Novel Virtual Reality App for Training Patients on MRI-guided Radiation Therapy

Purpose

Patients receiving respiratory gated magnetic resonance imaging-guided radiation therapy (MRIgRT) for abdominal targets must hold their breath for ≥25 seconds at a time. Virtual reality (VR) has shown promise for improving patient education and experience for diagnostic MRI scan acquisition. We aimed to develop and pilot-test the first VR app to educate, train, and reduce anxiety and discomfort in patients preparing to receive MRIgRT.

Methods and Materials

A multidisciplinary team iteratively developed a new VR app with patient input. The app begins with minigames to help orient patients to using the VR device and to train patients on breath-holding. Next, app users are introduced to the MRI linear accelerator vault and practice breath-holding during MRIgRT. In this quality improvement project, clinic personnel and MRIgRT-eligible patients with pancreatic cancer tested the VR app for feasibility, acceptability, and potential efficacy for training patients on using breath-holding during MRIgRT.

Results

The new VR app experience was tested by 19 patients and 67 clinic personnel. The experience was completed on average in 18.6 minutes (SD = 5.4) by patients and in 14.9 (SD = 3.5) minutes by clinic personnel. Patients reported the app was "extremely helpful" (58%) or "very helpful" (32%) for learning breath-holding used in MRIgRT and "extremely helpful" (28%) or "very helpful (50%) for reducing anxiety. Patients and clinic personnel also provided qualitative feedback on improving future versions of the VR app.

Conclusion

The VR app was feasible and acceptable for training patients on breath-holding for MRIgRT. Patients eligible for MRIgRT for pancreatic cancer and clinic personnel reported on future improvements to the app to enhance its usability and efficacy.

How does cognitive behavior therapy for dissociative seizures work? A mediation analysis of the CODES trial

BACKGROUND

We compared dissociative seizure specific cognitive behavior therapy (DS-CBT) plus standardized medical care (SMC) to SMC alone in a randomized controlled trial. DS-CBT resulted in better outcomes on several secondary trial outcome measures at the 12-month follow-up point. The purpose of this paper is to evaluate putative treatment mechanisms.

METHODS

We carried out a secondary mediation analysis of the CODES trial. 368 participants were recruited from the National Health Service in secondary / tertiary care in England, Scotland, and Wales. Sixteen mediation hypotheses corresponding to combinations of important trial outcomes and putative mediators were assessed. Twelve-month trial outcomes considered were final-month seizure frequency, Work and Social Adjustment Scale (WSAS), and the SF-12v2, a quality-of-life measure providing physical (PCS) and mental component summary (MCS) scores. Mediators chosen for analysis at six months (broadly corresponding to completion of DS-CBT) included: (a) beliefs about emotions, (b) a measure of avoidance behavior, (c) anxiety and (d) depression.

RESULTS

All putative mediator variables except beliefs about emotions were found to be improved by DS-CBT. We found evidence for DS-CBT effect mediation for the outcome variables dissociative seizures (DS), WSAS and SF-12v2 MCS scores by improvements in target variables avoidance behavior, anxiety, and depression. The only variable to mediate the DS-CBT effect on the SF-12v2 PCS score was avoidance behavior.

CONCLUSIONS

Our findings largely confirmed the logic model underlying the development of CBT for patients with DS. Interventions could be additionally developed to specifically address beliefs about emotions to assess whether it improves outcomes.

Examining disparities in large-scale patient-reported data capture using digital tools among cancer patients at clinical intake

BACKGROUND

Patient-reported data can improve quality of healthcare delivery and patient outcomes. Moffitt Cancer Center ("Moffitt") administers the Electronic Patient Questionnaire (EPQ) to collect data on demographics, including sexual orientation and gender identity (SOGI), medical history, cancer risk factors, and quality of life. Here we investigated differences in EPQ completion by demographic and cancer characteristics.

METHODS

An analysis including 146,142 new adult patients at Moffitt in 2009-2020 was conducted using scheduling, EPQ and cancer registry data. EPQ completion was described by calendar year and demographics. Logistic regression was used to estimate associations between demographic/cancer characteristics and EPQ completion. More recently collected information on SOGI were described.

RESULTS

Patient portal usage (81%) and EPQ completion rates (79%) were consistently high since 2014. Among patients in the cancer registry, females were more likely to complete the EPQ than males (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.14-1.20). Patients ages 18-64 years were more likely to complete the EPQ than patients aged ≥65. Lower EPQ completion rates were observed among Black or African American patients (OR = 0.59, 95% CI = 0.56-0.63) as compared to Whites and among patients whose preferred language was Spanish (OR = 0.40, 95% CI = 0.36-0.44) or another language as compared to English. Furthermore, patients with localized (OR = 1.16, 95% CI = 1.12-1.19) or regional (OR = 1.16, 95% CI = 1.12-1.20) cancer were more likely to complete the EPQ compared to those with metastatic disease. Less than 3% of patients self-identified as being lesbian, gay, or bisexual and <0.1% self-identified as transgender, genderqueer, or other.

CONCLUSIONS

EPQ completion rates differed across demographics highlighting opportunities for targeted process improvement. Healthcare organizations should evaluate data acquisition methods to identify potential disparities in data completeness that can impact quality of clinical care and generalizability of self-reported data.

Development of a Patient Activation Toolkit for Hepatitis C Virus Testing

We evaluated the acceptability of a patient activation toolkit for hepatitis C virus (HCV) testing amidst universal adult guidelines. We developed a patient-facing toolkit that included a letter to the patient from their healthcare provider, HCV factsheet, and question prompt list, which contained questions for their provider about HCV infection and testing. We conducted qualitative interviews with patients ages 18-78 (n = 17), using a semi-structured interview guide based on learner verification. We assessed attraction, comprehension, cultural-linguistic acceptability, self-efficacy, and persuasiveness of toolkit materials using direct content analysis. Participants reported materials were attractive, offering suggestions to improve readability. They reported some understanding of materials but requested use of less medical jargon, particularly for the factsheet. Participants discussed cultural acceptability and suggested ways to improve language inclusiveness and comfort with content, given stigma surrounding HCV risk factors. Participants reported that including a letter, factsheet, and QPL improved the persuasiveness of materials, and they conveyed their motivation to be tested for HCV. Results indicate preliminary acceptability for use of the patient activation toolkit, which will be refined based on participants' recommendations. Overall, this patient activation toolkit holds promise for increasing HCV testing rates.

Telemedicine Adoption in an NCI-Designated Cancer Center During the COVID-19 Pandemic: A Report on Patient Experience of Care

BACKGROUND

Patients with cancer require timely access to care so that healthcare providers can prepare an optimal treatment plan with significant implications for quality of life and mortality. The COVID-19 pandemic spurred rapid adoption of telemedicine in oncology, but study of patient experience of care with telemedicine in this population has been limited. We assessed overall patient experience of care with telemedicine at an NCI-designated Comprehensive Cancer Center during the COVID-19 pandemic and examined changes in patient experience over time.

PATIENTS AND METHODS

This was a retrospective study of outpatient oncology patients who received treatment at Moffitt Cancer Center. Press Ganey surveys were used to assess patient experience. Data from patients with appointments between April 1, 2020, and June 30, 2021, were analyzed. Patient experience was compared between telemedicine and in-person visits, and patient experience with telemedicine over time was described.

RESULTS

A total of 33,318 patients reported Press Ganey data for in-person visits, and 5,950 reported Press Ganey data for telemedicine visits. Relative to patients with in-person visits, more patients with telemedicine visits gave higher satisfaction ratings for access (62.5% vs 75.8%, respectively) and care provider concern (84.2% vs 90.7%, respectively) (P<.001). When adjusted for age, race/ethnicity, sex, insurance, and clinic type, telemedicine visits consistently outperformed in-person visits over time regarding access and care provider concern (P<.001). There were no significant changes over time in satisfaction with telemedicine visits regarding access, care provider concern, telemedicine technology, or overall assessment (P>.05).

CONCLUSIONS

In this study, a large oncology dataset showed that telemedicine resulted in better patient experience of care in terms of access and care provider concern compared with in-person visits. Patient experience of care with telemedicine visits did not change over time, suggesting that implementing telemedicine was effective.

Advancing Digital Health Innovation in Oncology: Priorities for High-Value Digital Transformation in Cancer Care

Although health care delivery is becoming increasingly digitized, driven by the pursuit of improved access, equity, efficiency, and effectiveness, progress does not appear to be equally distributed across therapeutic areas. Oncology is renowned for leading innovation in research and in care; digital pathology, digital radiology, real-world data, next-generation sequencing, patient-reported outcomes, and precision approaches driven by complex data and biomarkers are hallmarks of the field. However, remote patient monitoring, decentralized approaches to care and research, "hospital at home," and machine learning techniques have yet to be broadly deployed to improve cancer care. In response, the Digital Medicine Society and Moffitt Cancer Center convened a multistakeholder roundtable discussion to bring together leading experts in cancer care and digital innovation. This viewpoint highlights the findings from these discussions, in which experts agreed that digital innovation is lagging in oncology relative to other therapeutic areas. It reports that this lag is most likely attributed to poor articulation of the challenges in cancer care and research best suited to digital solutions, lack of incentives and support, and missing standardized infrastructure to implement digital innovations. It concludes with suggestions for actions needed to bring the promise of digitization to cancer care to improve lives.

Moderators of cognitive behavioural therapy treatment effects and predictors of outcome in the CODES randomised controlled trial for adults with dissociative seizures

OBJECTIVE

We explored moderators of cognitive behavioural therapy (CBT) treatment effects and predictors of outcome at 12-month follow-up in the CODES Trial (N = 368) comparing CBT plus standardised medical care (SMC) vs SMC-alone for dissociative seizures (DS).

METHODS

We undertook moderator analyses of baseline characteristics to determine who had benefited from being offered CBT 12 months post-randomisation. Outcomes included: monthly DS frequency, psychosocial functioning (Work and Social Adjustment Scale - WSAS), and health-related quality of life (Mental Component Summary (MCS) and Physical Component Summary (PCS) SF-12v2 scores). When moderating effects were absent, we tested whether baseline variables predicted change irrespective of treatment allocation.

RESULTS

Moderator analyses revealed greater benefits (p < 0.05) of CBT on DS frequency for participants with more (≥22) symptoms (Modified PHQ-15) or ≥ 1 current (M.I.N.I.-confirmed) comorbid psychiatric diagnosis at baseline. The effect of CBT on PCS scores was moderated by gender; women did better than men in the CBT + SMC group. Predictors of improved outcome included: not receiving disability benefits, lower anxiety and/or depression scores (PCS, MCS, WSAS); shorter duration, younger age at DS onset, employment, fewer symptoms and higher educational qualification (PCS, WSAS); stronger belief in the diagnosis and in CBT as a "logical" treatment (MCS). Some variables that clinically might be expected to moderate/predict outcome (e.g., maladaptive personality traits, confidence in treatment) were not shown to be relevant.

CONCLUSION

Patient complexity interacted with treatment. CBT was more likely to reduce DS frequency in those with greater comorbidity. Other patient characteristics predicted outcome regardless of the received intervention.

Longitudinal Collection of Patient-Reported Outcomes and Activity Data during CAR-T Therapy: Feasibility, Acceptability, and Data Visualization

Background: Clinicians must closely monitor patients for toxicities after chimeric antigen receptor T-cell therapy (CAR-T). Patient-reported outcomes (PROs) (e.g., toxicities, quality of life) and activity data (e.g., steps, sleep) may complement clinicians’ observations. This study tested the feasibility and acceptability of collecting PROs and activity data from patients with hematologic malignancies during CAR-T and explored preliminary data patterns. Methods: Participants wore a Fitbit tracker and completed PROs at several timepoints through 90-days post-infusion. Feasibility was assessed with a priori benchmarks for recruitment (≥50%), retention (≥70%), PRO completion (≥70%), and days wearing the Fitbit (≥50%). Acceptability was assessed with participant satisfaction (a priori benchmark > 2 on a 0−4 scale). Results: Participants (N = 12) were M = 66 years old (SD = 7). Rates of recruitment (68%), retention (83%), PRO completion (85%), and days wearing the Fitbit (85%) indicated feasibility. Satisfaction with completing the PROs (M = 3.2, SD = 0.5) and wearing the Fitbit (M = 2.9, SD = 0.5) indicated acceptability. Preliminary data patterns suggested that participants with better treatment response (vs. progressive disease) had a higher toxicity burden. Conclusions: Longitudinal PRO and activity data collection was feasible and acceptable. Data collected on a larger scale may be used to specify risk prediction models to identify predictors of severe CAR-T-related toxicities and inform early interventions.

Predictors and Outcomes of Patient Knowledge of Plan of Care in Hospital Medicine: A Quality Improvement Study

BACKGROUND

Patient understanding of plan of care is associated with positive outcomes in ambulatory settings. In hospital medicine settings, patient-physician agreement on plan of care (concordance) has been limited and difficult to improve. This study examined the impact of adding a hospitalist to interdisciplinary rounds (IDR) on physician-patient-nurse concordance and the relationship between concordance and outcomes.

METHODS

IDR were conducted by core teams made up of unit-based nurses, a case manager, and a pharmacist. Over time, with cohorting, hospitalists were included in IDR (hospitalist IDR) for some patients assigned to unit-based hospitalists. In developing hospitalist IDR, the researchers emphasized using an IDR checklist, including a patient communication plan. Patient-nurse-physician interviews were used to assess concordance in the domains of diagnosis, tests and procedures, and expected discharge date. Using two-hospitalist review, agreement was rated as none, partial, or complete, and a total concordance score was calculated for each patient in both IDR groups. Multivariate analysis was used to examine the relationship between concordance, IDR type, patient factors, and utilization outcomes.

RESULTS

For 658 patients, the mean concordance score was 11.71 out of a possible 18. There was no difference in concordance between hospitalist and core IDR groups (11.68 vs. 11.84, p = 0.7). Higher total concordance score was associated with lower lengths of stay (p < 0.001) and readmission rates (p = 0.001). Total concordance had a negative association with patient age (p = 0.04).

CONCLUSION

Concordance did not change with IDR type. Higher concordance appears to be related to positive utilization outcomes. Future studies are needed to evaluate potential interventions to improve concordance.

Mediators of increased self-harm and suicidal ideation in sexual minority youth: a longitudinal study

BACKGROUND

Sexual minority youth have elevated suicidal ideation and self-harm compared with heterosexual young people; however, evidence for mediating mechanisms is predominantly cross-sectional. Using a longitudinal design, we investigated self-esteem and depressive symptoms as mediators of increased rates of suicidal ideation or self-harm (SISH) among sexual minority youth, and the roles of childhood gender nonconformity (CGN) and sex as moderators of these relationships.

METHOD

In total, 4274 youth from the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort reported sexual orientation at age 15 years, and past-year SISH at age 20 years. Self-esteem and depressive symptoms were assessed at ages 17 and 18 years, respectively. CGN was measured at 30-57 months. Covariates included sociodemographic variables and earlier measures of mediator and outcome variables. Mediation pathways were assessed using structural equation modelling.

RESULTS

Sexual minority youth (almost 12% of the sample) were three times more likely than heterosexual youth to report past-year SISH (95% confidence interval 2.43-3.64) at 20 years. Two mediation pathways were identified: a single mediator pathway involving self-esteem and a multiple-mediated pathway involving self-esteem and depressive symptoms. Although CGN was associated with past-year SISH, it did not moderate any mediation pathways and there was no evidence for moderation by sex.

CONCLUSIONS

Lower self-esteem and increased depressive symptoms partly explain the increased risk for later suicidal ideation and self-harm in sexual minority youth. Preventive strategies could include self-esteem-enhancing or protecting interventions, especially in female sexual minority youth, and treatment of depression.

Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients

Background

Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame.

Objective

To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability.

Design

Prospective cohort study.

Setting

10 academic medical centers in the United States.

Patients

822 adults readmitted to a general medicine service.

Measurements

For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics.

Results

Overall, 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference, 13.0 percentage points [interquartile range, 5.5 to 26.4 percentage points]). Hospitals were identified as better locations for preventing early readmissions (47.2% vs. 25.5%; median risk difference, 22.8 percentage points [interquartile range, 17.9 to 31.8 percentage points]), whereas outpatient clinics (15.2% vs. 6.6%; median risk difference, 10.0 percentage points [interquartile range, 4.6 to 12.2 percentage points]) and home (19.4% vs. 14.0%; median risk difference, 5.6 percentage points [interquartile range, -6.1 to 17.1 percentage points]) were better for preventing late readmissions.

Limitation

Physician adjudicators were not blinded to readmission timing, community hospitals were not included in the study, and readmissions to nonstudy hospitals were not included in the results.

Conclusion

Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions.

Primary Funding Source

Association of American Medical Colleges.

The HOSPITAL Score Predicts Potentially Preventable 30-Day Readmissions in Conditions Targeted by the Hospital Readmissions Reduction Program

BACKGROUND/OBJECTIVES

New tools to accurately identify potentially preventable 30-day readmissions are needed. The HOSPITAL score has been internationally validated for medical inpatients, but its performance in select conditions targeted by the Hospital Readmission Reduction Program (HRRP) is unknown.

DESIGN

Retrospective cohort study.

SETTING

Six geographically diverse medical centers.

PARTICIPANTS/EXPOSURES

All consecutive adult medical patients discharged alive in 2011 with 1 of the 4 medical conditions targeted by the HRRP (acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, and heart failure) were included. Potentially preventable 30-day readmissions were identified using the SQLape algorithm. The HOSPITAL score was calculated for all patients.

MEASUREMENTS

A multivariable logistic regression model accounting for hospital effects was used to evaluate the accuracy (Brier score), discrimination (c-statistic), and calibration (Pearson goodness-of-fit) of the HOSPITAL score for each 4 medical conditions.

RESULTS

Among the 9181 patients included, the overall 30-day potentially preventable readmission rate was 13.6%. Across all 4 diagnoses, the HOSPITAL score had very good accuracy (Brier score of 0.11), good discrimination (c-statistic of 0.68), and excellent calibration (Hosmer-Lemeshow goodness-of-fit test, P=0.77). Within each diagnosis, performance was similar. In sensitivity analyses, performance was similar for all readmissions (not just potentially preventable) and when restricted to patients age 65 and above.

CONCLUSIONS

The HOSPITAL score identifies a high-risk cohort for potentially preventable readmissions in a variety of practice settings, including conditions targeted by the HRRP. It may be a valuable tool when included in interventions to reduce readmissions within or across these conditions.

Simplification of the HOSPITAL score for predicting 30-day readmissions

OBJECTIVE

The HOSPITAL score has been widely validated and accurately identifies high-risk patients who may mostly benefit from transition care interventions. Although this score is easy to use, it has the potential to be simplified without impacting its performance. We aimed to validate a simplified version of the HOSPITAL score for predicting patients likely to be readmitted.

DESIGN AND SETTING

Retrospective study in 9 large hospitals across 4 countries, from January through December 2011.

PARTICIPANTS

We included all consecutively discharged medical patients. We excluded patients who died before discharge or were transferred to another acute care facility.

MEASUREMENTS

The primary outcome was any 30-day potentially avoidable readmission. We simplified the score as follows: (1) 'discharge from an oncology division' was replaced by 'cancer diagnosis or discharge from an oncology division'; (2) 'any procedure' was left out; (3) patients were categorised into two risk groups (unlikely and likely to be readmitted). The performance of the simplified HOSPITAL score was evaluated according to its overall accuracy, its discriminatory power and its calibration.

RESULTS

Thirty-day potentially avoidable readmission rate was 9.7% (n=11 307/117 065 patients discharged). Median of the simplified HOSPITAL score was 3 points (IQR 2-5). Overall accuracy was very good with a Brier score of 0.08 and discriminatory power remained good with a C-statistic of 0.69 (95% CI 0.68 to 0.69). The calibration was excellent when comparing the expected with the observed risk in the two risk categories.

CONCLUSIONS

The simplified HOSPITAL score has good performance for predicting 30-day readmission. Prognostic accuracy was similar to the original version, while its use is even easier. This simplified score may provide a good alternative to the original score depending on the setting.

Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: A systematic review and suggested taxonomy

BACKGROUND

Interdisciplinary rounds (IDR) have been described to improve outcomes. However, there is limited understanding of optimal IDR design.

PURPOSE

To systematically review published reports of IDR to catalog types of IDR and outcomes, and assess the influence of IDR design on outcomes.

DATA SOURCES

Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Journals Ovid, Cumulative Index to Nursing and Allied Health Literature (EBSCOhost), and PubMed from 1990 through December 2014, and hand searching of article bibliographies.

STUDY SELECTION

Experimental, quasiexperimental, and observation studies in English-language literature where physicians rounded with another healthcare professional in inpatient medicine units.

DATA EXTRACTION

Studies were abstracted for study setting and characteristics, and design and outcomes of IDR.

DATA SYNTHESIS

Twenty-two studies were included in the qualitative analysis. Many were of low to medium quality with few high-quality studies. There is no clear definition of IDR in the literature. There was wide variation in IDR design and team composition across studies. We found three different models of IDR: pharmacist focused, bedside rounding, and interdisciplinary team rounding. There are reasonable data to support an association with length of stay and staff satisfaction but little data on patient safety or satisfaction. Positive outcomes may be related to particular components of IDR design, but the relationship between design and outcomes remains unclear.

CONCLUSIONS

Future studies should be more deliberately designed and fully reported with careful attention to team composition and features of IDR and their impact on selected outcomes. We present a proposed IDR definition and taxonomy for future studies. Journal of Hospital Medicine 2016;11:513-523. © 2016 Society of Hospital Medicine.

International Validity of the HOSPITAL Score to Predict 30-Day Potentially Avoidable Hospital Readmissions

IMPORTANCE

Identification of patients at a high risk of potentially avoidable readmission allows hospitals to efficiently direct additional care transitions services to the patients most likely to benefit.

OBJECTIVE

To externally validate the HOSPITAL score in an international multicenter study to assess its generalizability.

DESIGN, SETTING, AND PARTICIPANTS

International retrospective cohort study of 117 065 adult patients consecutively discharged alive from the medical department of 9 large hospitals across 4 different countries between January 2011 and December 2011. Patients transferred to another acute care facility were excluded.

EXPOSURES

The HOSPITAL score includes the following predictors at discharge: hemoglobin, discharge from an oncology service, sodium level, procedure during the index admission, index type of admission (urgent), number of admissions during the last 12 months, and length of stay.

MAIN OUTCOMES AND MEASURES

30-day potentially avoidable readmission to the index hospital using the SQLape algorithm.

RESULTS

Overall, 117 065 adults consecutively discharged alive from a medical department between January 2011 and December 2011 were studied. Of all medical discharges, 16 992 of 117 065 (14.5%) were followed by a 30-day readmission, and 11 307 (9.7%) were followed by a 30-day potentially avoidable readmission. The discriminatory power of the HOSPITAL score to predict potentially avoidable readmission was good, with a C statistic of 0.72 (95% CI, 0.72-0.72). As in the derivation study, patients were classified into 3 risk categories: low (n = 73 031 [62.4%]), intermediate (n = 27 612 [23.6%]), and high risk (n = 16 422 [14.0%]). The estimated proportions of potentially avoidable readmission for each risk category matched the observed proportion, resulting in an excellent calibration (Pearson χ2 test P = .89).

CONCLUSIONS AND RELEVANCE

The HOSPITAL score identified patients at high risk of 30-day potentially avoidable readmission with moderately high discrimination and excellent calibration when applied to a large international multicenter cohort of medical patients. This score has the potential to easily identify patients in need of more intensive transitional care interventions to prevent avoidable hospital readmissions.

Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients

IMPORTANCE

Readmission penalties have catalyzed efforts to improve care transitions, but few programs have incorporated viewpoints of patients and health care professionals to determine readmission preventability or to prioritize opportunities for care improvement.

OBJECTIVES

To determine preventability of readmissions and to use these estimates to prioritize areas for improvement.

DESIGN, SETTING, AND PARTICIPANTS

An observational study was conducted of 1000 general medicine patients readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013. We surveyed patients and physicians, reviewed documentation, and performed 2-physician case review to determine preventability of and factors contributing to readmission. We used bivariable statistics to compare preventable and nonpreventable readmissions, multivariable models to identify factors associated with potential preventability, and baseline risk factor prevalence and adjusted odds ratios (aORs) to determine the proportion of readmissions affected by individual risk factors.

MAIN OUTCOME AND MEASURE

Likelihood that a readmission could have been prevented.

RESULTS

The study cohort comprised 1000 patients (median age was 55 years). Of these, 269 (26.9%) were considered potentially preventable. In multivariable models, factors most strongly associated with potential preventability included emergency department decision making regarding the readmission (aOR, 9.13; 95% CI, 5.23-15.95), failure to relay important information to outpatient health care professionals (aOR, 4.19; 95% CI, 2.17-8.09), discharge of patients too soon (aOR, 3.88; 95% CI, 2.44-6.17), and lack of discussions about care goals among patients with serious illnesses (aOR, 3.84; 95% CI, 1.39-10.64). The most common factors associated with potentially preventable readmissions included emergency department decision making (affecting 9.0%; 95% CI, 7.1%-10.3%), inability to keep appointments after discharge (affecting 8.3%; 95% CI, 4.1%-12.0%), premature discharge from the hospital (affecting 8.7%; 95% CI, 5.8%-11.3%), and patient lack of awareness of whom to contact after discharge (affecting 6.2%; 95% CI, 3.5%-8.7%).

CONCLUSIONS AND RELEVANCE

Approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients' readiness for discharge, enhanced disease monitoring, and better support for patient self-management.

Conformationally restricted calpain inhibitors

Oxidised α-mercaptoacrylic acid derivatives are potent conformationally restricted calpain-I inhibitors that mimic the endogenous inhibitor calpastatin.

The cysteine protease calpain-I is linked to several diseases and is therefore a valuable target for inhibition. Selective inhibition of calpain-I has proved difficult as most compounds target the active site and inhibit a broad spectrum of cysteine proteases as well as other calpain isoforms. Selective inhibitors might not only be potential drugs but should act as tools to explore the physiological and pathophysiological roles of calpain-I. α-Mercaptoacrylic acid based calpain inhibitors are potent, cell permeable and selective inhibitors of calpain-I and calpain-II. These inhibitors target the calcium binding domain PEF(S) of calpain-I and -II. Here X-ray diffraction analysis of co-crystals of PEF(S) revealed that the disulfide form of an α-mercaptoacrylic acid bound within a hydrophobic groove that is also targeted by a calpastatin inhibitory region and made a greater number of favourable interactions with the protein than the reduced sulfhydryl form. Measurement of the inhibitory potency of the α-mercaptoacrylic acids and X-ray crystallography revealed that the IC₅₀ values decreased significantly on oxidation as a consequence of the stereo-electronic properties of disulfide bonds that restrict rotation around the S–S bond. Consequently, thioether analogues inhibited calpain-I with potencies similar to those of the free sulfhydryl forms of α-mercaptoacrylic acids.

The Hospital Medicine Reengineering Network (HOMERuN): a learning organization focused on improving hospital care

Converting the health care delivery system into a learning organization is a key strategy for improving health outcomes. Although the collaborative learning organization approach has been successful in neonatal intensive care units and disease-specific collaboratives, there are few examples in general medicine and none in adult medicine that have leveraged the role of hospitalists nationally across multiple institutions to implement improvements. The authors describe the rationale for and early work of the Hospital Medicine Reengineering Network (HOMERuN), a collaborative of hospitals, hospitalists, and multidisciplinary care teams founded in 2011 that seeks to measure, benchmark, and improve the efficiency, quality, and outcomes of care in the hospital and afterwards. Robust and timely evaluation, with learning and refinement of approaches across institutions, should accelerate improvement efforts. The authors review HOMERuN's collaborative model, which focuses on a community-based participatory approach modified to include hospital-based staff as well as the larger community. HOMERuN's initial project is described, focusing on care transition measurement using perspectives from the patient, caregiver, and providers. Next steps and sustainability of the organization are discussed, including benchmarking, collaboration, and effective dissemination of best practices to stakeholders.

Patient-centered outcomes of a value-based insurance design program for patients with diabetes

Value-based insurance design (VBID) initiatives have been associated with modest improvements in adherence based on evaluations of administrative claims data. The objective of this prospective cohort study was to report the patient-centered outcomes of a VBID program that eliminated co-payments for diabetes-related medications and supplies for employees and dependents with diabetes at a large health system. The authors compared self-reported values of medication adherence, cost-related nonadherence, health status, and out-of-pocket health care costs for patients before and 1 year after program implementation. Clinical metrics and satisfaction with the program also are reported. In all, 188 patients completed the follow-up evaluation. Overall, patients reported a significant reduction in monthly out-of-pocket costs (P<0.001), which corresponded to a significant reduction in cost-related nonadherence from 41% to 17.5% (P<0.001). Self-reported medication adherence increased for hyperglycemic medications (P=0.011), but there were no apparent changes in glycemic control. Overall, 89% of participants agreed that the program helped them take better care of their diabetes. The authors found that a VBID program for employees and dependents with diabetes was associated with self-reported reductions in cost-related nonadherence and improvements in medication adherence. Importantly, the program was associated with high levels of satisfaction among participants and strongly perceived by participants to facilitate medication utilization and self-management for diabetes. These findings suggest that VBID programs can accomplish the anticipated goals for medication utilization and are highly regarded by participants. Patient-centered outcomes should be included in VBID evaluations to allow decision makers to determine the true impact of VBID programs on participants.

Systemic barriers to diabetes management in primary care: a qualitative analysis of Delaware physicians

Primary care providers deliver the majority of care for patients with diabetes. This article presents a qualitative analysis of systemic barriers to primary care diabetes management in the small office setting in Delaware. Grounded theory was used to identify key themes of focus group discussions with 25 Delaware physicians. A total of 6 systemic barriers were identified: (1) a persistent orientation toward acute care; (2) an inability to provide proactive, population-based patient management; (3) an inability to provide adequate self-management education; (4) poor integration of payer-driven disease management activities; (5) lack of universally available clinical information; and (6) lack of public health support. The results suggest that significant systemic barriers limit the ability of primary care providers, particularly those in small practices, to effectively manage diabetes in current practice. Future primary care reform should consider how to support providers, particularly those in small practices, to overcome these barriers.

Customers' recall of information given in community pharmacies

Three studies are reported in which the giving of information to customers, orally, in community pharmacies was tape recorded, and the customers were interviewed the following day. Customers' recall of information, including instructions considered to be essential, was low. In study 1, involving 44 customers in two pharmacies, a mean of 11 items of information was given to customers, but on average only three were recalled. Customers who took a more active part in discussion with the pharmacist (who were more likely to purchase self-medication than to be prescription customers) tended to be given more new information and more repeated information, to recall more but also to forget more than passive customers. In study 2, 42 customers of three pharmacists were interviewed to determine the influence of a number of variables on recall. Whether customers reported feeling ill or in a hurry, or reported having received the information already from their general practitioner, or having had prior experience of the medication, were all unrelated to the amount of information recalled. The few customers who reported that the information provided by the pharmacist was not welcome were particularly poor at recalling it. In Study 3, the amount of information given or recalled was found to be unaffected by whether customers talked to a pharmacist in the busy sales area (n=25) or in a quiet counselling area (n=27). If pharmacists are to be effective providers of information about health and illness, attention must be paid to ways of improving customers' retention of information given.

Lay public's understanding of equipoise and randomisation in randomised controlled trials

OBJECTIVES

To research the lay public's understanding of equipoise and randomisation in randomised controlled trials (RCTs) and to look at why information on this may not be not taken in or remembered, as well as the effects of providing information designed to overcome barriers.

DESIGN

Investigations were informed by an update of systematic review on patients' understanding of consent information in clinical trials, and by relevant theory and evidence from experimental psychology. Nine investigations were conducted with nine participants.

SETTING

Access (return to education), leisure and vocational courses at Further Education Colleges in the Midlands, UK.

PARTICIPANTS

Healthy adults with a wide range of educational backgrounds and ages.

INVESTIGATIONS

Participants read hypothetical scenarios and wrote brief answers to subsequent questions. Sub-samples of participants were interviewed individually to elaborate on their written answers. Participants' background assumptions concerning equipoise and randomisation were examined and ways of helping participants recognise the scientific benefits of randomisation were explored.

MAIN OUTCOME MEASURES

Judgments on allocation methods; treatment preferences; the acceptability of random allocation; whether or not individual doctors could be completely unsure about the best treatment; whether or not doctors should reveal treatment preferences under conditions of collective equipoise; and how sure experts would be about the best treatment following random allocation vs doctor/patient choice. Assessments of understanding hypothetical trial information.

RESULTS

Recent literature continues to report trial participants' failure to understand or remember information about randomisation and equipoise, despite the provision of clear and readable trial information leaflets. In current best practice, written trial information describes what will happen without offering accessible explanations. As a consequence, patients may create their own incorrect interpretations and consent or refusal may be inadequately informed. In six investigations, most participants identified which methods of allocation were random, but judged the random allocation methods to be unacceptable in a trial context; the mere description of a treatment as new was insufficient to engender a preference for it over a standard treatment; around half of the participants denied that a doctor could be completely unsure about the best treatment. A majority of participants judged it unacceptable for a doctor to suggest letting chance decide when uncertain of the best treatment, and, in the absence of a justification for random allocation, participants did not recognise scientific benefits of random allocation over normal treatment allocation methods. The pattern of results across three intervention studies suggests that merely supplementing written trial information with an explanation is unlikely to be helpful. However, when people manage to focus on the trial's aim of increasing knowledge (as opposed to making treatment decisions about individuals), and process an explanation actively, they may be helped to understand the scientific reasons for random allocation.

CONCLUSIONS

This research was not carried out in real healthcare settings. However, participants who could correctly identify random allocation methods, yet judged random allocation unacceptable, doubted the possibility of individual equipoise and saw no scientific benefits of random allocation over doctor/patient choice, are unlikely to draw upon contrasting views if invited to enter a real clinical trial. This suggests that many potential trial participants may have difficulty understanding and remembering trial information that conforms to current best practice in its descriptions of randomisation and equipoise. Given the extent of the disparity between the assumptions underlying trial design and the assumptions held by the lay public, the solution is unlikely to be simple. Nevertheless, the results suggest that including an accessible explanation of the scientific benefits of randomisation may be beneficial provided potential participants are also enabled to reflect on the trial's aim of advancing knowledge, and to think actively about the information presented. Further areas for consideration include: the identification of effective combinations of written and oral information; helping participants to reflect on the aim of advancing knowledge; and an evidence-based approach to leaflet construction.

Can one written word mean many things? Prereaders' assumptions about the stability of written words' meanings

Results of three experiments confirmed previous findings that in a moving word task, prereaders 3 to 5 years of age judge as if the meaning of a written word changes when it moves from a matching to a nonmatching toy (e.g., when the word "dog" moves from a dog to a boat). We explore under what circumstances children make such errors, we identify new conditions under which children were more likely correctly to treat written words' meanings as stable: when the word was placed alongside a nonmatching toy without having been alongside a matching toy previously, when two words were moved from a matching toy to a nonmatching toy, and when children were asked to change what the print said. Under these conditions, children more frequently assumed that physical forms had stable meanings as they do with other forms of external representation.

When can children handle referential opacity? Evidence for systematic variation in 5- and 6-year-old children's reasoning about beliefs and belief reports

Five- and 6-year-olds (N=51) heard stories in which a character sorted items into two locations. Either the character had a false belief about one of the items (e.g., thought a tin contained biscuits, not Lego), or was only partially informed of an item's dual identity (e.g., did not know that a tie was a present). Children found it easier to reject a report of the character's belief that described the true state of affairs when the character had a false belief (e.g., Is Fred's uncle thinking "where shall I put this Lego?"), than to reject one in which an object known to the character was described using a term of which she was ignorant (e.g., Is Mum thinking "where shall I put this present?"). Similarly, children found it easier to predict the character's incorrect sorting of the target items for false belief (with food not toys) than for dual identity (in the wardrobe not with things to take on a visit). Correct reasoning about beliefs and reports of beliefs that misrepresent an object does not imply mastery of the fact that beliefs represent an object in a particular way.

Children's suggestibility in relation to their understanding about sources of knowledge

In the experiments reported here, children chose either to maintain their initial belief about an object's identity or to accept the experimenter's contradicting suggestion. Both 3- to 4-year-olds and 4- to 5-year-olds were good at accepting the suggestion only when the experimenter was better informed than they were (implicit source monitoring). They were less accurate at recalling both their own and the experimenter's information access (explicit recall of experience), though they performed well above chance. Children were least accurate at reporting whether their final belief was based on what they were told or on what they experienced directly (explicit source monitoring). Contrasting results emerged when children decided between contradictory suggestions from two differentially informed adults: Three- to 4-year-olds were more accurate at reporting the knowledge source of the adult they believed than at deciding which suggestion was reliable. Decision making in this observation task may require reflective understanding akin to that required for explicit source judgments when the child participates in the task.

Five-year-olds' handling of reference and description in the domains of language and mental representation

Children's concurrent success on false belief tasks and their handling of two labels for one object (e.g., bunny/rabbit) has been interpreted as demonstrating understanding about the essential features of representation. Three experiments reveal the limitations in 5-year-olds' understanding for both mental and linguistic representations. We report relatively poor performance on a task involving two labels for one object (e.g., dice/eraser) which required children to treat another's knowledge as representing only some of the feature of its real referent: Dice but not eraser. Five year olds who made errors also had difficulty handling the fact that a written word 'dice' referring to such a dice/eraser, can also be applied to a standard dice but not to a standard eraser. These children lacked metalinguistic awareness of words as entities that both refer and describe.

Children's ability to make tentative interpretations of ambiguous messages

Consistent with prior research, 5- and 6-year-old children overestimated their knowledge of the intended referent of ambiguous messages. Yet they correctly revised their interpretations of ambiguous messages in light of contradicting information that followed immediately, while maintaining their initial interpretations of unambiguous messages (Experiment 1). Children of this age were able to integrate information over two successive ambiguous messages to identify the intended referent (Experiment 2). However, unlike 7- and 8-year-olds, they were no more likely to search for further information following ambiguous messages compared with unambiguous ones (Experiment 3). We conclude that although 5- and 6-year-olds' interpretations of ambiguous messages are not tentative at the outset, they can use source monitoring skills to treat them as tentative retrospectively, at least over short time spans.

Children's difficulties handling dual identity

Thirty-nine 6-year-old children participated in a longitudinal study using tasks that required handling of dual identity. Pre- and posttest sessions employed tasks involving a protagonist who was partially informed about an object or person; for example, he knew an item as a ball but not as a present. Children who judged correctly that the protagonist did not know the ball was a present (thereby demonstrating some understanding of the consequences of limited information access), often judged incorrectly (1) that he knew that there was a present in the box, and (2) that he would search as if fully informed. Intervening sessions added contextual support and tried to clarify the experimenter's communicative intentions in a range of ways. Despite signs of general improvement, the distinctive pattern of errors persisted in every case. These findings go beyond previous studies of children's handling of limited information access, and are hard to accommodate within existing accounts of developing understanding of the mind.

Information presentation and decisions to enter clinical trials: a hypothetical trial of hormone replacement therapy

We examined recruitment to an imaginary trial of hormone replacement therapy (HRT) following two different styles of information about HRT. We predicted that for treatments which, like HRT, are available outside a trial, people offered the facts as currently known would be less likely to remain unsure about the relative costs and benefits, and so less likely to agree to enter a randomised trial. In contrast, when the information provided reflected the current state of uncertainty which justified the trial, we predicted that people would be less likely to form a preference for one treatment arm over the other, and so more likely to agree to enter a trial. One hundred women aged 25-40 years were informed about HRT via a video and an information leaflet. For half the participants the information was framed in a way which emphasised the current state of uncertainty about the relative costs and benefits of HRT, and in that respect it reflected the justification for a trial. This version was considered to be similar in style to information commonly provided to potential trial participants. For half the participants the same information was framed in a way which offered explicit numerical detail about currently known facts, and in that respect it was considered to be similar in style to information commonly available to doctors prior to a trial. Women learned as much about HRT in the two conditions, but women given the explicit versions were more likely (i) to hold a stronger view about whether or not they would take HRT (ratings were not elicited from the first 30 participants in this condition. N = 20, p < 0.05 1 tailed) and (ii) to refuse entry to the trial (N = 50, p < 0.05 2 tailed). Those who, given the explicit version, agreed rather than refused to enter the trial, scored higher on believing that others control their health (p < 0.01 2 tailed).

High rates of infant macrosomia: a comparison of a Canadian native and a non-native population

The Cree of James Bay have the highest ever reported mean birth weight and a high prevalence of infant macrosomia. This study was designed to examine independent risk factors for infant macrosomia among the Cree, to compare these to risk factors among non-Native Canadians and to determine if ethnic differences persist after adjusting for differences in the distribution of other risk factors. Macrosomia was defined as birth weight >90(th) percentile for gestational age of a reference population. Independent determinants of macrosomia were examined in 385 Cree and 5644 non-Native women. The potential effect of ethnicity (Cree vs. non-Native) was determined after statistically adjusting for age, parity, pregravid weight, height, net rate of weight gain, gestational diabetes mellitus (GDM) and smoking status. The prevalence of macrosomia among the Cree was 34.3% vs. 11.1% among non-Natives. Although GDM significantly increased the risk for macrosomia among the Cree (odds ratio: 4.46, 95% CI: 2.24-9.26), it was not a significant risk factor among non-Natives (odds ratio: 1.15, 95% CI: 0.79-1.65). The risk for infant macrosomia remained elevated among the Cree compared with non-Natives after adjusting for other risk factors (odds ratio: 3.64, 95% CI: 2.69-4.90). In conclusion, the Cree have a high prevalence of macrosomia despite controlling for important differences in pregravid weight and GDM. Some of this variation may be due to genetic differences in fetal growth. The differential impact of GDM on macrosomia in the two ethnic groups may be due to differences in treatment strategies for GDM.

Interaction of body weight and ethnicity on risk of gestational diabetes mellitus

BACKGROUND

The James Bay Cree of Canada have one of the highest recorded rates of gestational diabetes mellitus (GDM) among aboriginal people worldwide; the reasons for this elevated risk remain to be documented.

OBJECTIVE

Our objective was to compare predictors and risk of GDM between the James Bay Cree and non-Native Canadians.

DESIGN

Risk for GDM was compared between Cree and non-Native women by 1) adjusting statistically for differences in age, parity, pregravid weight, and smoking status (n = 402 Cree, 7718 non-Natives), and 2) matching Cree women with non-Native women for age and pregravid weight (n = 394 Cree, 788 non-Natives). Dietary and physical activity information was available for a subset of Cree women (n = 152).

RESULTS

Age and pregravid weight were independent predictors of GDM in both Cree and non-Native women. After these predictors were controlled for, normal-weight (</=77 kg) Cree women were not at increased risk of GDM (OR: 1.42; 95% CI: 0.67, 2.71) but overweight Cree women had a higher risk than did overweight non-Native women (OR: 2.25; 95% CI: 1.32, 3.80).

CONCLUSIONS

Overweight Cree women are at increased risk of GDM. Given the high prevalence of pregravid overweight among the Cree, the burden of GDM is higher than among non-Native Canadians.

Realist errors in children's responses to pictures and words as representations

In three experiments we examined the judgments made by 3- to 4- year-old children about out-of-date physical representations which no longer matched their referents. The referent was a doll wearing a sticker, and the sticker was swapped for a different one after a picture had been drawn of the initial state of affairs (Experiments 1 and 2) or after the name of the doll and its original sticker had been written down (Experiment 3). We confirmed previous findings of realist errors in identity judgments for pictures and showed also that children tended to misidentify the name of a sticker in a written list to match a change to its referent. Thus, realist errors are not confined to representations which are iconically similar to their referents. Furthermore, children also judged incorrectly that the pictures and words had actually been changed, indicating that realist errors to external representations extend to operations performed on their referents as well as to their identities.

Children's understanding that utterances emanate from minds: using speaker belief to aid interpretation

Children interpreted an utterance made by a protagonist with a false belief, such as, 'I would like the car in the garage.' Calculating the speaker's belief in conjunction with the literal meaning of the utterance would lead to the correct interpretation that the intended referent is the car on the track, given that the car in the garage swapped places with the one on the track. In Experiments 1 and 2, many children aged around 4 and 5 years wrongly indicated the car in the garage. In contrast, many correctly indicated the car on the track when it was unnecessary to consider the speaker's belief because the utterance was, 'the car I put in the garage'. Six-year-olds found both kinds of utterance equally easy in Experiment 1, while 3-year-olds had equal difficulty with both. In Experiments 2 and 3, the speaker gave an ambiguous utterance and many children aged between 3 and 6 years successfully used information about the speaker's belief to identify which of several candidate referents was intended. We discuss the results in relation to characteristics of utterance comprehension and consider implications for developments in understanding the mind by children beyond 4 years.

Children's ability to infer utterance veracity from speaker informedness

Children between the ages of 3 years 7 months and 6 years 5 months experienced a contradiction between what they knew or guessed to be inside a box and what they were told by an adult. The authors investigated whether children believed what they were told by asking them to make a final judgment about the box's content. Children tended to believe utterances from speakers who were better informed than they themselves were and to disbelieve those from less well-informed speakers, with no age-related differences. This behavior implies an understanding of the speaker's knowledge and suggests that children can learn from oral input while being appropriately skeptical of its truth. Children also gave explicit knowledge judgments on trials on which no utterances were given. Performance on knowledge trials was less accurate than, and unrelated to, performance on utterance trials. Research on children's developing explicit theory of mind needs to be broadened to include behavioral indexes of understanding the mind.

Membrane topology and cellular location of the Treponema pallidum glycerophosphodiester phosphodiesterase (GlpQ) ortholog

Recent reports that isolated Treponema pallidum outer membranes contain an ortholog for glycerophosphodiester phosphodiesterase (GlpQ) (D. V. Shevchenko, D. R. Akins, E. J. Robinson, M. Li, O. V. Shevchenko, and J. D. Radolf, Infect. Immun. 65:4179-4189, 1997) and that this protein is a potential opsonic target for T. pallidum (C. E. Stebeck, J. M. Shaffer, T. W. Arroll, S. A. Lukehart, and W. C. Van Voorhis, FEMS Microbiol. Lett. 154:303-310, 1997) prompted a more detailed investigation of its physicochemical properties and cellular location. [14C]palmitate radiolabeling studies of a GlpQ-alkaline phosphatase fusion expressed in Escherichia coli confirmed the prediction from DNA sequencing that the protein is lipid modified. Studies using Triton X-114 phase partitioning revealed that the protein's amphiphilicity is due to lipid modification and that a substantial portion of the polypeptide is associated with the T. pallidum peptidoglycan sacculus. Three different approaches, i.e., (i) proteinase K treatment of intact treponemes, (ii) indirect immunofluorescence analysis of treponemes encapsulated in agarose beads, and (iii) opsonophagocytosis of treponemes incubated with antiserum against recombinant GlpQ by rabbit peritoneal macrophages, confirmed that GlpQ is entirely subsurface in T. pallidum. Moreover, rabbits hyperimmunized with GlpQ were not protected against intradermal challenge with virulent treponemes. Circular dichroism spectroscopy confirmed that the recombinant form of the polypeptide lacked discernible evidence of denaturation. Finally, GlpQ was not radiolabeled when T. pallidum outer membranes were incubated with 3-(trifluoromethyl)-3-(m-[125I]iodophenyl)-diazarene, a photoactivatable, lipophilic probe which promiscuously labels both proteins and lipids within phospholipid bilayers. Taken as a whole, these studies indicate that the T. pallidum GlpQ ortholog is a periplasmic protein associated predominantly with the spirochete's peptidoglycan-cytoplasmic membrane complex.

Children's ability to infer utterance veracity from speaker informedness

Children between the ages of 3 years 7 months and 6 years 5 months experienced a contradiction between what they knew or guessed to be inside a box and what they were told by an adult. The authors investigated whether children believed what they were told by asking them to make a final judgment about the box's content. Children tended to believe utterances from speakers who were better informed than they themselves were and to disbelieve those from less well-informed speakers, with no age-related differences. This behavior implies an understanding of the speaker's knowledge and suggests that children can learn from oral input while being appropriately skeptical of its truth. Children also gave explicit knowledge judgments on trials on which no utterances were given. Performance on knowledge trials was less accurate than, and unrelated to, performance on utterance trials. Research on children's developing explicit theory of mind needs to be broadened to include behavioral indexes of understanding the mind.

Basal cells are progenitors of luminal cells in primary cultures of differentiating human prostatic epithelium

BACKGROUND

Human prostatic epithelium consists mainly of basal and secretory luminal cells: the origin of these phenotypes from a common stem cell, within the basal compartment, has been proposed but not yet demonstrated.

METHODS

Analyses by light and electron microscopy, immunocytochemistry, and flow cytometry were used to determine lineage. The criteria for identifying the different phenotypes were characteristic morphology, and organization and expression of luminal- and basal-specific markers.

RESULTS

After organoids attached, outgrowths appeared with cells maintaining close cell-to-cell associations. The dividing cell compartment contained a subpopulation of cells with stem-cell characteristics and a major population that may correspond to amplifying cells. The characteristics of the stem-cell phenotype included reactivity with antibodies CKbasal, CK14, and Ki67. The amplifying cells were characterized as an intermediate phenotype between basal and luminal, as reactivity was demonstrated with CKbasal, CK14, and CK18. As outgrowths eventually merged, multilayering was apparent and cells on the uppermost layer had numerous secretory vacuoles and reacted strongly with antibodies CK18 and CK19, androgen receptor, and prostate-specific antigen, which is characteristic of secretory luminal cells in vivo. In passaged cultures, loss of reactivity with CKbasal was detected; we postulate that this population contains the stem-cell fraction.

CONCLUSIONS

These findings demonstrate that basal and luminal cells are of the same lineage and are derived from a common stem cell. Moreover, the progenitor stem cells reside within the basal compartment.

'Theory of mind' skills during an acute episode of psychosis and following recovery

BACKGROUND

A neuropsychological formulation of schizophrenia has suggested that problems with meta-representation underpin both positive and negative symptoms. This study tested Frith's account by asking patients experiencing an acute episode of psychosis to complete a set of tasks that involved Theory of Mind (ToM) skills.

METHODS

Fourteen patients who fulfilled criteria for schizophrenia, 10 deluded patients who were suffering from psychotic disorders other than schizophrenia and 12 depressed patients completed second-order false belief tasks, a test which involved substitution of a co-referential term in a linguistic description of an event, and metaphor and irony tasks. The battery of tests was completed during the acute phase and following recovery. Selection of these patient groups allowed comparisons to be made between schizophrenia patients and non-schizophrenia patients and between patients with and without persecutory delusions.

RESULTS

Schizophrenia patients, who had a multiplicity of positive and negative symptoms, performed significantly worse than non-schizophrenia patients on some of the ToM tasks during an acute episode. Patients with delusions of persecution and reference did not perform significantly worse than non-deluded patients on ToM tasks. There was no significant difference between groups in performance on any of the tasks at recovery.

CONCLUSIONS

The results provide at best weak support for Frith's account and it remains unclear whether the ToM deficits demonstrated are genuine deficits or are a result of information-processing overload. However, it is clear that difficulties interpreting interpersonal contexts, as shown by some schizophrenia patients, are state rather than trait characteristics.

Children's mental representation of referential relations

We identify a surprising discrepancy in children's performance in two tasks which appear superficially to require handling of the same properties of the representational mind. Four- to six-year-olds made judgements about the knowledge of a protagonist who had only partial information about an object: the child knew that an object in a box had two descriptions, X and Y (e.g. dice and eraser), but the protagonist had access to only one of these, X. In Experiment 1, children who passed a standard false-belief task also judged correctly that the protagonist did not know the X was Y, but often judged wrongly that he did know there was a Y in the box. In Experiment 2, children predicted wrongly where the protagonist would look for a Y: the problem was not purely linguistic. We argue that success on standard theory-of-mind tasks can be supported by a more basic representing ability than is assumed in current theories, and that children's mental representation of referential relations between the world and the mind subsequently undergoes important change.

Identification of homologs for thioredoxin, peptidyl prolyl cis-trans isomerase, and glycerophosphodiester phosphodiesterase in outer membrane fractions from Treponema pallidum, the syphilis spirochete

In this study, we characterized candidate rare outer membrane (OM) proteins with apparent molecular masses of 19, 27, 38, and 38.5 kDa, which had been identified previously in OM fractions from Treponema pallidum (J. D. Radolf et al., Infect. Immun. 63:4244-4252, 1995). Using N-terminal and internal amino acid sequences, a probe for the 19-kDa candidate was PCR amplified and used to screen a T. pallidum genomic library in Lambda Zap II. The corresponding gene (tlp) encoded a homolog for periplasmic thioredoxin-like proteins (Tlp), which reduce c-type cytochromes. A degenerate oligonucleotide derived from the N terminus of the 27-kDa protein was used to PCR amplify a duplex probe from a T. pallidum genomic library in pBluescript II SK+. With this probe, the corresponding gene (ppiB) was identified and found to code for a presumptive periplasmic cyclophilin B-type peptidyl prolyl cis-trans isomerase (PpiB). We postulate that PpiB assists the folding of proteins within the T. pallidum periplasmic space. The N terminus of the 38-kDa candidate was blocked to Edman degradation. However, internal sequence data revealed that it was basic membrane protein (Bmp), a previously characterized, signal peptidase I-processed protein. Triton X-114 phase partitioning revealed that despite its name, Bmp is hydrophilic and therefore likely to be periplasmic. The final candidate was also blocked to Edman degradation; as before, a duplex probe was PCR amplified with degenerate primers derived from internal sequences. The corresponding gene (glpQ) coded for a presumptively lipid-modified homolog of glycerophosphodiester phosphodiesterase (GlpQ). Based upon findings with other treponemal lipoproteins, the hydrophilic GlpQ polypeptide is thought to be anchored by N-terminal lipids to the periplasmic leaflet(s) of the cytoplasmic membrane and/or OM. The discovery of T. pallidum periplasmic proteins with potentially defined functions provides fresh insights into a poorly understood aspect of treponemal physiology. At the same time, however, these findings also raise important issues regarding the use of OM preparations for identifying rare OM proteins of T. pallidum.

Effects of a new 5 alpha reductase inhibitor (epristeride) on human prostate cell cultures

BACKGROUND

Inhibitors of 5 alpha reductase (5 alpha R), the enzyme that converts testosterone to dihydrotestosterone (DHT), have been shown to retard the growth of hyperplastic prostates. This study evaluates the effects of the 5 alpha R inhibitor, epristeride, on cultured stromal and epithelial cells from benign, hyperplastic adult prostates.

METHODS

[3H]-thymidine incorporation was used as a measure of proliferation. Prostate-specific antigen (PSA) was quantified by ELISA and reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

Stromal cell proliferation in response to testosterone was dose-dependently inhibited by epristeride (1 x 10(-9) -3 x 10(-7) M, P < 0.05). However, epristeride had no effect on DHT-induced growth or the growth of androgen-unresponsive stroma. Upregulation of PSA secretion from epithelial cells by androgens was downregulated by epristeride (3 x 10(-9) M, P < 0.05) in testosterone-treated cells. Transforming growth factor beta-1 (TGF beta-1) secretion was downregulated by testosterone treatment and increased following treatment with epristeride (3 x 10(-9) M, P < 0.05).

CONCLUSIONS

This demonstrates that epristeride specifically blocks testosterone-induced effects on prostatic cultures. TGF beta-1 may be a marker of 5 alpha reductase activity.

Measurement of polyethylene wear in acetabular components inserted with and without cement. A randomized trial

We measured the three-dimensional wear of polyethylene after total hip arthroplasty with a titanium metal-backed Mallory-Head prosthesis that was inserted with cement in sixty-nine patients (sixty-nine hips) and with a press-fit titanium metal-backed Mallory-Head prosthesis that was inserted without cement in seventy patients (seventy hips). A modular titanium femoral head was used in all of the hips. The patients in the present study were part of a larger double-blind randomized trial comparing the result of total hip arthroplasty performed with cement with that of the same procedure performed without cement in 250 patients. The criterion for inclusion in the study of polyethylene wear was a minimum duration of follow-up of four years, which was met by 148 patients. As adequate radiographs for digitization were not available for nine patients, 139 patients were included in the present study. The age of the patient, the postoperative Harris hip score, the diameter of the femoral head, the thickness of the liner in the polar region of the acetabular component, and the duration of follow-up were similar for the two groups. The mean rate of volumetric wear of the polyethylene was significantly greater in the prostheses that had been inserted without cement than in those that had been inserted with cement (155.1 cubic millimeters per year compared with 98.5 cubic millimeters per year; p = 0.000008). Thirty-four (49 per cent) of the seventy hips in which the prosthesis had been inserted without cement had evidence of osteolysis on radiographs, compared with twelve (17 per cent) of the sixty-nine hips in the other group (p = 0.0002). Osteolysis was associated with an increased rate of polyethylene wear only in the hips in which the prosthesis had been inserted without cement.

When speech conflicts with seeing: young children's understanding of informational priority

In a series of investigations we found that children between 3 and 5 years of age judged that an utterance (such as, "There's milk in the jug") would be ignored by a listener who had previously seen something contradictory (orange juice in the jug). However, children judged that the listener would believe the message "There's milk in the jug" when he had not previously seen inside. In these various conditions, child participants had not seen for themselves what was inside the jug, so it was impossible for their own directly perceived knowledge to contaminate their judgments of what the protagonist believed. Under these conditions, even many false-belief failers did not assume that the listener would believe whatever they themselves thought was true. Moreover, the results of control conditions suggested that children's success could not be attributed to low-level strategies. These results seem to indicate an early understanding of how people prioritize information, with the consequence that they acknowledge that one and the same message would be believed in one context but not in another.

Benign prostatic stromal cells are regulated by basic fibroblast growth factor and transforming growth factor-beta 1

The current study was undertaken, using cultures of prostatic epithelial and stromal cells, to determine the functional interactions between androgens, basic fibroblast growth factor (FGF2) and transforming growth factor-beta 1 (TGF beta 1) and their importance in maintaining stromal homeostasis. Treatment of stromal cells with TGF beta 1 significantly increased intracellular FGF2 and FGF2 sequestered to the extracellular matrix. FGF2 was also detected in stromal conditioned medium (SCM), but at levels 70-fold less than found in cell lysates. TGF beta 1 (0.1 ng/ml) treatment caused an initial increase of 86% in secreted FGF2 levels, but high concentrations of TGF beta 1 (5 ng/ml) decreased FGF2 levels by 38%, relative to the untreated control. Further studies showed that epithelial conditioned medium (ECM), androgen-treated, stromal conditioned medium (ASCM), but not SCM were mitogenic for stromal cells. Both ECM and ASCM caused a threefold increase in DNA synthesis. FGF2 may be the mediator of these interactions, since the mitogenic effect of both ECM and ASCM was significantly reduced by the addition of anti-FGF2 neutralising antibody. We hypothesise that the lack of response of stromal cells to SCM is due to TGF beta 1 blocking the mitogenic effect of FGF2. Thus down-regulation of TGF beta 1 synthesis, by androgens, results in stromal proliferation by ASCM.