rates of follow-up colonoscopy, there is little information among patients in safety-net health systems and few data characterizing reasons for low follow-up rates. This study aimed to characterize factors contributing to lack of follow-up colonoscopy in a racially diverse and socioeconomically disadvantaged cohort of patients with abnormal results on FIT ("abnormal FIT" for brevity) receiving care in an integrated safety-net health system.

METHODS

We performed a retrospective electronic medical record review of patients aged 50-64 years with abnormal FIT at a population-based safety-net health system between January 2010 and July 2013. Review of electronic medical records focused on patients without follow-up colonoscopy to characterize patient-, provider-, and system-level reasons for lack of diagnostic evaluation. We used logistic regression analysis to identify predictors of follow-up colonoscopy within 12 months of abnormal FIT.

RESULTS

Of 1267 patients with abnormal FIT, 536 (42.3%) failed to undergo follow-up colonoscopy within 1 year. Failure was attributable to patient-level factors in 307 (57%) cases, provider factors in 97 (18%) cases, and system factors in 118 (22%) cases. In multivariate analysis, follow-up colonoscopy was less likely among those aged 61-64 years (odds ratio 0.63, 95% confidence interval 0.46-0.87) compared with 50-55 year olds.

CONCLUSIONS

Nearly half (42%) of patients with abnormal FIT failed to undergo follow-up colonoscopy within 1 year. Lack of diagnostic evaluation is related to a combination of patient-, provider-, and system-level factors, highlighting the need for multilevel interventions to improve follow-up colonoscopy completion rates.

Primary-Care Weight-Management Strategies: Parental Priorities and Preferences

OBJECTIVE

To examine parental perspectives/rankings of the most important weight-management clinical practices and to determine whether preferences/rankings differ when parents disagree that their child is overweight.

METHODS

We performed mixed-methods analysis of a 32-question survey of parents of 2- to 18-year-old overweight children assessing parental agreement that their child is overweight, the single most important thing providers can do to improve weight status, ranking American Academy of Pediatrics-recommended clinical practices, and preferred follow-up interval. Four independent reviewers analyzed open-response data to identify qualitative themes/subthemes. Multivariable analyses examined parental rankings, preferred follow-up interval, and differences by agreement with their child's overweight assessment.

RESULTS

Thirty-six percent of 219 children were overweight, 42% obese, and 22% severely obese; 16% of parents disagreed with their child's overweight assessment. Qualitative analysis of the most important practice to help overweight children yielded 10 themes; unique to parents disagreeing with their children's overweight assessments was "change weight-status assessments." After adjustment, the 3 highest-ranked clinical practices included, "check for weight-related problems," "review growth chart," and "recommend general dietary changes" (all P < .01); parents disagreeing with their children's overweight assessments ranked "review growth chart" as less important and ranked "reducing screen time" and "general activity changes" as more important. The mean preferred weight-management follow-up interval (10-12 weeks) did not differ by agreement with children's overweight assessments.

CONCLUSIONS

Parents prefer weight-management strategies that prioritize evaluating weight-related problems, growth-chart review, and regular follow-up. Parents who disagree that their child is overweight want changes in how overweight is assessed. Using parent-preferred weight-management strategies may prove useful in improving child weight status.

Engineering hydrophobically modified chitosan for enhancing the dispersion of respirable microparticles of levofloxacin

The potential of amphiphilic chitosan formed by grafting octanoyl chains on the chitosan backbone for pulmonary delivery of levofloxacin has been studied. The success of polymer synthesis was confirmed using FT-IR and NMR, whilst antimicrobial activity was assessed against Pseudomonas aeruginosa. Highly dispersible dry powders for delivery as aerosols were prepared with different amounts of chitosan and octanoyl chitosan to study the effect of hydrophobic modification and varying concentration of polymer on aerosolization of drug. Powders were prepared by spray-drying from an aqueous solution containing levofloxacin and chitosan/amphiphilic octanoyl chitosan. l-leucine was also used to assess its effect on aerosolization. Following spray-drying, the resultant powders were characterized using scanning electron microscopy, laser diffraction, dynamic light scattering, HPLC, differential scanning calorimetry, thermogravimetric analysis and X-ray powder diffraction. The in vitro aerosolization profile was determined using a Next Generation Impactor, whilst in vitro antimicrobial assessment was performed using MIC assay. Microparticles of chitosan have the property of mucoadhesion leading to potential increased residence time in the pulmonary mucus, making it important to test the toxicity of these formulations. In-vitro cytotoxicity evaluation using MTT assay was performed on A549 cell line to determine the toxicity of formulations and hence feasibility of use. The MTT assay confirmed that the polymers and the formulations were non-cytotoxic. Hydrophobically modifying chitosan showed significantly lower MIC (4-fold) than the commercial chitosan against P. aeruginosa. The powders generated were of suitable aerodynamic size for inhalation having a mass median aerodynamic diameter less than 4.5μm for formulations containing octanoyl chitosan. These highly dispersible powders have minimal moisture adsorption and hence an emitted dose of more than 90% and a fine particle fraction (FPF) of 52%. Powders with non-modified chitosan showed lower dispersibility, with an emitted dose of 72% and FPF of 20%, as a result of high moisture adsorption onto the chitosan matrix leading to cohesiveness and subsequently decreased dispersibility.

Laparoscopic-assisted ureteroureterostomy for duplication anomalies in children

PURPOSE

To describe a novel laparoscopic-assisted technique for ureteroureterostomy for the surgical management of a completely duplicated collecting system with an obstructed and/or ectopic ureter.

PATIENTS AND METHODS

A camera is placed through a 5-mm infraumbilical port and the duplicated ureters identified and delivered through a small inguinal incision with a laparoscopic Babcock clamp. The ureteroureterostomy is performed in an open fashion. The mean operative time, length of stay, success, and complications of nine patients who underwent this technique were reviewed and compared with a cohort of patients who underwent open ureteroureterostomy at a single institution. In addition, the existing literature on laparoscopic and robot-assisted ureteroureterostomy is reviewed.

RESULTS

There were no statistically significant differences in operative time (134 vs 133 min, P=0.950), length of stay (0.32 vs 0.33 days, P=0.929), complications (2 and 2, P=0.574), or rates of success (95% vs 100%, P=1.00) between the open and laparoscopic-assisted ureteroureterostomy groups. In addition, the operative times and length of stay in our laparoscopic cohort were shorter than a majority of the laparoscopic and robotic cases reported in the literature.

CONCLUSIONS

Laparoscopic-assisted ureteroureterostomy is a successful technique for the management of an ectopic and/or obstructed ureter in a completely duplicated collecting system. This technique combines the speed and ease of the open technique with the improved cosmesis and visualization of a laparoscopic approach and is thus a useful approach for the pediatric urologist.

Ascorbyl palmitate/DSPE-PEG nanocarriers for oral iron delivery: preparation, characterisation and in vitro evaluation

The objective of this study was to encapsulate iron in nanocarriers formulated with ascorbyl palmitate and 1,2-distearoyl-sn-glycero-3-phosphoethanolamine polyethylene glycol (DSPE-PEG) for oral delivery. Blank and iron (Fe) loaded nanocarriers were prepared by a modified thin film method using ascorbyl palmitate and DSPE-PEG. Surface charge of the nanocarriers was modified by the inclusion of chitosan (CHI) during the formulation process. Blank and iron loaded ascorbyl palmitate/DSPE nanocarriers were visualised by transmission electron microscopy (TEM) and physiochemical characterisations of the nanocarriers carried out to determine the mean particle size and zeta potential. Inclusion of chitosan imparted a net positive charge on the nanocarrier surface and also led to an increase in mean particle size. Iron entrapment in ascorbyl palmitate-Fe and ascorbyl palmitate-CHI-Fe nanocarriers was 67% and 76% respectively, suggesting a beneficial effect of chitosan on nanocarrier Fe entrapment. Iron absorption was estimated by measuring Caco-2 cell ferritin formation using ferrous sulphate as a reference standard. Iron absorption from ascorbyl palmitate-Fe (592.17±21.12 ng/mg cell protein) and ascorbyl palmitate-CHI-Fe (800.12±47.6 ng/mg, cell protein) nanocarriers was 1.35-fold and 1.5-fold higher than that from free ferrous sulphate, respectively (505.74±23.73 ng/mg cell protein) (n=6, p<0.05). This study demonstrates for the first time preparation and characterisation of iron loaded ascorbyl palmitate/DSPE PEG nanocarriers, and that engineering of the nanocarriers with chitosan leads to a significant augmentation of iron absorption.

BMS-201620: a selective beta 3 agonist

A series of N-(4-hydroxy-3-methylsulfonanilidoethanol)arylglycinamides were prepared and evaluated for their human beta3 adrenergic receptor agonist activity. SAR studies led to the identification of BMS-201620 (39), a potent beta3 full agonist (Ki = 93 nM, 93% activation). Based on its favorable safety profile, BMS-201620 was chosen for clinical evaluation.

Pancreatic exocrine enzymes during the neonatal period in postmature rats

Pancreatic content of exocrine enzymes in newborn rat pups shows a sharp decline soon after birth. To investigate if this decline is a preprogrammed and, therefore, inherently controlled phenomenon, or a result of external stimulus, prolonged gestation, or postmaturity (2 extra days in utero) in pregnant dams was induced by daily subcutaneous injection of progesterone from the 20th to 22nd days of gestation. Postmature pups showed the same high levels of lipase, trypsin(ogen), and amylase as control pups at birth. They also exhibited the same decline in these enzymes as control pups by the 2nd day after birth, suggesting that it is a response to external stimulus. Pups prevented from suckling retained the high levels of lipase, amylase, and trypsin(ogen) by the 2nd day. The stimulus, therefore, appeared to be the initiation of suckling. Pups prevented from suckling but given 5% glucose water orally every 4 h starting from birth for 24 h showed a sharp decline in amylase with only slight decreases in lipase and trypsin(ogen) by the 2nd day. The components in the feed, therefore, also seem to be an important determinant for selective enzyme release from the pancreas of the neonates. Electron microscopic studies revealed a sharp decrease in the number of zymogen granules in the continuously-suckled pups as compared to age-matched non-suckled counterparts. The reduction in enzyme content thus is the result of secretion in response to suckling.