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Gross MS, Ju H, Osborne LM, Jelin EB, Sekar P, Jelin AC. Indeterminate Prenatal Ultrasounds and Maternal Anxiety: A Prospective Cohort Study. Matern Child Health J 2021; 25:802-812. [PMID: 33392932 DOI: 10.1007/s10995-020-03042-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Prenatal ultrasounds often yield indeterminate (incomplete or minor abnormality) findings with limited clinical utility. We evaluate impact of indeterminate findings on maternal anxiety. METHODS A single-U.S.-center prospective cohort study administered the Perinatal Anxiety Screening Scale (PASS; control mean = 13.4; > 20 denotes clinically significant anxiety) before and after prenatal ultrasounds in February-May 2017. Ultrasound reports were coded as: normal; indeterminate; or major abnormality. Primary outcome was anxiety after indeterminate vs. normal ultrasounds. Secondary outcomes included anxiety change from pre-to-post-ultrasound and relative to women's characteristics. Linear regression adjusted for confounders. RESULTS Of 286 ultrasounds, 51.0% were normal, 40.5% indeterminate (22.0% incomplete; 18.5% minor abnormality), and 8.0% major abnormalities. Indeterminate findings were unrelated to age, race, parity, infertility, or psychiatric history, but associated with gestational age (26.6%/45.0%/52.5% for first/second/third trimesters; p < 0.001), and obesity (48.8 vs. 37.0%; p = 0.031). Pretest anxiety was highest in second/third trimesters (p = 0.029), and in subjects aged age ≤ 24 or younger(p < 0.001), with a history of anxiety (p < 0.001),) or with prior pregnancy loss (p = 0.011). Mean anxiety score decreased pre-to-posttest across all groups. Indeterminate findings were associated with higher PASS scores than normal findings: pretest 20.1 vs. 16.4 (p = 0.026) and posttest 16.9 vs. 12.2 (p = 0.009; adjusted-p = 0.01). Versus normal ultrasounds, incomplete findings were associated with higher post-ultrasound anxiety (p = 0.007; adjusted-p = 0.01) and smaller decreases from pre-to-posttest (adjusted-p = 0.03), whereas minor abnormalities had higher pretest anxiety (p = 0.029) with larger pre-to-posttest decreases (adjusted-p =0.010). DISCUSSION Indeterminate ultrasounds, especially incomplete findings, are associated with significantly higher anxiety than normal findings, suggesting need for evidence-based counseling, management and strategies for decreasing number of indeterminate results.
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Affiliation(s)
- Marielle S Gross
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Ave, Baltimore, MD, 21205, USA. .,Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Women's Mood Disorders Center, 550 N. Broadway, Suite 305, Baltimore, MD, 21205, USA. .,Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, 15222, USA.
| | - Hyeyoung Ju
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Women's Mood Disorders Center, 550 N. Broadway, Suite 305, Baltimore, MD, 21205, USA
| | - Lauren M Osborne
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Women's Mood Disorders Center, 550 N. Broadway, Suite 305, Baltimore, MD, 21205, USA.,Psychiatry and Behavioral Sciences, Women's Mood Disorders Center, 550 N. Broadway, Suite 305, Baltimore, MD, 21205, USA
| | - Eric B Jelin
- Children's Center Fetal Program, Johns Hopkins Children's Center, 1800 Orleans Street, Baltimore, MD, M230721287, USA
| | - Priya Sekar
- Pediatric Cardiology, Johns Hopkins Children's Center, 1800 Orleans Street, Baltimore, MD, M230721287, USA
| | - Angie C Jelin
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Women's Mood Disorders Center, 550 N. Broadway, Suite 305, Baltimore, MD, 21205, USA
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Bollinger JM, Geller G, Weinfurt K, May E, Morain SR, Mathews DJH, Sugarman J. Patients' Views About the Disclosure of Collateral Findings in Pragmatic Clinical Trials: a Focus Group Study. J Gen Intern Med 2020; 35:3436-3442. [PMID: 32815061 PMCID: PMC7728860 DOI: 10.1007/s11606-020-06113-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/05/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Pragmatic clinical trials (PCTs) are increasingly being conducted to efficiently generate evidence to inform healthcare decision-making. Despite their growing acceptance, PCTs may involve a variety of ethical issues, including the management of pragmatic clinical trial-collateral findings (PCT-CFs), that is, information that emerges in PCTs that is unrelated to the primary research questions but may have implications for patients, clinicians, and health systems. OBJECTIVE We sought to understand patients' views about PCT-CF disclosure, including how, by whom, and the nature and extent of information provided. DESIGN Prospective, qualitative focus group study. PARTICIPANTS Focus groups were conducted in Baltimore, MD; Houston, TX; and Seattle, WA (overall N = 66), during July and August 2019. APPROACH All groups discussed a hypothetical scenario involving the detection of a PCT-CF of contraindicated medications. Participants were asked about their reactions to the PCT-CF and issues related to its disclosure. KEY RESULTS Reactions to learning about the PCT-CF were mixed, ranging from fear of a significant health problem, anger that the contraindicated medications had gone unnoticed and/or for being included in research without their permission, to gratitude for the information. Preferences for how such disclosures are made varied but were driven by several consistent desires, namely minimizing patient harm and anxiety and demonstrating trust and respect. Many wanted their treating clinician to be informed of the PCT-CF so that they would be prepared to answer patients' questions and to discuss treatment options. CONCLUSIONS The detection of PCT-CFs is likely to increase with further expansion of PCTs. As such, clinicians will undoubtedly become involved in the management of PCT-CFs. Our data illustrate some of the challenges clinicians may face when their patients are informed of a PCT-CF and the need to develop guidance for disclosing PCT-CFs in ways that align with patients' preferences and values.
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Affiliation(s)
- Juli M Bollinger
- Berman Institute of Bioethics, Johns Hopkins University, , Baltimore, MD, USA.
| | - Gail Geller
- Berman Institute of Bioethics, Johns Hopkins University, , Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, , Baltimore, MD, USA
| | - Kevin Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, , Durham, NC, USA
| | - Elizabeth May
- Berman Institute of Bioethics, Johns Hopkins University, , Baltimore, MD, USA
| | - Stephanie R Morain
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, , Houston, TX, USA
| | - Debra J H Mathews
- Berman Institute of Bioethics, Johns Hopkins University, , Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, , Baltimore, MD, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, , Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, , Baltimore, MD, USA
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Morain SR, Weinfurt K, Bollinger J, Geller G, Mathews DJ, Sugarman J. Ethics and Collateral Findings in Pragmatic Clinical Trials. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:6-18. [PMID: 31896322 PMCID: PMC7027922 DOI: 10.1080/15265161.2020.1689031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Pragmatic clinical trials (PCTs) offer important benefits, such as generating evidence that is suited to inform real-world health care decisions and increasing research efficiency. However, PCTs also present ethical challenges. One such challenge involves the management of information that emerges in a PCT that is unrelated to the primary research question(s), yet may have implications for the individual patients, clinicians, or health care systems from whom or within which research data were collected. We term these findings as ?pragmatic clinical trial collateral findings,? or ?PCT-CFs?. In this article, we explore the ethical considerations associated with the identification, assessment, and management of PCT-CFs, and how these considerations may vary based upon the attributes of a specific PCT. Our purpose is to map the terrain of PCT-CFs to serve as a foundation for future scholarship as well as policy-making and to facilitate careful deliberation about actual cases as they occur in practice.
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Affiliation(s)
| | | | | | - Gail Geller
- Johns Hopkins University
- Johns Hopkins University School of Medicine
| | - Debra Jh Mathews
- Johns Hopkins University
- Johns Hopkins University School of Medicine
| | - Jeremy Sugarman
- Johns Hopkins University
- Johns Hopkins University School of Medicine
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Shim J, Lin T, Dashiell-Earp C, Nechrebecki M, Leung AM. Endocrinology practice patterns of hypothyroidism and osteoporosis management in a U.S. tertiary academic medical center. Clin Diabetes Endocrinol 2019; 5:10. [PMID: 31360539 PMCID: PMC6637534 DOI: 10.1186/s40842-019-0085-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/10/2019] [Indexed: 11/16/2022] Open
Abstract
Background The major published clinical guidelines for the management of hypothyroidism and osteoporosis are not uniformly consistent and may be a significant contributor to variability of clinical care delivered by endocrinologists, in addition to other factors, such as physician experience, physician and patient perceptions, and patient comorbidities. The purpose of this study was to assess practice patterns of hypothyroidism and osteoporosis within an academic endocrine clinic. Methods A retrospective medical record review of the first 200 adult patients (n = 100 with primary hypothyroidism and n = 100 with osteoporosis or osteopenia) seen by an endocrinologist beginning January 2, 2017at a large U.S. urban tertiary academic medical center was performed. Data were collected regarding patient demographics, clinic visit type, patterns of ordering laboratory tests and imaging, and choice of pharmacologic treatment. Results Most patients with hypothyroidism (99%) had a serum thyroid stimulating hormone concentration measured. Other thyroid indices measured included serum total thyroxine (10%), serum free thyroxine [T4] (82%), serum free T4 index (6%), serum total triiodothyronine [T3] (9%), and serum free T3 (12%). Forty-eight percent also had serum thyroid antibodies checked. A variety of thyroid hormone supplements were used to treat hypothyroidism, including levothyroxine (83%), levothyroxine and liothyronine combination (8%), and desiccated thyroid extract (6%). In regards to patients with osteoporosis, mean duration of all pharmacologic therapy combined was 73.4 ± 81.9 months. For those with more than one bone density (DXA) scans (64%), the mean time interval between two consecutive DXA scans was variable (mean 32.0 ± 24.7 [SD] months). Sixty eight percent of the patients had bone turnover markers assessed within 7 months of the visit. Conclusions This study reports a real-world experience of endocrinology practice patterns at a large U.S. academic healthcare system. For the common diagnoses of hypothyroidism and osteoporosis, there are opportunities for increased standardization of care, particularly regarding the ordering of laboratory testing and radiologic studies. Identifying areas with significant practice variability may improve the quality and health outcomes and reduce the cost of care for patients with these conditions. Increased understanding regarding the reasons behind ordering various studies may help physician and patients further align their goals.
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Affiliation(s)
- Jien Shim
- 1Division of Endocrinology, Diabetes, and Metabolism; Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA USA.,2Division of Endocrinology, Diabetes, and Metabolism; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
| | - Tiffany Lin
- 3UCLA David Geffen School of Medicine, Los Angeles, CA USA
| | - Cody Dashiell-Earp
- 3UCLA David Geffen School of Medicine, Los Angeles, CA USA.,4University of Colorado School of Medicine, Denver, CO USA
| | | | - Angela M Leung
- 1Division of Endocrinology, Diabetes, and Metabolism; Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA USA.,2Division of Endocrinology, Diabetes, and Metabolism; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
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Christensen KD, Bernhardt BA, Jarvik GP, Hindorff LA, Ou J, Biswas S, Powell BC, Grundmeier RW, Machini K, Karavite DJ, Pennington JW, Krantz ID, Berg JS, Goddard KAB. Anticipated responses of early adopter genetic specialists and nongenetic specialists to unsolicited genomic secondary findings. Genet Med 2018; 20:1186-1195. [PMID: 29388940 PMCID: PMC6103906 DOI: 10.1038/gim.2017.243] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 12/01/2017] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Secondary findings from genomic sequencing are becoming more common. We compared how health-care providers with and without specialized genetics training anticipated responding to different types of secondary findings. METHODS Providers with genomic sequencing experience reviewed five secondary-findings reports and reported attitudes and potential clinical follow-up. Analyses compared genetic specialists and physicians without specialized genetics training, and examined how responses varied by secondary finding. RESULTS Genetic specialists scored higher than other providers on four-point scales assessing understandings of reports (3.89 vs. 3.42, p = 0.0002), and lower on scales assessing reporting obligations (2.60 vs. 3.51, p < 0.0001) and burdens of responding (1.73 vs. 2.70, p < 0.0001). Nearly all attitudes differed between findings, although genetic specialists were more likely to assert that laboratories had no obligations when findings had less-established actionability (p < 0.0001 in interaction tests). The importance of reviewing personal and family histories, documenting findings, learning more about the variant, and recommending familial discussions also varied according to finding (all p < 0.0001). CONCLUSION Genetic specialists felt better prepared to respond to secondary findings than providers without specialized genetics training, but perceived fewer obligations for laboratories to report them, and the two groups anticipated similar clinical responses. Findings may inform development of targeted education and support.
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Affiliation(s)
- Kurt D Christensen
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
| | - Barbara A Bernhardt
- Division of Translational Medicine & Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gail P Jarvik
- Division of Medical Genetics, University of Washington, Seattle, Washington, USA
| | - Lucia A Hindorff
- Division of Genomic Medicine, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jeffrey Ou
- Division of Medical Genetics, University of Washington, Seattle, Washington, USA
| | - Sawona Biswas
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bradford C Powell
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kalotina Machini
- Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School, Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Boston Cambridge, Massachusetts, USA
| | - Dean J Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey W Pennington
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ian D Krantz
- Division of Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan S Berg
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Katrina A B Goddard
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
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Brink JA. Serving Up Incidental Findings: Just the Way You Like ’Em. J Am Coll Radiol 2016; 13:1285-1286. [DOI: 10.1016/j.jacr.2016.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 09/16/2016] [Accepted: 09/18/2016] [Indexed: 11/17/2022]
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