Guideline panel social dynamics influence the development of clinical practice recommendations: a mixed-methods systematic review

OBJECTIVES

To synthesize empirical studies that investigate the cognitive and social processes involved in the deliberation process of guideline development meetings and determine the distribution of deliberated topics.

STUDY DESIGN AND SETTING

We conducted a mixed-method systematic review using a convergent segregated approach. We searched for empirical studies that investigate the intragroup dynamics of guideline development meetings indexed in bibliographic databases.

RESULTS

Of the 5,899 citations screened, 12 studies from six countries proved eligible. Chairs, cochairs, and methodologists contributed to at least one-third of the discussion time in guideline development meetings; patient partners contributed the least. In interdisciplinary groups, male gender and occupation as a physician were positively associated with the amount of contribution. Compared to groups that used the Grading of Recommendations Assessment, Development and Evaluation approach, for groups that did not, when faced with insufficient or low-quality evidence, relied more on their clinical experience. The presence of a cognitive "yes" bias was apparent in meetings: panelists tended to acquiesce with positive statements that required less cognitive effort than negative statements.

CONCLUSION

The social dynamics of the discussions were linked to each panelist's activity role, professional background, and gender, all of which influenced the level of contributions they made in guideline development meetings.

A novel framework for incorporating patient values and preferences in making guideline recommendations: guideline panel surveys

OBJECTIVE

Universally acknowledged standards for trustworthy guidelines include the necessity to ground recommendations in patient values and preferences. When information is limited-which is typically the case-guideline panels often find it difficult to explicitly integrate patient values and preferences into their recommendations. Our objective was to develop and evaluate a framework for systematically navigating guideline panels in incorporating patient values and preferences in making recommendations.

STUDY DESIGN AND SETTING

In the context of developing a guideline for colorectal cancer screening, we generated an initial framework for creating panel surveys to elicit guideline panelists' views of patient values and preferences and to inform panel discussions on recommendations. With further applications in guidelines of diverse topic areas, we dynamically refined the framework through iterative discussions and consensus.

RESULTS

The finial framework consists of five steps for creating and implementing panel surveys. The surveys can serve three objectives following from the quantitative information regarding patient values and preferences that guideline panels usually require. An accompanying video provides detailed instructions of the survey.

CONCLUSION

The framework for creating and implementing panel surveys offers explicit guidance for guideline panels considering transparently and systematically incorporating patient values and preferences into guideline recommendations.

Qualitative study of guideline panelists: innovative surveys provided valuable insights regarding patient values and preferences

OBJECTIVES

To explore guideline panelists' understanding of panel surveys for eliciting panels' inferences regarding patient values and preferences, and the influence of the surveys on making recommendations.

STUDY DESIGN AND SETTING

We performed sampling and data collection from all four guideline panels that had conducted the surveys through October 2020. We collected the records of all panel meetings and interviewed some panelists in different roles. We applied inductive thematic analysis for analyzing and interpreting data.

RESULTS

We enrolled four guideline panels with 99 panelists in total and interviewed 25 of them. Most panelists found the survey was easy to follow and facilitated the incorporation of patient values and preferences in the tradeoffs between benefits and harms or burdens. The variation of patient preferences and uncertainty regarding patient values and preferences reflected in the surveys helped the panels ponder the strength of recommendations. In doing so, the survey results enhanced a rationale for panels' decision on the recommendations.

CONCLUSION

The panel surveys have proved to help guideline panels explicitly consider and incorporate patient values and preferences in making recommendations. Guideline panels would benefit from widespread use of the panel surveys, particularly when primary evidence regarding patient values and preferences is scarce.

The perceptions and experience of developing patient (version of) guidelines: a descriptive qualitative study with Chinese guideline developers

OBJECTIVE

To understand developers' perception of patient (versions of) guidelines (PVGs), and identify challenges during the PVG development, with the aim to inform methodological guidance for future PVG development.

METHODS

We used a descriptive qualitative design. Semi-structured interviews were conducted virtually from December 2021 to April 2022, with a purposive sampling of 12 PVG developers from nine teams in China. Conventional and directed content analysis was used for data analysis.

RESULTS

The interviews identified PVG developers' understanding of PVGs, their current practice experience, and the challenges of developing PVGs. Participants believed PVGs were a type of health education material for patients; therefore, it should be based on patient needs and be understandable and accessible. Participants suggested that PVGs could be translated/adapted from one or several clinical practice guidelines (CPG), or developed de novo (i.e., the creation of an entirely new PVG with its own set of research questions that are independent of existing CPGs). Participants perceived those existing methodological guidelines for PVG development might not provide clear instructions for PVGs developed from multiple CPGs and from de novo development. Challenges to PVG development include (1) a lack of standardized and native guidance on developing PVGs; (2) a lack of standardized guidance on patient engagement; (3) other challenges: no publicly known and trusted platform that could disseminate PVGs; concerns about the conflicting interests with health professionals.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Our study suggests clarifying the concept of PVG is the primary task to develop PVGs and carry out related research. There is a need to make PVG developers realize the roles of PVGs, especially in helping decision-making, to maximize the effect of PVG. It is necessary to develop native consensus-based guidance considering developers' perspectives regarding PVGs.

Corrigendum to “Exploring social movement concepts and actions in a knowledge uptake and sustainability context: A concept analysis” [Int J Nurs Sci 9/4 (2022) 411–421]

[This corrects the article DOI: 10.1016/j.ijnss.2022.08.003.].

Development of patient versions of guidelines in Chinese mainland: A systematic survey of current practices and methods

OBJECTIVES

To review current practices and methods underlying the development of patient versions of guidelines (PVGs) in Chinese mainland.

METHODS

We systematically searched for PVGs created or published between January 2010 and February 2022. We conducted a framework analysis for the development process and assessed the compliance of PVGs using the Reporting Checklist for Public Versions of Guidelines (RIGHT-PVG).

RESULTS

We identified 26 PVGs developed by 16 PVG-working teams. In accordance with the Guidelines International Network (GIN), only two PVGs were translated using one clinical practice guideline (CPG) provided by the CPG-working group source. Several CPGs and other information sources were integrated and translated into a single PVG by other PVG teams. Moreover, we identified various practices described by different PVG teams that could be structured into six steps. Out of the 17 RIGHT-PVG items, five items were fully reported in all PVGs, while two items ("Provide a summary of the PVG" and "Provide a list of terms and abbreviations") were not reported in any of the PVGs.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

A relatively small number of PVGs were developed in Chinese mainland. The development of a PVG requires comprehensive methodological guidance based on several CPGs and other sources of information as opposed to only using one.

Facilitating Access to Healthcare for Performing Artists Using Subsidized Health Services in Canada: An Interpretive Descriptive Study

BACKGROUND

Performing artists are often confronted with job insecurity and insufficient health coverage. As a result, artists may not have access to non-publicly funded health services that are essential to their well-being. A health centre in Canada that specializes in providing healthcare to artists offers eligible artists subsidized health services, with the aim to treat acute health issues that impact an artists' ability to engage in their artistic practice.

PURPOSE

We evaluated the use of the subsidized health services and explored the subsidy recipients' and the selection committee's perspectives on the impact of these services on the health of performing artists.

METHODS

We applied an interpretive descriptive approach to our qualitative inquiry. We conducted individual, semi-structured interviews with recipients of the subsidy and a focus group with the selection committee that selected recipients of the subsidy. Data were analyzed using thematic analysis.

RESULTS

A total of 14 artists and all members of the selection committee (n=3) participated. Recipients and selection committee perceived that subsidized health services were critical in enabling consistent and timely diagnosis and treatment. Several themes emerged from the data: 1) need for universal health benefits to restore equity and offset healthcare insecurity, 2) the critical role of subsidies in accessing health services, 3) risks of abruptly ending health services when subsidy runs out, 4) barriers in applying for and accessing subsidies, 5) mental health challenges, and 6) importance of the subsidy in the context of the COVID-19 pandemic. All recipients saw noticeable improvement in health outcomes that they believed would have been otherwise unattainable if they did not have timely access to care.

CONCLUSIONS

Subsidized health services play an important role in ensuring that performing artists have access to care for injuries and health conditions that are related to their profession. Future research can examine the long-term impact of subsidized services on the recipients' health and employment outcomes.

Learning while leading: a realist evaluation of an academic leadership programme

INTRODUCTION

Many academic health centres and universities have implemented leadership development programmes; however, their potential impact in different contexts in healthcare remains unknown. We assessed the impact of an academic leadership development programme on the self-reported leadership activities of faculty leaders in their respective work contexts.

METHODS

Ten faculty leaders who participated in a 10-month leadership development programme between 2017 and 2020 were interviewed. The realist evaluation approach was used to guide deductive content analysis, allowing concepts related to what works for whom, why and when to emerge from the data.

RESULTS

Faculty leaders benefited in different ways depending on the organisational context (eg, culture) in which they reside and their individual contexts (eg, personal aspirations as a leader). Faculty leaders who have minimal mentorship in their leadership role gained an increased sense of community and belongingness with peer leaders and received validation in their personal leadership approach from the programme. Faculty leaders with accessible mentors were more likely than their peers to apply the knowledge they learnt to their work settings. Prolonged engagement among faculty leaders in the 10-month programme fostered continuity of learning and peer support that extended beyond programme completion.

CONCLUSIONS

This academic leadership programme included participation of faculty leaders in different contexts, resulted in varying impacts on participants' learning outcomes, leader self-efficacy and application of acquired knowledge. Faculty administrators should look for programmes with a multitude of learning interfaces to extract knowledge, hone leadership skills and build networks.

Exploring social movement concepts and actions in a knowledge uptake and sustainability context: A concept analysis

Objectives

To share a concept analysis of social movement aimed at advancing its application to evidence uptake and sustainability in health-care.

Methods

We applied Walker and Avant method to clarify the concept of social movement in the context of knowledge uptake and sustainability. Peer-reviewed and grey literature databases were systematically searched for relevant reports that described how social movement action led to evidence-based practice changes in health and community settings. Titles, abstracts and full texts were reviewed independently and in duplicate, resulting in 38 included articles.

Results

Social movement action for knowledge uptake and sustainability can be defined as individuals, groups, or organizations that, as voluntary and intrinsically motivated change agents, mobilize around a common cause to improve outcomes through knowledge uptake and sustainability. The 10 defining attributes, three antecedents and three consequences that we identified are dynamic and interrelated, often mutually reinforcing each other to fortify various aspects of the social movement. Examples of defining attributes include an urgent need for action, collective action and collective identity. The concept analysis resulted in the development of the Social Movement Action Framework.

Conclusions

Social movement action can provide a lens through which we view implementation science. Collective action and collective identity – concepts less frequently canvassed in implementation science literature – can lend insight into grassroots approaches to uptake and sustainability. Findings can also inform providers and change leaders on the practicalities of harnessing social movement action for real-world change initiatives. By mobilizing individuals, groups, or organizations through social movement approaches, they can engage as powered change agents and teams that impact the individual, organizational and health systems levels to facilitate knowledge uptake and sustainability.

Assessing cough symptom severity in refractory or unexplained chronic cough: findings from patient focus groups and an international expert panel

Background

Cough symptom severity represents an important subjective end-point to assess the impact of therapies for patients with refractory or unexplained chronic cough (RCC/UCC). As existing instruments assessing the severity of cough are neither widely available nor tested for measurement properties, we aim to develop a new patient-reported outcome measure addressing cough severity.

Objective

The aim of this study was to establish items and domains that would inform development of a new cough severity instrument.

Methods

Three focus groups involving 16 adult patients with RCC/UCC provided data that we analysed using directed content analysis. Discussions led to consensus among an international panel of 15 experts on candidate items and domains to assess cough severity.

Results

The patient focus group provided 48 unique items arranged under broad domains of urge-to-cough sensations and cough symptom. Feedback from expert panel members confirmed the appropriateness of items and domains, and provided an additional subdomain related to cough triggers. The final conceptual framework comprised 51 items in the following domains: urge-to-cough sensations (subdomains: frequency and intensity) and cough symptom (subdomains: triggers, control, frequency, fit/bout duration, intensity, quality and associated features/sequelae).

Conclusions

Consensus findings from patients and international experts established domains of urge-to-cough and cough symptom with associated subdomains and relevant items. The results support item generation and content validity for a novel patient-reported outcome measure for use in health research and clinical practice.

The urge-to-cough (subdomains: frequency and intensity) and cough symptom (subdomains: triggers, control, frequency, fit/bout duration, intensity, quality, and associated features/sequelae) represent domains to assess cough severity in RCC/UCChttps://bit.ly/3fI6qkC

A few panel members dominated guideline development meeting discussions: Social network analysis

OBJECTIVES

To identify patterns of interactions that may influence guideline panels' decision-making.

STUDY DESIGN AND SETTING

Social network analysis (SNA) to describe the conversation network in a guideline development meeting in United States.

RESULTS

We analyzed one two-day guideline panel meeting that included 20 members who developed a guideline using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. The conversation pattern of the guideline panel indicated a well-connected network (density=0.59, clustering coefficient=0.82). GRADE topics on quality of evidence and benefits versus harms accounted for 46%; non-GRADE factors accounted for 30% of discussion. The chair, co-chair and methodologist initiated 53% and received 60% of all communications in the meeting; 42% of their communications occurred among themselves. SNA metrics (eigenvector, betweenness and closeness) indicated that these individuals also exerted highest influence on discussion, controlled information flow and were at the center of all communications. Members were more likely to continue previous discussion with the same individuals after both morning breaks (r=0.54, P<0.005; r=0.17, P=0.04), and after the last break on day 2 (r=0.44, P=0.015).

CONCLUSION

Non-GRADE factors such as breaks, and the members' roles, affect guideline development more than previously recognized. Collectively, the chair, co-chair and methodologist dominated the discussion.

Certainty of evidence and intervention's benefits and harms are key determinants of guidelines' recommendations

OBJECTIVE

Many factors are postulated to affect guidelines developments. We set out to identify the key determinants.

STUDY DESIGN AND SETTING

a) Web-based survey of 12 panels of 153 "voting" members who issued 2941 recommendations; b) qualitative analysis of 13 panels of 311 attendees (panel members, systematic review teams and observers).

RESULTS

Compared with "no recommendations", when intervention's benefit outweigh harms (BH-balance), probability of issuing strong recommendations in favor of intervention was 0.22 (95%CI: 0.08 to 0.36) when certainty of evidence (CoE) was very low; 0.5 (95%CI:0.36 to 0.63) when low; 0.74 (95%CI 0.61 to 0.87) when moderate and 0.85 (95%CI:0.71 to 1.00) when high. No other postulated factor significantly affected recommendations. The findings are consistent with a J- curve model when recommendations are issued in favor but not against an intervention. Panelists often changed their judgments as a result of the meeting discussion (67% for CoE to 92% for balance between benefits and harms). The panels spent over 50% of their time debating CoE; the chairs and co-chairs dominated discussion.

CONCLUSIONS

CoE and BH-balance are key determinants of recommendations in favor of an intervention. Chairs and co-chairs dominate discussion. Panelists often change their judgments as a result of panel deliberation.

The use of theories, frameworks, or models in knowledge translation studies in healthcare settings in China: a scoping review protocol

BACKGROUND

Knowledge translation (KT) theories, frameworks, and models (TFMs) can help guide and explain KT processes, and facilitate the evaluation of implementation outcomes. They play a critical role in conducting KT research and practice. Currently, little is known about the usage of TFMs in KT in Chinese healthcare settings. The aim of this scoping review is to identify which TFMs had been used for KT in healthcare settings in China, and how these TFMs were used.

METHODS

The protocol for this scoping review is in accordance with the Arksey and O'Malley framework and further enhanced by the recommendations suggested by Levac et al. We will search 8 databases (4 Chinese and 4 English) to identify relevant studies. Four reviewers (2 for Chinese, 2 for English) will independently screen studies based on the eligibility criteria. The basic characteristic of studies and the TFMs utilization (i.e., what, why, and how) will be extracted. Methodological quality and reporting quality will be assessed using the Mixed Method Appraisal Tool (MMAT) and the Standards for Reporting Implementation Studies (StaRI) (or Standards for Quality Improvement Reporting Excellence, SQUIRE 2.0 for quality improvement studies), respectively. All the retrieved TFMs will be categorized into Nilsen's classifications of TFMs for KT research. We will employ the qualitative content analysis approach to summarize how these TFMs have been used, and the rationale. A consultation will be conducted through a 1-h interactive virtual meeting with an expert panel of knowledge users.

DISCUSSION

By conducting this scoping review, we expect to gain a comprehensive and in-depth understanding of why and how TFMs have been used in KT research and practice in China, and to identify gaps and provide recommendations for more efficient and meaningful use of TFMs in the future.

SYSTEMATIC REVIEW REGISTRATION

This review has been registered with the Open Science Framework (10.17605/OSF.IO/8NXAM).

Autopsy-reported cause of death in a population-based cohort of sudden unexpected death in epilepsy

OBJECTIVE

Sudden unexpected death in epilepsy (SUDEP) is a diagnosis of exclusion; the definition includes individuals with epilepsy who die suddenly without an identifiable toxicological or anatomical cause of death. Limited data suggest underidentification of SUDEP as the cause of death on death certificates. Here, we evaluate the autopsy-reported cause of death in a population-based cohort of SUDEP cases.

METHODS

Case summaries of forensic autopsies conducted in Ontario, Canada between January 2014 and June 2016 were retrospectively screened using a language processing script for decedents with a history of epilepsy or seizures. After manual review for potential SUDEP cases, two neurologists independently examined the autopsy reports and classified deaths by Nashef criteria. Demographic characteristics and consideration by the forensic pathologist of the role of epilepsy, seizure, and SUDEP in death were summarized.

RESULTS

One hundred and eight Definite, 34 Definite Plus, and 22 Possible SUDEP cases were identified. Seventy-five percent of Definite/Definite Plus SUDEP cases identified by the neurologists were attributed to SUDEP, epilepsy, or seizure disorder in the autopsy report. There was a significant association between the proportion of cases listed in the autopsy report as SUDEP, epilepsy, or seizure disorder and neurologists' SUDEP classification (86% of Definite, 38% of Definite Plus, 0% of Possible). Age was significantly associated with SUDEP classification; Definite cases were younger than Definite Plus, which were younger than Possible SUDEP cases.

SIGNIFICANCE

Most SUDEP cases identified by neurologists were classified concordantly by forensic pathologists in Ontario, Canada; however, concordance decreased with increased case complexity. Although the role of epilepsy/seizures was considered in most Definite/Definite Plus cases, this study highlights the need for autopsy report review of potential SUDEP cases in research studies and assessments of the public health burden of SUDEP. The relationship between age and SUDEP classification has important public health implications; SUDEP incidence may be underappreciated in older adults.

A cluster randomized clinical trial to evaluate the effectiveness of the Implementation of Infant Pain Practice Change (ImPaC) Resource to improve pain practices in hospitalized infants: a study protocol

BACKGROUND

Hospitalized infants undergo multiple painful procedures daily. Despite the significant evidence, procedural pain assessment and management continues to be suboptimal. Repetitive and untreated pain at this vital developmental juncture is associated with negative behavioral and neurodevelopmental consequences. To address this knowledge to practice gap, we developed the web-based Implementation of Infant Pain Practice Change (ImPaC) Resource to guide change in healthcare professionals' pain practice behaviors. This protocol describes the evaluation of the intervention effectiveness and implementation of the Resource and how organizational context influences outcomes.

METHODS

An effectiveness-implementation hybrid type 1 design, blending a cluster randomized clinical trial and a mixed-methods implementation study will be used. Eighteen Neonatal Intensive Care Units (NICUs) across Canada will be randomized to intervention (INT) or standard practice (SP) groups. NICUs in the INT group will receive the Resource for six months; those in the SP group will continue with practice as usual and will be offered the Resource after a six-month waiting period. Data analysts will be blinded to group allocation. To address the intervention effectiveness, the INT and SP groups will be compared on clinical outcomes including the proportion of infants who have procedural pain assessed and managed, and the frequency and nature of painful procedures. Data will be collected at baseline (before randomization) and at completion of the intervention (six months). Implementation outcomes (feasibility, fidelity, implementation cost, and reach) will be measured at completion of the intervention. Sustainability will be assessed at six and 12 months following the intervention. Organizational context will be assessed to examine its influence on intervention and implementation outcomes.

DISCUSSION

This mixed-methods study aims to determine the effectiveness and the implementation of a multifaceted online strategy for changing healthcare professionals' pain practices for hospitalized infants. Implementation strategies that are easily and effectively implemented are important for sustained change. The results will inform healthcare professionals and decision-makers on how to address the challenges of implementing the Resource within various organizational contexts.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03825822. Registered 31 January 2019.

Attending Emergency Physicians' Perceptions of a Programmatic Workplace-Based Assessment System: The McMaster Modular Assessment Program (McMAP)

Construct: The McMaster Modular Assessment Program (McMAP) is a programmatic workplace-based assessment (WBA) system that provides emergency medicine trainees with competency judgments through frequent task-specific and global daily assessments. Background: The longevity of McMAP relative to other programmatic WBA systems affords a unique view that precedes large-scale transitions to competency-based medical education (CBME), particularly in North America. Although prior work has described the perspective of residents using this system, the in-depth experiences of assessors using the system have yet to be explored. This perspective is important for understanding the validity of the competency judgments the system produces. Approach: We conducted a qualitative study that used semi-structured interviews analyzed using interpretive description (Thorne) to explore 16 attending physicians' experiences using McMAP. Data analysis was completed independently by 2 researchers, who met regularly to discuss codes and resolve any disagreements. Results: Having a structured assessment framework for a range of clinical tasks has helped encourage what attendings perceived to be more frequent and better-quality assessments, with the added advantages of being holistic, flexible, and learner-driven. However, attendings also perceived a number of challenges of McMAP and programmatic WBA more broadly. These included a reluctance to give and to document negative feedback, "gaming" of the system by both attendings and residents, and a variety of logistic and technology-related concerns. Conclusions: Based on our findings, we offer several key recommendations that can help programs maximize the benefits of programmatic WBA as they transition to CBME.

Development of the summary of findings table for network meta-analysis

OBJECTIVES

The aim of the study was to develop a Grading of Recommendations, Assessment, Development and Evaluation (GRADE) summary of findings (SoF) table format that displays the critical information from a network meta-analysis (NMA).

STUDY DESIGN AND SETTING

We applied a user experience model for data analysis based on four rounds of semistructured interviews.

RESULTS

We interviewed 32 stakeholders who conduct or use MA. Four rounds of interviews produced six candidate NMA-SoF tables. Users found a final NMA-SoF table that included the following components highly acceptable: (1) details of the clinical question (PICO), (2) a plot depicting network geometry, (3) relative and absolute effect estimates, (4) certainty of evidence, (5) ranking of treatments, and (6) interpretation of findings.

CONCLUSION

Using stakeholder feedback, we developed a new GRADE NMA-SoF table that includes the relevant components that facilitate understanding NMA findings and health decision-making.

"All the ward's a stage": a qualitative study of the experience of direct observation of handoffs

Direct observation of clinical skills is central to assessment in a competency-based medical education model, yet little is known about how direct observation is experienced by trainees and observers. The objective of the study is to explore how direct observation was experienced by residents and faculty in the context of the I-PASS Handoff Study. In this multi-center qualitative study, we conducted focus groups and semi-structured interviews of residents and faculty members at eight tertiary pediatric centers in North America that implemented the I-PASS Handoff Bundle. We employed qualitative thematic analysis to interpret the data. Barriers to and strategies for direct observation were described relating to the observer, trainee, and clinical environment. Residents and faculty described a mutual awareness that residents change their performance of handoffs when observed, in contrast to their usual behavior in a clinical setting. Changes in handoff performance may depend on the nature of the observer or 'audience'. Direct observation also highlighted the importance of handoffs to participants, recognized as a clinical activity that warrants feedback and assessment. Dramaturgical theory can be used to understand our finding of 'front-stage' (observed) versus 'backstage' (unobserved) handoffs as distinct performances, tailored to an "audience". Educators must be cognizant of changes in performance of routine clinical activities when using direct observation to assess clinical competence.

Patient Values and Preferences Regarding Continuous Subcutaneous Insulin Infusion and Artificial Pancreas in Adults with Type 1 Diabetes: A Systematic Review of Quantitative and Qualitative Data

OBJECTIVE

We produced, through a systematic review of quantitative and qualitative evidence, a synthesis of the issues of importance (values and preferences) to adult patients with type 1 diabetes regarding treatment with automated insulin delivery systems.

METHODS

We searched MEDLINE, CINAHL, EMBASE, and PsycINFO from the inception of each database through September 2018. We included studies examining patient values and preferences for outcomes related to continuous subcutaneous insulin infusion or artificial pancreas treatment. We compiled structured summaries of the results and assessed the relative importance of each outcome. GRADE (Grading of Recommendations, Assessment Development, and Evaluation) and CERQual (Confidence in Evidence from Reviews of Qualitative research) approaches provided the structure for the evaluation of the quality of evidence and confidence in the findings. A mixed-methods result-based convergent design provided the structure for integration and presentation of results.

RESULTS

We reviewed 1665 unique citations; 19 studies (8 quantitative and 11 qualitative) proved eligible. Glycemic control is the key attribute that drives patients' preference. Reduction of glycemic variability and decreased incidence of hypoglycemia and chronic complications proved of intermediate importance and were ranked similarly to components of treatment burden, including the size and appearance of devices, cost, ease of use, and the embarrassment of public use.

CONCLUSIONS

Clinician guidance may play a crucial role in determining patient values and preferences (for instance, patients' priority in glucose control rather than avoiding diabetic complications). Our results provide guidance for clinicians in discussing preferred insulin delivery systems with patients with type 1 diabetes.

Structured decision-making drives guidelines panels' recommendations "for" but not "against" health interventions

BACKGROUND AND OBJECTIVES

The determinants of guideline panels' recommendations remain uncertain. The objective of this study was to investigate factors considered by members of 8 panels convened by the American Society of Hematology (ASH) to develop guidelines using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

STUDY DESIGN AND SETTING

Web-based survey of the participants in the ASH guidelines panels.

ANALYSIS

two-level hierarchical, random-effect, multivariable regression analysis to explore the relation between GRADE and non-GRADE factors and strength of recommendations (SOR).

RESULTS

In the primary analysis, certainty in evidence [OR = 1.83; (95CI% 1.45-2.31)], balance of benefits and harms [OR = 1.49 (95CI% 1.30-1.69)] and variability in patients' values and preferences [OR = 1.47 (95CI% 1.15-1.88)] proved the strongest predictors of SOR. In a secondary analysis, certainty of evidence was associated with a strong recommendation [OR = 3.60 (95% CI 2.16-6.00)] when panel members recommended "for" interventions but not when they made recommendations "against" interventions [OR = 0.98 (95%CI: 0.57-1.8)] consistent with "yes" bias. Agreement between individual members and the group in rating SOR varied (kappa ranged from -0.01 to 0.64).

CONCLUSION

GRADE's conceptual framework proved, in general, to be highly associated with SOR. Failure of certainty of evidence to be associated with SOR against an intervention, suggest the need for improvements in the process.

Incidence of sudden unexpected death in epilepsy in children is similar to adults

Objective

To determine the incidence of sudden unexpected death in epilepsy (SUDEP) in children in Ontario, Canada.

Methods

Cases of suspected pediatric SUDEP occurring between January 1, 2014, and December 31, 2015, in Ontario, Canada, were eligible for inclusion. Potential cases were identified through 3 sources: a national pediatrician surveillance program, child neurologist report, and screening of provincial forensic autopsies. Cases were classified as definite, definite plus, probable, possible, and near/near plus according to criteria described by Nashef et al. (Epilepsia 2012). Overall crude pediatric SUDEP incidence and the incidence of definite or probable pediatric SUDEP were calculated using estimates of the prevalence of pediatric epilepsy in Canada drawn from government survey data and the number of children living in Ontario. Capture-recapture analysis was used to estimate the number of missing cases and determine an adjusted definite/probable SUDEP incidence.

Results

Seventeen cases of pediatric SUDEP resulted in an overall incidence of 1.17 (95% confidence interval 0.68–1.88) per 1,000 pediatric epilepsy person-years. The definite/probable incidence, including definite (n = 11), definite plus (n = 2), or probable (n = 3) SUDEP cases, was 1.11 (0.63–1.79). Capture-recapture analysis indicated an estimated 21 (16–39) definite/probable SUDEP cases occurred during the study period, giving an adjusted incidence of definite/probable SUDEP of 1.45 (0.90–2.22) per 1,000 pediatric epilepsy person-years.

Conclusion

SUDEP may be more common in children than widely reported, with the incidence rate of definite/probable SUDEP in children being similar to rates reported in adults.

Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review

BACKGROUND

Organizational contextual features have been recognized as important determinants for implementing evidence-based practices across healthcare settings for over a decade. However, implementation scientists have not reached consensus on which features are most important for implementing evidence-based practices. The aims of this review were to identify the most commonly reported organizational contextual features that influence the implementation of evidence-based practices across healthcare settings, and to describe how these features affect implementation.

METHODS

An integrative review was undertaken following literature searches in CINAHL, MEDLINE, PsycINFO, EMBASE, Web of Science, and Cochrane databases from January 2005 to June 2017. English language, peer-reviewed empirical studies exploring organizational context in at least one implementation initiative within a healthcare setting were included. Quality appraisal of the included studies was performed using the Mixed Methods Appraisal Tool. Inductive content analysis informed data extraction and reduction.

RESULTS

The search generated 5152 citations. After removing duplicates and applying eligibility criteria, 36 journal articles were included. The majority (n = 20) of the study designs were qualitative, 11 were quantitative, and 5 used a mixed methods approach. Six main organizational contextual features (organizational culture; leadership; networks and communication; resources; evaluation, monitoring and feedback; and champions) were most commonly reported to influence implementation outcomes in the selected studies across a wide range of healthcare settings.

CONCLUSIONS

We identified six organizational contextual features that appear to be interrelated and work synergistically to influence the implementation of evidence-based practices within an organization. Organizational contextual features did not influence implementation efforts independently from other features. Rather, features were interrelated and often influenced each other in complex, dynamic ways to effect change. These features corresponded to the constructs in the Consolidated Framework for Implementation Research (CFIR), which supports the use of CFIR as a guiding framework for studies that explore the relationship between organizational context and implementation. Organizational culture was most commonly reported to affect implementation. Leadership exerted influence on the five other features, indicating it may be a moderator or mediator that enhances or impedes the implementation of evidence-based practices. Future research should focus on how organizational features interact to influence implementation effectiveness.

Resident Development via Progress Testing and Test-Marking: An Innovation and Program Evaluation

Introduction

Since 2008, the McMaster University Royal College Emergency Medicine residency training program has run practice Short Answer Question (SAQ) examinations to help residents test their knowledge and gain practice in answering exam-style questions. However, marking this type of SAQ exam is time-consuming.

Methods

To help address this problem, we require that senior residents help mark at least one exam per year alongside faculty members. Examinees’ identities are kept anonymous by assigning a random number to each resident, which is only decoded after marking. Aggregation of marks is done by faculty only. The senior residents and faculty members all share sequential marking of each question. Each question is reviewed, and exemplar “best practice” answers are discussed. As novel/unusual answers appear, instantaneous fact-checking (via textbooks, or the internet) and discussions occur allowing for real-time modification to the answer keys as needed.

Results

A total of 22 out of 37 residents (post graduate year 1 to post graduate year 5 (PGY1 to PGY5)) participated in a recent program evaluation focus group. This evaluation showed that residents feel quite positive about this process. With the anonymization process, residents do not object to their colleagues seeing and marking their answers. Senior residents have found this process informative and have felt that this process helps them gain insight into better “examsmanship.”

Conclusions

Involving residents in marking short-answer exams is acceptable and perceived as useful experience for improving exam-taking skills. More studies of similar innovations would be required to determine to what extent this may be the case.

Investigating the Effects of a Personalized, Spectrally Altered Music-Based Sound Therapy on Treating Tinnitus: A Blinded, Randomized Controlled Trial

OBJECTIVE

This blinded, randomized controlled trial assessed the effectiveness of a personalized, spectrally altered music-based sound therapy over 12 months of use.

METHOD

Two groups of participants (n = 50) were randomized to receive either altered or unaltered classical music. The treatment group received classical music that had been modified based on spectral alterations specific to their tinnitus characteristics. Tinnitus and psychological functioning were assessed at baseline and 3, 6, and 12 months after initial testing using self-reports. Participants, investigators and research assistants were blinded from group assignment.

RESULTS

Data from 34 participants were analyzed. The treatment group reported significantly lower levels of tinnitus distress (primary outcome, assessed using the Tinnitus Handicap Inventory) than the control group throughout the follow-up period. Among the treatment group, there were statistically significant and clinically meaningful levels of reduction in tinnitus distress, severity, and functional impairment at 3- and 6-month follow-ups, which was sustained at the 12-month follow-up.

CONCLUSION

The personalized music therapy was effective in reducing subjective tinnitus and represents a meaningful advancement in tinnitus intervention.

Canadian Primary Care Physicians' Attitudes Toward Understanding Clinical Practice Guidelines for Diabetes Screening

OBJECTIVES

The Canadian Task Force on Preventive Health Care (CTFPHC) produces guidelines for Canadian physicians regarding screening and prevention. To better appreciate the barriers to and facilitators of guideline adherence, we sought to explore physicians' views of guidelines in general and their understanding of this CTFPHC diabetes screening guideline in particular because they pertain to screening and positive treatment.

METHODS

We included Canadian physicians (N=10) who agreed to be interviewed regarding their use of guidelines as part of practice, focusing on the CTFPHC 2012 diabetes screening guideline. Individual semistructured interviews explored primary care physicians' experiences and perspectives on the use, relevance and feasibility of guidelines as part of practice, approaches to screening for diabetes, and suggestions for improving guidelines.

RESULTS

Overall, physicians recognized the need for guidelines and the benefits of using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods in the guideline development process. Physicians also noted several barriers to guideline adherence, including the lack of opportunity for physicians to provide input during guideline formulation, insufficient guidance on interpreting GRADE's weak or conditional recommendations, and feasibility issues concerning using risk calculators. The predominant challenge raised by physicians was the unclear guidance for pharmacologic interventions; all respondents were unclear about the guidelines' implicit assumption that screen-positive patients would be treated with statins and aspirin (ASA).

CONCLUSIONS

These interviews suggest the need for greater clarity in guideline recommendations, including clarification of the quality of evidence ratings and the strength of recommendation grading. Our low participation rate raises the issue of representativeness; replication in samples with greater willingness to participate would be desirable.

Sensitivity subgroup analysis based on single-center vs. multi-center trial status when interpreting meta-analyses pooled estimates: the logical way forward

OBJECTIVES

Prior studies regarding whether single-center trial estimates are larger than multi-center are equivocal. We examined the extent to which single-center trials yield systematically larger effects than multi-center trials.

STUDY DESIGN AND SETTING

We searched the 119 core clinical journals and the Cochrane Database of Systematic Reviews for meta-analyses (MAs) of randomized controlled trials (RCTs) published during 2012. In this meta-epidemiologic study, for binary variables, we computed the pooled ratio of ORs (RORs), and for continuous outcomes mean difference in standardized mean differences (SMDs), we conducted weighted random-effects meta-regression and random-effects MA modeling. Our primary analyses were restricted to MAs that included at least five RCTs and in which at least 25% of the studies used each of single trial center (SC) and more trial center (MC) designs.

RESULTS

We identified 81 MAs for the odds ratio (OR) and 43 for the SMD outcome measures. Based on our analytic plan, our primary analysis (core) is based on 25 MAs/241 RCTs (binary outcome) and 18 MAs/173 RCTs (continuous outcome). Based on the core analysis, we found no difference in magnitude of effect between SC and MC for binary outcomes [RORs: 1.02; 95% confidence interval (CI): 0.83, 1.24; I(2) 20.2%]. Effect sizes were systematically larger for SC than MC for the continuous outcome measure (mean difference in SMDs: -0.13; 95% CI: -0.21, -0.05; I(2) 0%).

CONCLUSIONS

Our results do not support prior findings of larger effects in SC than MC trials addressing binary outcomes but show a very similar small increase in effect in SC than MC trials addressing continuous outcomes. Authors of systematic reviews would be wise to include all trials irrespective of SC vs. MC design and address SC vs. MC status as a possible explanation of heterogeneity (and consider sensitivity analyses).

Health care and social service professionals' perceptions of a home-visit program for young, first-time mothers

INTRODUCTION

Little is known about health care and social service professionals' perspective on the acceptability of long-term home-visit programs serving low-income, first-time mothers. This study describes the experiences and perspectives of these community care providers involved with program referrals or service delivery to mothers who participated in the Nurse-Family Partnership (NFP), a targeted nurse home-visit program.

METHODS

The study included two phases. Phase I was a secondary qualitative data analysis used to analyze a purposeful sample of 24 individual interviews of community care providers. This was part of a larger case study examining adaptations required to increase acceptability of the NFP in Hamilton, Ontario, Canada. In Phase II (n = 4), themes identified from Phase I were further explored through individual, semi-structured interviews with community health care and social service providers, giving qualitative description.

RESULTS

Overall, the NFP was viewed as addressing an important service gap for first-time mothers. Providers suggested that frequent communication between the NFP and community agencies serving these mothers could help improve the referral process, avoid service duplication, and streamline the flow of service access. The findings can help determine key components required to enhance the success of integrating a home-visit program into an existing network of community services.

CONCLUSION

The function of home-visit programs should not be viewed in isolation. Rather, their potential can be maximized when they collaborate and share information with other agencies to provide better services for first-time mothers.

The effects of steroidal estrogens in ACI rat mammary carcinogenesis: 17beta-estradiol, 2-hydroxyestradiol, 4-hydroxyestradiol, 16alpha-hydroxyestradiol, and 4-hydroxyestrone

Several investigators have suggested that certain hydroxylated metabolites of 17beta-estradiol (E2) are the proximate carcinogens that induce mammary carcinomas in estrogen-sensitive rodent models. The studies reported here were designed to examine the carcinogenic potential of different levels of E2 and the effects of genotoxic metabolites of E2 in an in vivo model sensitive to E2-induced mammary cancer. The potential induction of mammary tumors was determined in female ACI rats subcutaneously implanted with cholesterol pellets containing E2 (1, 2, or 3 mg), or 2-hydroxyestradiol (2-OH E2), 4-hydroxyestradiol (4-OH E2), 16alpha-hydroxyestradiol (16alpha-OH E2), or 4-hydoxyestrone (4-OH E1) (equimolar to 2 mg E2). Treatment with 1, 2, or 3 mg E2 resulted in the first appearance of a mammary tumor between 12 and 17 weeks, and a 50% incidence of mammary tumors was observed at 36, 19, and 18 weeks respectively. The final cumulative mammary tumor incidence in rats treated with 1, 2, or 3 mg E2 for 36 weeks was 50%, 73%, and 100% respectively. Treatment of rats with pellets containing 2-OH E2, 4-OH E2, 16alpha-OH E2, or 4-OH E1 did not induce any detectable mammary tumors. The serum levels of E2 in rats treated with a 1 or 3 mg E2 pellet for 12 weeks was increased 2- to 6-fold above control values (approximately 30 pg/ml). Treatment of rats with E2 enhanced the hepatic microsomal metabolism of E2 to E1, but did not influence the 2- or 4-hydroxylation of E2). In summary, we observed a dose-dependent induction of mammary tumors in female ACI rats treated continuously with E2; however, under these conditions 2-OH E2, 4-OH E2, 16alpha-OH E2, and 4-OH E1 were inactive in inducing mammary tumors.

Ectopic uterine stem cell tumors in the hamster kidney. A unique model for estrogen-induced oncogenesis

Estrogens are intimately involved in the causation of some of the most prevalent cancers afflicting women, particularly, breast, endometrial, cervico-vaginal, and possibly ovarian. Therefore, it has become particularly pertinent to elucidate the molecular mechanisms whereby estrogens elicit their oncogenic actions so that better prevention strategies can be developed. The estrogen-induced Syrian hamster tumors of the kidney have emerged as one of the most intensively studied in vivo models in solely estrogen oncogenesis. An advantage of this model is that the tumors occur in the absence of any intervening morphologic changes, but rather they are the result of the continuous progression of some interstitial stem cells in the kidney leading to tumor formation. Evidence is presented that the origin of these tumors is derived from ectopic "uterine" stem cells, which are responsive to estrogenic hormones. Their steroid receptor and many other gene alterations have been delineated. Importantly, a crucial early event in this solely estrogen-induced oncogenic process is the overexpression and amplification of c-myc and its protein product. Chromosomal instability, in both early and large frank tumors, is another important characteristic of this process. This later feature has commonly been shown in solely estrogen-induced murine mammary tumors, and in ductal carcinomas in situ and in primary invasive ductal breast carcinomas. These changes are considered crucial in eliciting estrogen-induced tumorigenesis.

Prevention of solely estrogen-induced mammary tumors in female aci rats by tamoxifen: evidence for estrogen receptor mediation

There is increasing evidence that both endogenous and exogenously ingested estrogens play a primary role in sporadic breast cancer causation. To establish further that solely estrogen-induced mammary oncogenesis in female ACI rats is an estrogen receptor (ERalpha)-driven process, we show for the first time that concomitant treatment with the antiestrogen, tamoxifen citrate (TAMc), completely prevents the induction of 17beta-estradiol (E(2))-induced mammary gland tumors (MGTs). This finding is also supported by the reduced mammary gland (MG) lobulo-alveolar development and proliferative activity observed in TAMc+E(2)-treated animals compared with MGs from animals treated with E(2) alone. These data also correlated with a marked decrease in the number of MG cells expressing ERalpha and progesterone receptor (PR) in immunostained MG tissue sections from TAMc+E(2)-treated animals. Additionally, a marked decline in the level of expression of ERalpha 47, 56 and 66 kDa forms, and PR-A and PR-B was seen in TAMc+E(2)-treated MGs, compared with MGs treated solely with E(2). Thus, both ERalpha and PR MG profiles in TAMc+E(2)-treated rats essentially revert to their respective receptor profiles seen in untreated control and TAMc-alone-treated rats. The presence of 56 and 54 kDa isoforms in chronically E(2)-treated MGs and in MGTs respectively may contribute to fostering the enhanced E(2)-dependent growth response of both precursor and frank MGT epithelial cells. These findings are consistent with an ERalpha/PR-mediated mg cell proliferation, a prerequisite for generating the high frequency of chromosomal instability seen in E(2)-induced ductal carcinomas in situ and primary MGTs in female ACI rats reported by us previously.

Determination of S-[2-carboxy-1-(1H-imidazol-4-yl)ethyl]glutathione, a novel metabolite of L-histidine, in tissue extracts from sunlight-irradiated rat by capillary electrophoresis

Exposure of the skin to sunlight results in an increase in the content of epidermal urocanic acid, a key metabolite of L-histidine, and some portions of the metabolite penetrate into the body fluid. S-[2-Carboxy-1-(1H-imidazol-4-yl)ethyl]glutathione (GS(CIE)), an adduct of glutathione and urocanic acid, was proposed to be an origin of a urinary compound, S-[2-carboxy-1-(1 H-imidazol-4-yl)ethyl]-L-cysteine (Cys(CIE)). Various catabolites of Cys(CIE) were also isolated from human urine previously. However, no direct evidence to show the existence of GS(CIE) as a biological material had been found. By using capillary electrophoresis, the glutathione adduct has now been found in the extracts of rat tissues from the kidney, liver, skin and blood when the rat was kept under conditions of sunlight irradiation after the fur on the dorsal skin had been clipped. On the other hand, no or a trace of GS(CIE) was determined in rat tissue extracts when the animal was kept indoor in usual manner. The glutathione adduct was isolated from the kidney extract of the sunlight-irradiated rat using ion-exchangers and high-voltage paper electrophoresis, and determined by fast-atom-bombardment mass spectrometry. These results indicate that GS(CIE) formation actually occurs in the body and that the formation is accelerated by exposing the rat to sunlight irradiation. From these findings, we propose an alternative pathway of histidine metabolism which is initiated by the adduction of urocanic acid to glutathione to form GS(CIE) and terminates with the formation of the urinary compounds via Cys(CIE).

ER and PR in renomedullary interstitial cells during Syrian hamster estrogen-induced tumorigenesis: evidence for receptor-mediated oncogenesis

The estrogen-induced and -dependent Syrian hamster renal tumor is the most intensively studied model in estrogen carcinogenesis. Yet, it remains confounding that the kidney of this species behaves as an estrogen target tissue. As both reproductive and urinary systems arise from the same germinal ridge, we propose that some of the germinal cells, normally destined for the uterus, migrate and establish themselves in the renal corticomedullary region in this hamster strain. These ectopically located germinal cells remain dormant unless exposed to estrogen. Supporting this contention, a subset of renal interstitial cells, primarily located in the corticomedullary region, express PR after only 2 wk and ER alpha after 1.5--3.0 months of estrogen treatment. As treatment continues, groups of cells of the renal interstitium and small and large renal tumors show ER alpha(+) and PR(+) staining. Although ER alpha and PR isoform profiles in estrogen-treated hamster kidneys are distinctly different from corresponding uterine patterns, both receptor isoform profiles in primary renal tumors closely resemble those seen in hamster uteri. Renal ER alpha protein and mRNA expression increased after 2.0 and 4.0 months of estrogen treatment and in all renal tumors examined. Using nuclear image cytometry, both early small and large renal tumors were highly aneuploid, indicating that genomic instability is probably a critical early event in estrogen carcinogenesis.

Unusual deregulation of cell cycle components in early and frank estrogen-induced renal neoplasias in the Syrian hamster

There is strong evidence that estrogens are involved in the etiology, promotion and progression of a variety of cancers, including the cancers of the breast and endometrium. The Syrian hamster estrogen-induced, estrogen-dependent renal neoplasm is a well-established animal model used to elucidate the cellular and molecular mechanisms involved in solely estrogen-induced carcinogenic processes. G(1) cell cycle progression was studied in estrogen-induced early renal tumor foci and in large kidney tumors of castrated male hamsters. Levels of cyclin D1, cyclin E and retinoblastoma (pRb) proteins were higher in these renal neoplasias than in adjacent uninvolved renal tissue and kidneys from untreated, age-matched animals. Of particular interest is the presence of a predominant 35 kDa cyclin E protein variant form in primary renal tumors. In addition, amounts of the phosphorylated forms of cyclin-dependent kinases (cdk) 2 and 4 were decreased, and both RNA and protein levels of p27(kip1) (p27), a cyclin-dependent kinase inhibitor, were markedly higher in early and frank renal tumors than in adjacent uninvolved renal tissue and kidneys of untreated, age-matched animals. These changes in cell cycle components coincided with a rise in renal tumor cell proliferation. Binding of the elevated p27 protein to cyclin E, cdk2 and cdk4, however, was not impaired, suggesting that this cell cycle suppressor protein is functional. In addition, cyclin D1-, cdk2-, cdk4- and cyclin E-associated kinase activities were also lower in these estrogen-induced renal neoplasms than in untreated, age-matched kidneys. Interestingly, when compared with untreated kidney tissue, early and frank renal neoplasms had less of the 62 kDa native form of E2F1 and contained a 57 kDa variant form. Thus we have characterized an unusual deregulation of the cell cycle during estrogen-induced renal tumorigenesis in Syrian hamsters which still allows for estrogen-driven kidney tumor cell proliferation and may contribute to the early genomic instability found.

Overexpression and amplification of c-myc in the Syrian hamster kidney during estrogen carcinogenesis: a probable critical role in neoplastic transformation

An estrogen receptor-driven, multistep process for estrogen carcinogenesis in the Syrian hamster kidney is proposed. Because in this species the reproductive and urogenital tracts arise from the same embryonic germinal ridge, it is evident that the kidney has carried over genes that are responsive to estrogens. Using in situ hybridization, overexpression of early estrogen-response genes, i.e., c-myc and c-fos, has been shown to be localized preferentially in early renal tumor foci after 3.5-4.0 months of estrogen treatment. This event coincides with an increased number of S-phase proliferating cell nuclear antigen-labeled cells in these tumor foci, along with a rapid rise in aneuploid frequency in the kidney. Western blot analyses of c-MYC and c-FOS protein products support the overexpression of these genes. Amplification of c-myc, 2.4-3.6-fold, but not of c-fos, was detected in 67% of the primary renal tumors examined, by Southern blot analyses. Consistent chromosomal gains, common to both diethylstilbestrol- and estradiol-induced renal neoplasms, were observed in chromosomes 1, 2, 3, (6), 11, (13), 16, 20, and 21 (chromosome number alterations are indicated in parentheses). Using fluorescence in situ hybridization, the c-myc gene was localized to hamster chromosome 6qb. Chromosome 6 exhibited a high frequency of trisomies and tetrasomies in the kidney after 5.0 months of estrogen treatment and in primary renal tumors. The data presented indicate that estrogen-induced genomic instability may be a key element in carcinogenic processes induced by estrogens.

Promotion of estrogen-induced mammary gland carcinogenesis by androgen in the male Noble rat: probable mediation by steroid receptors

Both endogenous and exogenous estrogen exposure is associated with an increased breast cancer risk. In some studies, elevated serum testosterone levels have also been linked to an increased breast cancer risk. Estrogen alone or combined with progesterone induces high mammary tumor incidences in various strains of both male and female rats. Mammary gland ductal adenocarcinomas were induced after 17beta-estradiol (E2) and testosterone propionate (TP) treatment in male Noble rats. Tumor incidence was 100% after 8-9 months of treatment. Such neoplasms were not detected after either estrogen or androgen exposure alone within this time period. TP alone caused disruption of mammary gland ducts and proliferation of stromal tissue, while E2 treatment alone induced both ductal epithelial growth and nodular atypical hyperplasia. To study the interaction of these hormones in mammary tumorigenesis, sex hormone receptors were characterized in mammary glands of Noble rats. Estrogen receptor-alpha (ER) was detected in age-matched, untreated mammary gland epithelium; in most early atypical hyperplastic lesions appearing after E2 and E2 + TP treatment and in E2 + TP-induced mammary tumors. Two major ER putative isoforms, 116 and 120 kDa, were detected in E2- and E2 + TP-treated mammary glands, and in the induced tumors. A 54 kDa ER protein was found in untreated and TP-treated mammary glands, and in the induced tumors. Both progesterone receptor-B (PR-B) and PR-A2, as well as androgen receptor-B (AR-B) and AR-A isoforms were markedly elevated in all E2 + TP-induced mammary tumors. However, the levels of both PR and AR were very low in mammary glands of E2- and E2 + TP-treated male rats. Low and moderate levels of AR and PR, respectively, were detected in most atypical hyperplastic lesions induced by E2- and E2 + TP-treated mammary glands. These results suggest that androgens may interact with either AR or PR, and perhaps both receptors, in E2 + TP-induced mammary glands and the induced tumors to effect the reduction in latency period, enhance tumor size, and increase incidence to 100%.

Prevention of estrogen carcinogenesis in the hamster kidney by ethinylestradiol: some unique properties of a synthetic estrogen

Ethinylestradiol (EE) has evident paradoxical effects on cancer risk for human breast and hepatic cancer which parallel in some respects its effects on estrogen-induced neoplasms in the hamster kidney and liver. EE has been shown to be only weakly carcinogenic in the hamster kidney, but the most potent carcinogenic estrogen in the hamster liver following prolonged treatment. Unexpectedly, when EE and potent carcinogenic estrogens, such as diethylstilbestrol (DES), 17beta-estradiol (E2) and Moxestrol (MOX), are administered concomitantly, estrogen-induced carcinogenesis in the kidney is completely prevented. In studying this novel finding, we found that, compared with E2 exposure alone, EE at 0.05 and 1.0 nM significantly (P < 0.001) inhibited the rise in proliferation of cultured primary hamster proximal renal tubular (PRT) cells in the presence of E2 (1.0 nM). Consistent with these findings, combined EE + DES treatment for 5.0 months reduced hamster kidney c-myc, c-fos and c-jun RNA expression to 43, 37 and 52%, respectively, compared with levels observed after DES treatment alone. Interestingly, TAM + DES treatment for the same period also resulted in the same low level of RNA expression of these proto-oncogenes. c-MYC, c-FOS and c-JUN protein products were comparably reduced after either EE + DES or TAM + DES treatment. It appears that c-fos expression and c-FOS protein levels in the hamster kidney were more responsive to TAM inhibition. These data demonstrate that EE possesses unique anti-tumorigenic properties in vivo in the hamster kidney. Additionally, the observed anti-estrogen-like effect of EE on cell proliferation of cultured PRT cells suggests that EE may interfere critically with estrogen receptor (ER)-mediated mitogenic pathway(s) affected by potent carcinogenic estrogens, thus preventing subsequent gene dysregulation and, hence, tumor development. Based on competition studies, the differential binding of EE to hamster kidney ER relative to that of the other estrogens (E2, DES, MOX) appears not to contribute to the prevention of estrogen carcinogenesis at this organ site by EE.

Induction of cathepsin D protein during estrogen carcinogenesis: possible role in estrogen-mediated kidney tubular cell damage

We have proposed that an early step in estrogen carcinogenesis in the hamster kidney is tubular damage followed by reparative cell proliferation. This tubular injury is progressive and increases in severity with continued estrogen treatment; one pertinent feature is a marked rise in the number of both secondary and tertiary lysosomes. Data presented herein indicate that cathepsin D, an estrogen-responsive lysosomal proteolytic enzyme, is increased in the kidney following estrogen treatment in the hamster. Three isoforms of cathepsin D were detected in estrogen-treated kidneys, 52, 31, and 27 kDa, the major being 52 kDa. At 1 and 3 months of estrogen treatment, 52-kDa cathepsin D content increased 1.4- to 1.6-fold. These changes coincided with a rise in renal estrogen receptor levels during the same estrogen treatment periods. More pronounced rises in cathepsin D levels, 2.7- and 3.5-fold, were seen after 4 and 5 months of estrogen treatment, respectively. A concomitant, 3.0- to 4.0-fold rise in estrogen receptor content was also observed. At 5 months of estradiol or DES treatment, both 27- and 31-kDa isoforms were present in hamster kidneys, in addition to the 52-kDa form. Neither progesterone nor DHT treatment affected the untreated levels of cathepsin D. Interestingly, either concomitant tamoxifen or DHT and estrogen treatment prevented the rise in cathepsin D and estrogen receptor content observed after estrogen treatment alone. Primary estrogen-induced renal tumors and their metastases exhibited markedly elevated levels of all three isoforms of cathepsin D. Immunohistochemical analysis of cathepsin D in kidney sections confirmed the Western blot findings. These data suggest a novel role for estrogen-induced cathepsin D in the hamster kidney during tumorigenesis; that is, mediating renal tubular damage as a prelude to reparative cell proliferation, thus initiating a multi-step estrogen-driven process which leads to renal tumor formation.

Glutathione S-transferase Yc cDNA from Syrian hamster kidney

A cDNA encoding alpha-class glutathione S-transferase Yc (GSTYc) has been isolated from a Syrian hamster kidney library, and its nucleotide sequence (968 bp) has been determined. Analysis of the deduced amino acid sequence revealed a high level of identity between Syrian hamster GSTYc, rat GST Yc1 and Yc2 and mouse GSTYc. Northern-blot experiments demonstrated that Syrian hamster GSTYc expression is tissue-specific. A GSTYc mRNA of approx. 1 kb is expressed in liver, kidney, vas deferens and epididymis. Expression of the GSTYc transcript was not detected in testis or uterus.

Estrogen-induced proto-oncogene and suppressor gene expression in the hamster kidney: significance for estrogen carcinogenesis

Chronic administration of estrogen to male Syrian hamsters for 7.0 to 9.0 months induces a high frequency of estrogen-dependent renal cancers. We have proposed a sequential multistage scheme involving tubular cell damage, regenerative cell proliferation, aneuploidy, chromosomal imbalance, genetic instability, gene alteration, and amplification as essential steps for estrogen carcinogenesis in this model. A systematic study was undertaken to assess the expression of nuclear proto-oncogenes, c-myc, c-fos, and c-jun, and suppressor genes, p53 and WT-1, by Northern blot analysis to further support this scheme. Hamster kidney RNA, taken at monthly intervals (1.0 to 6.0 months) from diethylstilbestrol (DES)-treated castrated male hamsters and corresponding age-matched untreated controls was used in these studies, as well as primary estrogen-induced renal tumor RNA, for reference. Although no significant changes in the expression of these proto-oncogenes were detected in the first 4 months of estrogen treatment relative to age-matched controls, 2.1-kb c-myc expression was elevated 2.8- and 4.1-fold at 5.0 and 6.0 months, respectively. Moreover, the expression of 2.2-kb c-fos transcript rose 4.6- and 4.8-fold; and 3.2- and 2.7-kb c-jun expression increased 2.8- and 5.1-fold at these same respective estrogen treatment time intervals. Tumor suppressor gene expression, p53 and WT-1, was also evaluated in similar estrogen-exposed hamsters. Although no significant changes were found in hamster kidney p53 expression in the first 5.0 months of DES treatment, it rose 1.8-fold at 6.0 months of estrogen treatment and more than 2.0-fold in the primary renal tumor. In contrast, no detectable changes in WT-1 expression were found during the first 6.0 months of DES treatment. However, a dramatic 7.0-fold increase in WT-1 expression was observed in the primary renal tumor. It is evident that two WT-1 transcripts reside in the hamster kidney; a lower molecular weight transcript was found in the normal adult kidney, and a higher molecular weight 3.2-kb transcript was observed in the renal tumor, similar to that seen in the newborn mouse kidney. In summary, the estrogen-induced inappropriate gene expression, including p53, reported herein, is consistent with the view that the elevations seen in gene expression contribute to proliferative advantages of certain proximal tubular interstitial cells necessary for estrogen-driven tumor formation in the hamster.

Carcinogenic activities of various steroidal and nonsteroidal estrogens in the hamster kidney: relation to hormonal activity and cell proliferation

The therapeutic use of estrogens has been associated with an increased risk of some of the most predominant, as well as less prevalent, cancers in women. The estrogen-induced renal tumor is one of the primary animal models to evaluate the carcinogenic properties of estrogens. Correlations were made with various estrogens by using parameters of estrogenicity end points such as competitive binding, progesterone receptor induction, and alterations in prolactin levels; in vitro renal proximal cell proliferation; and in vivo estrogen-induced carcinogenicity. The most potent estrogens were Moxestrol (MOX), diethylstilbestrol (DES), and 17 beta-estradiol, followed by indenestrol B, 16 alpha-hydroxyestrone, and 11 beta-methoxyestradiol with moderate estrogenic activities, whereas 11 beta-methylestradiol, 17 alpha-estradiol, indanestrol, and deoxoestrone were all relatively weaker. As expected, hydrolyzed Premarin (unconjugated estrogens) was strongly estrogenic. Of the estrogens tested, MOX was the most potent carcinogenic estrogen in the hamster kidney. Both 16 alpha-hydroxyestrone and 11 beta-methoxyestradiol induced intermediate tumor incidences with distinctly lower frequencies of renal tumor foci compared to the most potent carcinogenic estrogens. However, hamsters treated for 9.0 months with 11 beta-methylestradiol, 17 alpha-estradiol, deoxoestrone, and indanestrol exhibited no tumors. In contrast, treatment with estrone, equilin plus d-equilenin, and hydrolyzed Premarin for the same time period resulted in 100% renal tumor incidences and numerous tumor foci. Cell proliferation studies of cultured hamster kidney proximal tubule cells were carried out at varying estrogen concentrations (0.01-100 nM). Exposure to MOX resulted in consistently high renal cell proliferative response over a concentration range of 0.1-10 nM. Strongly carcinogenic estrogens such as estrone had a maximal renal cell proliferation response (2.4-fold above untreated control levels) between 0.1 and 10 nM, DES and 17 beta-estradiol responded at 1.0 nM, and 4-hydroxyestradiol responded at 10 nM. Interestingly, exposure to ethinylestradiol, a potent estrogen, at similar or higher doses as those used for DES and 17 beta-estradiol, yielded only a 10% renal tumor incidence and induced only a 1.7-fold increase in proximal tubule cell proliferation. In contrast, 17 alpha-estradiol, deoxoestrone, indanestrol, and 11 beta-methylestradiol, all weakly estrogenic and noncarcinogenic agents, had relatively little effect on tubule cell proliferation. The hydrolyzed Premarin exhibited a maximal 2.0-fold cell proliferative response at 10 nM. The present results provide clear evidence that, in the hamster kidney, the degree of carcinogenicity of a given estrogen correlates with its ability to induce proximal tubule cell proliferation in vitro.(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of parental alcoholism and life stress on Hispanic and Non-Hispanic Caucasian adolescents: a prospective study

Investigated ethnicity and parental alcoholism as factors that might influence the stress vulnerability of adolescents. It extended an initial cross-sectional study of this same sample by adding two annual assessments which allowed for additional cross-sectional analyses and longitudinal tests. Hispanic and Caucasian adolescents (N = 306 at Time 1) completed measures of their own life stress, family conflict, and alcohol use. Their parents reported on adolescents' internalizing and externalizing symptoms. Cross-sectional analyses at Time 2, and prospective analyses involving Time 1 and Time 2 measures were, for the most part, consistent with the original study's results. Caucasian adolescents and children of alcoholic parents appeared to be more vulnerable to stress than Hispanic adolescents and children of nonalcoholic parents. Family conflict was a partial explanation for this increased vulnerability.

Induction of chromosome aberrations in Syrian hamster renal cortical cells by various estrogens

Estrogens, both natural and synthetic, have been implicated in carcinogenesis at different organ sites in a variety of animals, including man, for more than six decades. However, the molecular mechanism(s) involved in the carcinogenic action of estrogens still remains both controversial and elusive. Cytogenetic damage in the hamster kidney has been studied after in vivo treatment with either potent or weak estrogens for varying periods. Compared to age-matched untreated control, diethylstilbestrol (DES) treatment resulted in significant increases in the number of chromatid gaps and breaks, chromosome breaks, and endoreduplicated cells in hamster renal cortical cells. These chromosomal aberrations (CA) were cumulative with continued hormone exposure from 1.0 to 5.0 months. However, chromosome exchanges as a result of the breaks were not elevated. After 5.0 months of hormone treatment, potent estrogens such as 17 beta-estradiol and Moxestrol exhibited similar frequencies of CA in the hamster kidney to that found for DES, whereas weak estrogens such as 17 alpha-estradiol and beta-dienestrol exhibited CA frequencies that were not significantly different from untreated levels. Ethinylestradiol treatment for a similar period resulted in significant increases in chromatid gaps, although these did not evolve into increases in either chromatid or chromosome breaks, and in a rise in endoreduplicated cells. These results raise the possibility that the CA generated after estrogen treatment may be involved in renal tumorigenic processes.

Serum and tissue levels of estradiol during estrogen-induced renal tumorigenesis in the Syrian hamster

The estrogen-induced renal tumor in the hamster has emerged as a major animal model in hormonal carcinogenesis. However, a fundamental aspect of this experimental model has as yet not been investigated. In the present study, comparisons between the serum and tissue 17 beta-estradiol (E2) levels in cyclic female hamsters and corresponding hormone levels in E2-treated castrated male hamsters have been made. Data is provided concerning the concentration of estrogenic hormones in the serum and target tissue typically required to elicit renal tumorigenesis in this species. Serum E2 levels in the cyclic female hamster average 79 pg/ml on days 1-2 and 311 pg/ml on days 3-4, attaining a maximum of 358 pg/ml on day 4 of the cycle. Elevation in uterine, renal and hepatic E2 tissue levels during days 3-4 of the cycle reflect increases in serum E2 levels which were 3.0-, 2.0-, and 2.6-fold higher when compared to day 1 of the cycle in these tissues. As expected, serum E2 levels of untreated castrated male hamsters did not appreciably vary over a 6 month period of aging and averaged about 32 pg/ml. Under conditions which produced essentially 100% renal tumor incidence, a rapid rise in serum E2 levels, averaging 71.0-fold higher than untreated castrated levels, was seen. A steady state serum E2 level of 2400 to 2700 pg/ml was maintained from 45-180 days of continuous estrogen treatment. Compared to kidneys of untreated hamsters, renal E2 levels in E2-treated hamsters rose only on average 5.4-fold between 15-180 days of hormone exposure. Serum levels of E2-treated hamsters were 5.7- to 8.0-fold higher than those observed in cyclic female hamsters on days 3 and 4. However, at these higher E2-treated serum levels there was no apparent effect either on weight loss or mortality of the animals.

Estrogen carcinogenesis in the hamster kidney: role of cytotoxicity and cell proliferation

Both natural and synthetic estrogens are capable of inducing renal neoplasms in Syrian hamsters with an incidence approaching 100%. Neither the sequence of events nor the mechanisms involved in estrogen carcinogenesis in this model have been established. Results presented here indicate that estrogen induces renal tubular damage in the hamster kidney that is progressive and cumulative. Tubular injury was evident both as abnormal or lost microvilli, accumulation of cytoplasmic lipid droplets, vacuolization, and increases in secondary and tertiary lysosomes after 1.5 months of diethylstilbestrol (DES) treatment. Increasing tubular damage was evidence by the detachment of tubular cells, cell debris, and occluded renal tubular lumens. In an effort to repair proximal tubular damage in the hamster kidney elicited by estrogens, a 4.0-fold increase in proximal tubule BrdU labeling was evident at 4 months of DES or 17 beta-estradiol (E2) treatment and in earlier estrogen treatment periods (1-3 months). During this period, there was a significant increase in aneuploid cells in the hamster kidney, the near diploid frequency increased more than 6.0-fold, and the near tetraploid frequency increased at least 3.0-fold between 1.5 and 3.5 months of estrogen treatment. Based on these data, the early sequence of events leading to estrogen-induced renal neoplastic transformation in the hamster is presented.

Ethnic group differences in vulnerability to parental alcoholism and life stress: a study of Hispanic and non-Hispanic Caucasian adolescents

Tested Hispanic and Caucasian adolescents' vulnerability to parental alcoholism and life stress. Sixty-nine Hispanic and 237 Caucasian adolescents completed measures of life stress, social support, and alcohol use. Their parents reported on the adolescents' psychological symptoms and their own alcohol and substance use. Parental alcoholism and life stress were related to almost all indicators of adolescents' psychological distress and alcohol use. In addition, results showed some evidence that Caucasian adolescents were more vulnerable to the effects of life stress and parental alcoholism than Hispanics. Neither social support nor the higher substance use of Caucasian parents provided a good explanation for this differential vulnerability.