Trajectories of Traumatic Stress Symptoms Among Siblings of Children With Cancer: The First Two Years Post-Diagnosis

OBJECTIVE

Identify and describe trajectories of cancer-related posttraumatic stress symptoms (PTSS) among siblings of children with cancer within two years of diagnosis.

METHOD

Siblings (aged 8-18; M = 11.2 years) across the United States, and for each, one caregiver, were recruited for a cohort sequential longitudinal study with three data collection points six months apart beginning at 6- or 12-months after cancer diagnosis. Siblings (N = 229; 42% of eligible/approached; 53% identifying as female; 68% identifying as non-Hispanic White) completed the Child Posttraumatic Stress Disorder Symptom Scale. Caregivers completed the Strengths and Difficulties Questionnaire (SDQ). Latent class growth analysis (LCGA) and growth mixture modeling (GMM) identified PTSS patterns across time.

RESULTS

Fit statistics supported models with three to five PTSS trajectories. The three-class LCGA model included a large mild PTSS group (61%), a moderate PTSS group (35%), and a small (4%) stable severe PTSS group. The four-class LCGA and three- and four-class GMM included groups improving from moderate to mild PTSS (7-21%) and worsening to moderate PTSS across time (12-17%). Across models, siblings with mild PTSS had fewer caregiver-reported emotional and behavioral difficulties on the SDQ.

CONCLUSIONS

A large group of siblings of children with cancer demonstrate resiliency, however, substantial subsets experience patterns of PTSS that include levels in the moderate-to-severe range during the first two years post-diagnosis. Future research should examine these patterns in more diverse/representative samples and identify factors associated with increasing and sustained severe PTSS to inform intervention targets and reduce cancer-related burden on families.

The potential positive epigenetic effects of various mind-body therapies (MBTs): a narrative review

Mind-body therapies (MBTs), such as mindfulness, meditation, yoga, and tai-chi, are said to improve quality of life by contributing to positive thinking and reducing overall distress. MBTs not only play a role in reducing stress and anxiety, but they are also found to epigenetically affect genes and other areas in our genomes that are implicated in inflammation, stress, and distress. This review analyzes the role of MBTs in reducing the epigenetic changes as reported in five previously conducted controlled studies found in the NCBI PubMed database. The methylation of the tumor necrosis factor gene, implicated in psychological distress, was shown to significantly decrease for the women who performed yoga. For people who took part in mindfulness meditation, there was a significant alteration in a variety of modifications of histone deacetylase enzymes as well as their expression patterns when compared to the control group. Other studies found that long-term meditators had slower biomarkers of aging, known as epigenetic clocks, and methylation in genes associated with immune cell metabolism and inflammation. Different genomic regions known as CpG dinucleotide sites ("CpG islands") were also found to be epigenetically altered in participants of tai-chi. These controlled studies were promising evidence on the potential of MBTs to affect the epigenetics of an individual. This information will be useful in diagnostic, therapeutic, and preventative measures, and can be an addition to western medicine, in a way that is more holistic and beneficial to the individual.

Resident physician outlook on death, dying and end-of-life care during the COVID-19 pandemic: effect of religion and burnout

OBJECTIVES

Religion and spirituality are important aspects of many physicians and patients' lives and may impact their views of death and the way they interact with terminally ill patients, specifically comfort discussing end-of-life care and death and dying. This study explores the religious and spiritual beliefs of resident physicians, if they affect interactions with their patients and if burnout impedes this interaction.

METHODS

A 28-item questionnaire was administered to residents and fellows at an urban academic hospital.

RESULTS

65 residents and fellows answered the survey. Religiosity but not spirituality correlated with reported comfort interacting with patients dealing with death or dying. Resident specialty, biological sex and spirituality were not associated with comfort and conversations about religion and end-of-life care. The majority (60%) reported that the pandemic has not affected how they speak to their patients about death and dying. Caring for a higher volume of terminally ill patients was not associated with high levels of burnout though 71% reported increased burnout due to COVID-19.

CONCLUSION

Further research can be done to determine whether additional training or resources should be provided to resident physicians to cope with death and dying in the setting of a pandemic.

A biopsychosocial approach to death, dying, and bereavement: a course on end-of-life education for medical students

Background: Despite the inevitable nature of death and dying, the conversations surrounding this subject are still uncomfortable for many physicians and medical students. Methods: A six-week humanities-based course, "A Biopsychosocial Approach to Death, Dying, & Bereavement," at Cooper Medical School of Rowan University, United States, which covers definitions of death and dying, the process of dying, ethical dilemmas, and new concepts of the grieving process. Through development of a curriculum using various academic and medical literature and resources, we sought to bring attention to the necessity of having a medical education curriculum on death and dying to prepare medical students for the difficult conversations and patient experiences that lie ahead of them. Qualitative data in the form of surveys and reflection papers submitted by students and quantitative data (Likert scores on course satisfaction) were collected and analyzed both pre- and post-course. Results: 90.7% (49/54) of the respondents answered that they agree or strongly agree with the statement that this selective course was useful in the student's medical education experience. The top three qualitative themes brought up the most in reflection papers (n=54) were: the utility and instruction of the course (21 times), the importance of hospice and palliative care (20 times), avoidance around topics of death (15 times). Conclusions : Medical students are often not prepared to cope with the realities of patient loss and of caring for the patient and their families throughout the dying process. We created this course to familiarize medical students with an aspect of the medical experience that is frequently neglected in traditional medical curricula. We learned that integrating such a course can help educate medical students facilitate important conversations, teach them to act with kindness and dignity in a physician-patient setting, and enhance their personal understanding of death and dying.

A biopsychosocial approach to death, dying, and bereavement: a course on end-of-life education for medical students

Background: Despite the inevitable nature of death and dying, the conversations surrounding this subject are still uncomfortable for many physicians and medical students. Methods: A six-week humanities-based course, “A Biopsychosocial Approach to Death, Dying, & Bereavement,” at Cooper Medical School of Rowan University, United States, which covers definitions of death and dying, the process of dying, ethical dilemmas, and new concepts of the grieving process. Through development of a curriculum using various academic and medical literature and resources, we sought to bring attention to the necessity of having a medical education curriculum on death and dying to prepare medical students for the difficult conversations and patient experiences that lie ahead of them. Qualitative data in the form of surveys and reflection papers submitted by students and quantitative data (Likert scores on course satisfaction) were collected and analyzed both pre- and post-course. Results: 90.7% (49/54) of the respondents answered that they agree or strongly agree with the statement that this selective course was useful in the student’s medical education experience. The top three qualitative themes brought up the most in reflection papers (n=54) were: the utility and instruction of the course (21 times), the importance of hospice and palliative care (20 times), avoidance around topics of death (15 times). Conclusions: Medical students are often not prepared to cope with the realities of patient loss and of caring for the patient and their families throughout the dying process. We created this course to familiarize medical students with an aspect of the medical experience that is frequently neglected in traditional medical curricula. We learned that integrating such a course can help educate medical students facilitate important conversations, teach them to act with kindness and dignity in a physician-patient setting, and enhance their personal understanding of death and dying.

The effect of COVID-19 on breast cancer care and treatment in North America: A scoping review

Background

Methods

Results

Conclusion

A biopsychosocial approach to death, dying, and bereavement: a course on end-of-life education for medical students

Background: Despite the inevitable nature of death and dying, the conversations surrounding this subject are still uncomfortable for many physicians and medical students. Methods: A six-week humanities-based course, “A Biopsychosocial Approach to Death, Dying, & Bereavement,” at Cooper Medical School of Rowan University, United States, which covers definitions of death and dying, the process of dying, ethical dilemmas, and new concepts of the grieving process. Through development of a curriculum using various academic and medical literature and resources, we sought to bring attention to the necessity of having a medical education curriculum on death and dying to prepare medical students for the difficult conversations and patient experiences that lie ahead of them. Qualitative data in the form of surveys and reflection papers submitted by students and quantitative data (Likert scores on course satisfaction) were collected and analyzed both pre- and post-course. Results: 90.7% (49/54) of the respondents answered that they agree or strongly agree with the statement that this selective course was useful in the student’s medical education experience. The top three qualitative themes brought up the most in reflection papers (n=50) were: the utility and instruction of the course (23 times), the importance of hospice and palliative care (23 times), and respecting patient autonomy (16 times). Conclusions: Medical students are often not prepared to cope with the realities of patient loss and of caring for the patient and their families throughout the dying process. We created this course to familiarize medical students with an aspect of the medical experience that is frequently neglected in traditional medical curricula. We learned that integrating such a course can help educate medical students facilitate important conversations, teach them to act with kindness and dignity in a physician-patient setting, and enhance their personal understanding of death and dying.

A biopsychosocial approach to death, dying, and bereavement: a course on end-of-life education for medical students

Background: Despite the inevitable nature of death and dying, the conversations surrounding this subject are still uncomfortable for many physicians and medical students. Methods: A six-week humanities-based course, “A Biopsychosocial Approach to Death, Dying, & Bereavement,” at Cooper Medical School of Rowan University, United States, which covers definitions of death and dying, the process of dying, ethical dilemmas, and new concepts of the grieving process. Through development of a curriculum using various academic and medical literature and resources, we sought to bring attention to the necessity of having a medical education curriculum on death and dying to prepare medical students for the difficult conversations and patient experiences that lie ahead of them. Qualitative data in the form of surveys and reflection papers submitted by students and quantitative data (Likert scores on course satisfaction) were collected and analyzed both pre- and post-course. Results: 90.7% (49/54) of the respondents answered that they agree or strongly agree with the statement that this selective course was useful in the student’s medical education experience. The top three qualitative themes brought up the most in reflection papers (n=50) were: the utility and instruction of the course (23 times), the importance of hospice and palliative care (23 times), and respecting patient autonomy (16 times). Conclusions: Medical students are often not prepared to cope with the realities of patient loss and of caring for the patient and their families throughout the dying process. We created this course to familiarize medical students with an aspect of the medical experience that is frequently neglected in traditional medical curricula. We learned that integrating such a course can help educate medical students facilitate important conversations, teach them to act with kindness and dignity in a physician-patient setting, and enhance their personal understanding of death and dying.

What to do When Decompressive Gastrostomies and Jejunostomies are not Options? A Scoping Review of Transesophageal Gastrostomy Tubes for Advanced Malignancies

BACKGROUND

In advanced malignant bowel obstruction, decompressive gastrostomy tubes (GTs) may not be feasible due to ascites, peritoneal carcinomatosis, and altered gastric anatomy. Whereas nasogastric tubes (NGTs) allow temporary decompression, percutaneous transesophageal gastrostomy tubes (PTEGs) are an alternative method for long-term palliative decompression. This study performed a scoping review to determine outcomes with PTEG in advanced malignancies.

METHODS

A systematic literature search was performed to include all studies that reported the clinical results of PTEGs for malignancy. No language, national, or publication status restrictions were used.

RESULTS

The analysis included 14 relevant studies with a total of 340 patients. In 11 studies, standard PTEGs were inserted with a rupture-free balloon's placement into the mouth or nose and esophageal puncture under fluoroscopy or ultrasound, followed by a guidewire into the stomach with placement of a single-lumen tube. Of 340 patients, 65 (19.1%) had minor complications, and 5 (2.1%) had significant complications, including bleeding and severe aspiration pneumonia. Of 171 patients, 169 with PTEGs (98.8%) reported relief of nasal discomfort from NGT and alleviation of obstructive symptoms. The one randomized controlled trial reported a significantly higher quality of life with PTEGs than with NGTs.

CONCLUSIONS

When decompression for advanced malignancy is technically not feasible with a gastrostomy tube, the PTEG is a viable, safe option for palliation. The PTEG is associated with lower significant complication rates than the gastrostomy tube and significantly higher patient-derived outcomes than the NGT.

Intrapancreatic Accessory Spleen Diagnosed As Neuroendocrine Tumor: The Dangers of False Positives and Their Implications in Subsequent Management

This case serves as a reminder to consider ectopic splenic tissue in the differential diagnosis of pancreatic masses. The literature shows a lack of awareness and overtreatment of this condition due to clinical and radiologic concern for malignancy, namely neuroendocrine tumors (NETs) identified on positron emission tomography (PET)-CT NETSPOT. Given the vast difference in management and prognosis of ectopic splenic anomalies and malignant neoplasms involving the pancreas, accurate diagnosis is imperative to avoid unnecessary invasive procedures such as Whipple or distal pancreatectomy and splenectomy, which are associated with increased morbidity and mortality.

The Role of Religion in Physician Outlook on Death, Dying, and End of Life Care

One of the many roles a physician provides to their patients is compassion and comfort, which includes tending to any psychological, spiritual, and religious needs the patient has. The goal of this pilot study was to explore whether religious or spiritual values of physicians at an urban academic hospital affect how physicians care for and communicate with their patients, especially when dealing with death, dying, and end-of-life matters. After surveying 111 inpatient physicians at an academic hospital, we found that 92% of physicians are extremely or somewhat comfortable having end-of-life discussions. We also found that physician religiosity and spirituality are not necessarily required for discussing death and dying and that the religious and spiritual values of the physician do not correlate with their ability to have end-of-life conversations with the patient. We found no difference between years in practice and comfort discussing religion and spirituality, though we did find that, of the physicians who believe they are comfortable talking to patients about religion or belief systems, most of them had more than five end-of-life patients in the past 12 months. Lastly, referrals to Palliative Care or pastoral services were not impacted by the physician's religious or spiritual beliefs. Future studies can explore how religious beliefs may more subtly influence physicians' interactions with patients, patient satisfaction, and physician well-being and resilience.

Randomized controlled trial of a pictorial aid intervention for medication adherence among HIV-positive patients with comorbid diabetes or hypertension

As the HIV-infected population ages and the burden of chronic comorbidities increases, adherence to medications for HIV and diabetes and hypertension is crucial to improve outcomes. We pilot-tested a pictorial aid intervention to improve medication adherence for both HIV and common chronic conditions. Adult patients with HIV and diabetes (DM) and/or hypertension (HTN) attending a clinic for underserved patients and at risk for poor health outcomes were enrolled. Patients were randomized to receive either a pictorial aid intervention (a photographic representation of their medications, the indications, and the dosing schedule) or a standard clinic visit discharge medication list. Adherence to antiretroviral therapy (ART) for HIV and therapy for DM or HTN was compared. Predictors of ART adherence at baseline were determined using logistic regression. Medication adherence was assessed using medication possession ratio (MPR) for the 6-month interval before and after the intervention. Change in adherence by treatment group was compared by ANOVA. Among the 46 participants, there was a trend towards higher adherence to medications for HIV compared with medications for hypertension/diabetes (baseline median MPR for ART 0.92; baseline median MPR for the medication for the comorbid condition 0.79, p = 0.07). The intervention was feasible to implement and satisfaction with the intervention was high. With a small sample size, the intervention did not demonstrate significant improvement in adherence to medications for HIV or comorbid conditions. Patients with HIV are often medically complex and may have multiple barriers to medication adherence. Medication adherence is a multifaceted process and adherence promotion interventions require an approach that targets patient-specific barriers.

Transition of care for hospitalized elderly patients--development of a discharge checklist for hospitalists

BACKGROUND

Discharge from the hospital is a critical transition point in a patient's care. Incomplete handoffs at discharge can lead to adverse events for patients and result in avoidable rehospitalization. Care transitions are especially important for elderly patients and other high-risk patients who have multiple comorbidities. Standardizing the elements of the discharge process may help to address the gaps in quality and safety that occur when patients transition from the hospital to an outpatient setting.

METHODS

The Society of Hospital Medicine's Hospital Quality and Patient Safety committee assembled a panel of care transition researchers, process improvement experts, and hospitalists to review the literature and develop a checklist of processes and elements required for ideal discharge of adult patients. The discharge checklist was presented at the Society of Hospital Medicine's Annual Meeting in April 2005, where it was reviewed and revised by more than 120 practicing hospitalists and hospital-based nurses, case managers, and pharmacists. The final checklist was endorsed by the Society of Hospital Medicine.

RESULTS

The finalized checklist is a comprehensive list of the processes and elements considered necessary for optimal patient handoff at hospital discharge. This checklist focused on medication safety, patient education, and follow-up plans.

CONCLUSIONS

The development of content and process standards for discharge is the first step in improving the handoff of care from the inpatient to the posthospital setting. Refining this checklist for patients with specific diagnoses, in specific age categories, and with specific discharge destinations may further improve information transfer and ultimately affect patient outcomes.

Interventions to enhance medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

Computerized searches were updated to September 2004 without language restriction in MEDLINE, EMBASE, CINAHL, The Cochrane Library, International Pharmaceutical Abstracts (IPA), PsycINFO and SOCIOFILE. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of original and review articles on the topic.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one reviewer and confirmed by at least one other reviewer. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed.

MAIN RESULTS

For short-term treatments, four of nine interventions reported in eight RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient compliance, but did not enhance the clinical outcome. For long-term treatments, 26 of 58 interventions reported in 49 RCTs were associated with improvements in adherence, but only 18 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes. Six studies showed that telling patients about adverse effects of treatment did not affect their adherence.

AUTHORS' CONCLUSIONS

Improving short-term adherence is relatively successful with a variety of simple interventions. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Screening behaviors and long-term compliance with mammography guidelines in a breast cancer screening program

INTRODUCTION

Screening for breast cancer is generally underused. In an effort to remove common barriers to screening, a free breast cancer screening and education program was created for the employees of a large hospital, incorporating mammography, clinical breast examination (CBE), and breast self-examination (BSE).

METHODS

The present study was conducted to evaluate the screening behaviors and long-term compliance of asymptomatic women over age 50 who participated in the program. Data were obtained from questionnaires administered at the time of enrollment (time 1) and annual reenrollment, as well as from radiology records. (Time 2 represents the most recent data.) Long-term compliance with mammography guidelines was measured by calculating a compliance quotient (CQ) for each participant.

RESULTS

From time 1 to time 2, subjects significantly increased their use of mammography, CBE, and BSE. At time 2, 89.5% of women had ever received a mammogram, 42.7% had gotten one in the last year, nearly all women (94.6%) had received at least one CBE, 58.0% reported annual CBE, and 44.6% of women practiced monthly BSE. CQ was higher among women who remained in the program longer, were still active in the program at the time of the study, and used screening prior to enrollment. It was also higher in Caucasians and women with a family history of breast cancer.

CONCLUSIONS

These results show that a worksite program that eliminates common barriers to screening can significantly increase use of early detection practices. It also demonstrates one method of quantifying long-term compliance with mammography guidelines.

Screening for breast and prostate cancer: a survey of Texas primary care physicians

Screening for breast and prostate cancer is underutilized, and according to previous studies, physicians often fail to comply with recommended screening guidelines. We surveyed Texas physicians to determine their screening behaviors and their compliance with National recommendations. For women aged 40 through 49 years, 75.5% of respondents recommend mammography every 1 to 2 years, and 8.4% suggest it annually. For women 50 years and older, 16.1% of clinicians screen every 1 to 2 years, and 81.4% recommend annual mammography. Thus, 71.7% of physicians match or exceed the American Cancer Society guidelines for screening mammography in women 40 years and older. Texas physicians also report a high rate of prostate cancer screening, with more than 90% of respondents offering testing by age 60 years. The screening method preferred by 72.0% of clinicians combines digital rectal examination and the prostate-specific antigen blood test. Overall, the screening practices reported by this sample of Texas physicians compare very favorably with those reported by other groups.

Caring for survivors of the Chernobyl disaster. What the clinician should know

The health status of approximately 1 million immigrants in the United States and Israel may have been adversely affected by radiation exposure as a result of the Chernobyl nuclear power plant disaster and cleanup efforts. Many of these immigrants suffer from significant psychological distress, fearing that they have a radiation-induced illness. Based on a review of the literature and our experience from the US National Chernobyl Registry Coordinating Center, we recommend that medical management of these immigrants include routine physical examination, with particular attention to the thyroid gland. Adults should receive regular cancer screening as well as routine blood chemistry tests, thyroid function tests, complete blood cell count, and urinalysis. Children should be examined regularly, with attention to the thyroid and overall body growth. It is reasonable for children to undergo thyroid studies, a complete blood cell count, or neuropsychiatric testing if there is clinical suspicion of a disorder. Given the long latency period for disease induction by radiation exposure, it is still too early to fully assess and draw conclusions concerning the possible health effects of the Chernobyl disaster, and long-term follow-up of all potentially affected individuals is important.

The write stuff. Simple guidelines can help you write and design effective patient education materials

Most of the time and energy that go into patient education focus on the brief encounter between a doctor and patient in the physician's office. Although face-to-face interaction is indispensable in educating patients about their conditions, it also poses many problems. The stressful nature of the situation may cause patients to forget to ask questions or forget what they are told, and they may not get enough information to satisfy their needs and curiosities.