Brenda Beaty

Newborn screening for HLA markers associated with IDDM: Diabetes Autoimmunity Study in the Young (DAISY)

SummaryAutoimmunity causing insulin-dependent diabetes mellitus (IDDM) begins in early childhood due to interactions between genes and unknown environmental factors that may be identified through follow-up of a large cohort of genetically susceptible children. Such a cohort has been established using a simple and rapid cord blood screening for HLA alleles. The DRB1 and DQB1 second exon sequences were co-amplified using the polymerase chain reaction and hybridized with single and pooled sequence-specific oligonucleotide probes. Four individual probes were used to detect the susceptibility alleles DRB1*03, DRB1*04, and DQBl*0302 as well as the usually protective DRB1*15/16 (DR2) alleles. In addition, pooled probes allow the distinction of DR3/3 from the DR3/x genotype (where x is neither DR2, 3, nor 4) and DR4/4 from DR4/x. Among 5000 newborns from the general Denver population, we have found the high-risk genotype (DRBl*03/ DRB1*04, DQBl*0302) to be present in 2.4% of non-Hispanic whites, 2.8% of Hispanics, and 1.6% of African Americans. The moderate-risk genotypes (DRB1*04, DQBl*0302/DRBl*04, DQB1*0302, DRB1*04, DQBl*0302/x, or DRBl*03/DRBl*03) are present in 17 % of American non-Hispanic whites, 24% of Hispanics and in 10% of African Americans. These results demonstrate the feasibility of a large-scale newborn screening for genes associated with IDDM. The ultimate role for such a screening in future routine prediction and prevention of IDDM will depend on the availability of an effective and acceptable form of clinical intervention.

Predictors of Nonadherence to Screening Colonoscopy

AbstractBACKGROUND: Colonoscopy has become a preferred colorectal cancer (CRC) screening modality. Little is known about why patients who are referred for colonoscopy do not complete the recommended procedures. Prior adherence studies have evaluated colonoscopy only in combination with flexible sigmoidoscopy, failed to differentiate between screening and diagnostic procedures, and have examined cancellations/no-shows, but not nonscheduling, as mechanisms of nonadherence. METHODS: Sociodemographic predictors of screening completion were assessed in a retrospective cohort of 647 patients referred for colonoscopy at a major university hospital. Then, using a qualitative study design, a convenience sample of patients who never completed screening after referral (n=52) was interviewed by telephone, and comparisons in reported reasons for nonadherence were made by gender. RESULTS: Half of all patients referred for colonoscopy failed to complete the procedure, overwhelmingly because of nonscheduling. In multivariable analysis, female sex, younger age, and insurance type predicted poorer adherence. Patient-reported barriers to screening completion included cognitive-emotional factors (e.g., lack of perceived risk for CRC, fear of pain, and concerns about modesty and the bowel preparation), logistic obstacles (e.g., cost, other health problems, and competing demands), and health system barriers (e.g., scheduling challenges, long waiting times). Women reported more concerns about modesty and other aspects of the procedure than men. Only 40% of patients were aware of alternative screening options. CONCLUSIONS: Adherence to screening colonoscopy referrals is suboptimal and may be improved by better communication with patients, counseling to help resolve logistic barriers, and improvements in colonoscopy referral and scheduling mechanisms.

Obstetric anesthesia work force survey, 1981 versus 1992.

Background: In 1981, with support from the American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists, anesthesia and obstetric providers were surveyed to identify the personnel and methods used to provide obstetric anesthesia in the United States. The survey was expanded and repeated in 1992 with support from the same organizations. Methods: Comments and questions from the American Society of Anesthesiologists Committee on Obstetrical Anesthesia and the American College of Obstetricians and Gynecologists Committee on Obstetric Practice were added to the original survey instrument to include newer issues while allowing comparison with data from 1981. Using the American Hospital Association registry of hospitals, hospitals were differentiated by number of births per year (stratum I, >or= to 1,500 births; stratum II, 500–1,499 births; stratum III, < 500 births) and by U.S. census region. A stratified random sample of hospitals was selected. Two copies of the survey were sent to the administrator of each hospital, one for the chief of obstetrics and one for the chief of anesthesiology. Results: Compared with 1981 data, there was an overall reduction in the number of hospitals providing obstetric care (from 4,163 to 3,545), with the decrease occurring in the smallest units (56% of stratum III hospitals in 1981 compared with 45% in 1992). More women received some type of labor analgesia, and there was a 100% increase in the use of epidural analgesia. However, regional analgesia was unavailable in 20% of the smallest hospitals. Spinal analgesia for labor was used in 4% of parturients. In 1981, obstetricians provided 30% of epidural analgesia for labor; they provided only 2% in 1992. Regional anesthesia was used for 78–85% (depending on strata) of patients undergoing cesarean section, resulting in a marked decrease in the use of general anesthesia. Anesthesia for cesarean section was provided by nurse anesthetists without the medical direction of an anesthesiologist in only 4% of stratum I hospitals but in 59% of stratum III hospitals. Anesthesia personnel provided neonatal resuscitation in 10% of cesarean deliveries compared with 23% in 1981. Conclusions: Compared with 1981, analgesia is more often used by parturients during labor, and general anesthesia is used less often in patients having cesarean section deliveries. In the smallest hospitals, regional analgesia for labor is still unavailable to many parturients, and more than one half of anesthetics for cesarean section are provided by nurse anesthetists without medical direction by an anesthesiologist. Obstetricians are less likely to personally provide epidural analgesia for their patients. Anesthesia personnel are less involved in newborn resuscitation.

Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.

OBJECTIVES: The objectives of this study were to assess, in a nationally representative network of pediatricians and family physicians, (1) human papillomavirus (HPV) vaccination practices, (2) perceived barriers to vaccination, and (3) factors associated with whether physicians strongly recommended HPV vaccine to 11- to 12-year-old female patients. METHODS: In January through March 2008, a survey was administered to 429 pediatricians and 419 family physicians. RESULTS: Response rates were 81% for pediatricians and 79% for family physicians. Ninety-eight percent of pediatricians and 88% of family physicians were administering HPV vaccine in their offices (P < .001). Among those physicians, fewer strongly recommended HPV vaccination for 11- to 12-year-old female patients than for older female patients (pediatricians: 57% for 11- to 12-year-old patients and 90% for 13- to 15-year-old patients; P < .001; family physicians: 50% and 86%, respectively; P < .001). The most-frequently reported barriers to HPV vaccination were financial, including vaccine costs and insurance coverage. Factors associated with not strongly recommending HPV vaccine to 11- to 12-year-old female patients included considering it necessary to discuss sexuality before recommending HPV vaccine (risk ratio: 1.27 [95% confidence interval: 1.07–1.51]) and reporting more vaccine refusals among parents of younger versus older adolescents (risk ratio: 2.09 [95% confidence interval: 1.66–2.81]). CONCLUSIONS: Eighteen months after licensure, the vast majority of pediatricians and family physicians reported offering HPV vaccine. Fewer physicians strongly recommended the vaccine for younger adolescents than for older adolescents, and physicians reported financial obstacles to vaccination.

Massage Therapy versus Simple Touch to Improve Pain and Mood in Patients with Advanced Cancer: A Randomized Trial

Context Some patients nearing death seek pain relief with massage, but little is known about the effectiveness of massage in managing pain in palliative care settings. Contribution In this randomized trial in 380 patients with advanced cancer, improvement in pain and mood immediately after treatment was greater with massage than with simple touch. Unfortunately, there were no sustained differences in pain, quality of life, or analgesic use during 3 weeks. Adverse effects were infrequent and similar in both groups. Implication Massage may offer some immediate relief for patients with advanced cancer, but the absence of sustained effects demonstrates the need for more effective strategies to manage pain at the end of life. The Editors Symptom relief is central to end-of-life care; however, many terminally ill individuals experience serious pain and other physical and emotional symptoms (14). Studies examining the efficacy of therapies that may mediate these symptoms deserve the highest priority. The Institute of Medicine and the National Institutes of Health recommend research directed at improving end-of-life care (5, 6). Pain associated with advanced cancer can cause physical and emotional distress, leading to decreased functional ability and quality of life. Massage may interrupt the cycle of distress through the therapists intention (presence, communication, and desire to produce a therapeutic response), induction of a relaxation response, increased blood and lymphatic circulation, potentiation of analgesic effects, decreased inflammation and edema, manual release of muscle spasms, increased endogenous endorphin release, and competing sensory stimuli that override pain signals (711). Despite theoretical bases supporting the use and growing acceptance of massage therapy, few randomized clinical trials have assessed its efficacy. Large trials have been difficult to design and carry out; challenges include frailty of patients with late-stage cancer and reluctance of health care providers to refer patients because of the possibility of randomization to nonmassage therapy control (12). Therapeutic massage can reduce pain and improve symptom distress and quality of life for patients with cancer at the end of life. The purpose of the REST (Reducing End-of-Life Symptoms with Touch) study was to evaluate the efficacy of massage compared with an exposure controlling for time, attention, and touch. We hypothesized that massage would decrease pain and explored effects on quality of life, physical and emotional symptom distress, and analgesic medicine use. Methods Design Overview We conducted this prospective, 2-group, randomized, single-blind trial between November 2003 and October 2006. After we evaluated patients for inclusion and exclusion criteria, patients provided written informed consent. Then we randomly assigned patients to a treatment group (massage) or control exposure (simple touch). Figure 1 depicts the timing of the study procedures for a hypothetical participant. We collected individual characteristics, disease, pain characteristics, symptom distress, quality of life, functional status (Karnofsky Performance Scale score) (13), expected helpfulness of massage for pain, and concurrent interventions (pharmacologic and nonpharmacologic) at baseline (within 72 hours of study enrollment) and at 3 subsequent weekly visits over the 3 to 4 weeks of participation (sustained outcomes). Final data collection occurred approximately 1 week after the final treatment. Data collectors were blinded to treatment assignment. Participants received up to six 30-minute treatments over 2 weeks, with at least 24 hours between treatment sessions. The initial treatment session occurred within 48 hours of baseline data collection. The treatment provider and patient determined the scheduling of treatment sessions. Treatment providers who were not blinded to treatment assignment obtained the immediate outcomes just before and after every treatment session. All participants received routine care in addition to the specified interventions. The Colorado Multiple Institutional Review Board and, where applicable, site-specific institutional review boards approved the study. Figure 1. Study overview: timing of study procedures. Setting and Participants Study sites included 15 U.S. hospices that are members of the Population-based Palliative Care Research Network (PoPCRN) (14) and the University of Colorado Cancer Center, Aurora, Colorado. Eligible participants were English-speaking adults with advanced cancer (stage III or IV, all cancer types, any care setting) who had at least moderate pain (score 4 on a 0- to 10-point scale) in the week before enrollment, an anticipated life expectancy of at least 3 weeks, and the ability to consent. Exclusion criteria included receipt of professional massage within 1 month of enrollment, anticoagulant therapy, known platelet count less than 10109 cells/L, or known unstable spine. Randomization and Interventions Verification of eligibility was forwarded by a study coordinator from each study site to the University of Colorado researchers. Two designated investigators randomly assigned patients; assignments were transmitted back to the requesting site. All study personnel other than the on-site study coordinators and these 2 designated investigators were blinded to the randomization sequence. An SAS software program (SAS Institute, Cary, North Carolina) generated the randomization sequence by producing a randomized block design stratified by study site. Block size randomly varied among 2, 4, and 6 so that it was not possible to predict the next assignment. To minimize the likelihood that potential participants would decline enrollment because of reluctance to be randomly assigned, we offered massage after study completion to those assigned to the control group. Experimental Treatment: Massage Therapy The massage intervention included gentle effleurage, petrissage, and myofascial trigger point release. Effleurage is a smooth, gliding stroke; petrissage is squeezing, rolling, and kneading the muscles; and trigger point release provides concentrated finger pressure to painful localized areas in muscles to break cycles of spasm and pain (15). Individual therapist judgment dictated the frequency of rhythm, rate, or stroke; sequence or mix of strokes; time spent in each stroke; stroke length; and body area massaged (16). Massage therapists spent 65% of the time in effleurage and 35% in petrissage. The most frequently massaged areas of the body were the neck and upper back (about 80% of the time) and arms, hands, lower legs, and feet (about 75% of the time). Other areas, such as the chest, abdomen, buttocks, back of the thighs, and forehead were massaged less than 50% of the time. Therapists appropriately modified massage in persons with skin fragility, postural limitations, edema, osteoporosis, or bone metastasis. Therapists avoided sites of inflammation or infection, hyperesthesias, injury, surgery, ports, catheters, deep venous thrombosis, and tumors. Therapists identified and treated up to 3 myofascial trigger points per session (located 15% to 25% of the time in the neck, upper trapezius, and lower trapezius regions). One half of the sessions were provided with the patient supine, 25% seated, and the remainder split between side-lying and prone positions. Temperature and level of privacy varied with setting. Fewer than 25% of participants were unclothed during treatments. Massage was performed by licensed massage therapists who had at least 6 months of experience treating patients with advanced cancer or hospice patients and completed a minimum 500-hour program of study in massage from an institution recognized by their state as a vocational school. Control Exposure We designed the control exposure, simple touch, to control for the time, attention, touch, and healing intent components of the intervention (17). The control consisted of placement of both hands on the participant for 3 minutes at each of the following locations bilaterally: base of neck, shoulder blades, lower back, calves, heels, clavicles, lower arms, hands, patellae, and feet. Pressure was light and consistent, with no side-to-side hand movement. Control therapy providers interrupted conscious healing intention by silently counting backward from 100 by 7, reciting nursery rhymes, or planning their days activities (18, 19). The control treatments were provided by individuals with no past body or energy work experience. All treatment providers participated in standardized hands-on training, received a study manual and training video, and were evaluated for competency in study procedures. We monitored adherence to study protocols during twice-yearly site visits. Treatment providers in both groups used Biotone hypoallergenic unscented massage cream (Biotone, San Diego, California). For the purposes of standardization and to mediate the presence of intervening variables, we did not permit music, essential oils, or energy work and instructed treatment providers to limit their communication to providing instructions or responding to therapy-related questions. To minimize variation by treatment provider, 1 primary massage therapist or simple-touch provider per participant at each study site administered study treatments. Outcomes and Follow-up We used face-to-face, interviewer-administered questionnaires to collect all study data. We measured neuropathic pain at baseline only by the Neuropathy Pain Scale (0- to 10-point scale), which is sensitive to pain qualities most common to neuropathic pain syndromes (20, 21). Presence of neuropathic pain was defined as a Neuropathy Pain Scale summary score greater than 3. Primary Outcomes: Immediate and Sustained Change in Pain The immediate effect was measured by the pain intensity scale of the Memorial Pain Assessment Card (MPAC) (0 to 10 points; 10 = worst pain) (22). The sustained effect was measured b

A National Survey of Pediatrician Knowledge and Attitudes Regarding Human Papillomavirus Vaccination

OBJECTIVE. A human papillomavirus vaccine was licensed in June 2006. The vaccine is quadrivalent, protecting against 2 human papillomavirus strains that cause cervical cancer and 2 that cause genital warts. The objective of this study was to determine physician characteristics, knowledge, and attitudes associated with an intention to recommend human papillomavirus vaccination. METHODS. Between August and October 2005, a cross-sectional survey was administered to a national network of 431 pediatricians. The network was developed from a random sample of American Academy of Pediatrics members and was designed to be representative of the organization’s membership with respect to urban/rural location, practice type, and region. The survey was conducted before human papillomavirus vaccine licensure and therefore focused on a candidate quadrivalent human papillomavirus vaccine and a range of potential vaccination recommendations. The main outcome measure was intention to recommend a quadrivalent human papillomavirus vaccine to young adolescent (10- to 12-year-old) females. RESULTS. Survey response rate was 68%. If endorsed by national health organizations, 46% of respondents would recommend vaccination for 10- to 12-year-old females, 77% for 13- to 15-year-old females, and 89% for 16- to 18-year-old females. Corresponding rates for males were 37%, 67%, and 82%, respectively. Whereas 60% of respondents thought that parents would be concerned that human papillomavirus vaccination may encourage risky sexual behaviors, 11% reported that they themselves had this concern. Respondents who believed that other new adolescent immunization recommendations (eg, meningococcal, pertussis) would facilitate human papillomavirus vaccine implementation were more likely to intend to recommend vaccination. CONCLUSIONS. Although a national sample of pediatricians expressed a high level of acceptance of human papillomavirus vaccination in older adolescent females, fewer than one half anticipated giving human papillomavirus vaccine to younger female patients. Provider concerns about parental vaccine acceptance will need to be addressed to optimize human papillomavirus vaccination implementation.

School-Based Health Centers: Improving Access and Quality of Care for Low-Income Adolescents

OBJECTIVES. We sought to compare visit rates, emergency care use, and markers of quality of care between adolescents who use school-based health centers and those who use other community centers within a safety-net health care system for low-income and uninsured patients. PATIENTS AND METHODS. In this retrospective cohort study we used Denver Health electronic medical chart data, the Denver Health immunization registry, and Denver Public Schools enrollment data for the period from August 1, 2002, to July 31, 2003. The cohort included all 14- to 17-year-old Denver Public Schools high school enrollees who were active Denver Health patients and were either uninsured or insured by Medicaid or the State Childrens Health Insurance Program. “School-based health center users” were those who had used a Denver Health school-based health center; “other users” were those who had used a Denver Health community clinic but not a school-based health center. Markers of quality included having a health maintenance visit and receipt of an influenza vaccine, tetanus booster, and hepatitis B vaccine if indicated. Multiple logistic regression analysis that controlled for gender, race/ethnicity, insurance status, chronic illness, and visit rate was used to compare school-based health center users to other users. RESULTS. Although school-based health center users (n = 790) were less likely than other users (n = 925) to be insured (37% vs 73%), they were more likely to have made ≥3 primary care visits (52% vs 34%), less likely to have used emergency care (17% vs 34%), and more likely to have received a health maintenance visit (47% vs 33%), an influenza vaccine (45% vs 18%), a tetanus booster (33% vs 21%), and a hepatitis B vaccine (46% vs 20%). CONCLUSIONS. These findings suggest that, within a safety-net system, school-based health centers augment access to care and quality of care for underserved adolescents compared with traditional outpatient care sites.

Influenza Among Healthy Young Children: Changes in Parental Attitudes and Predictors of Immunization During the 2003 to 2004 Influenza Season

BACKGROUND. In Colorado, the 2003 to 2004 influenza season was unusually early and severe and received substantial media attention. OBJECTIVES. Among parents of healthy young children, to determine how parental knowledge and attitudes regarding influenza infection and immunization changed during the 2003 to 2004 influenza season and to identify factors predictive of influenza immunization. METHODS. The study was conducted in 5 metropolitan Denver pediatric practices. A total of 839 healthy children age 6 to 21 months and their parents were randomly selected for participation. Parents were surveyed by telephone before (August 18 to October 7, 2003) and after (March 31 to June 10, 2004) the influenza season. RESULTS. Among 828 eligible parents, 472 (57%) completed the preseason survey; 316 (67%) of these parents subsequently completed the postseason survey. All analyses were performed for the 316 subjects who completed both preseason and postseason surveys. Compared with their attitudes before the influenza season, 48% of parents interviewed after the season viewed their child as more susceptible to influenza, 58% viewed influenza infections as more severe, and 66% perceived fewer risks associated with influenza vaccine. Ninety-five percent of parents reported hearing in the media about Colorado’s influenza outbreak, and having heard about the outbreak in the media was associated with viewing influenza infections as more severe. A total of 258 parents (82%) immunized their child against influenza. In multivariate analyses, positive predictors of immunization included a physician recommendation for immunization and a preseason to postseason increase in the perception that immunization was the social norm. Negative predictors of immunization included high perceived barriers to immunization, less parental education, and preseason intention not to immunize. CONCLUSIONS. Parent attitudes about influenza infection and immunization changed substantially during the 2003 to 2004 influenza season, with changes favoring increased parental acceptance of influenza vaccination for young children. During an intensively publicized influenza outbreak, a physician recommendation of vaccination was an important predictor of influenza immunization.

Marriage and ethnicity predict treatment in localized prostate carcinoma

Primary treatment for early‐stage prostate carcinoma includes expectant management or, for curative intent, radical prostatectomy or radiotherapy. Treatment recommendations are generally guided by clinical factors such as Gleason grade, prostate‐specific antigen level, comorbid illnesses, and patient age. Sociocultural factors may also have influences on patient and urologist treatment choices.

Barriers to the Use of Herpes Zoster Vaccine

BACKGROUND The herpes zoster vaccine is the most expensive vaccine recommended for older adults and the first vaccine to be reimbursed through Medicare Part D. Early uptake has been 2% to 7% nationally. OBJECTIVE To assess current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination among general internists and family medicine physicians. DESIGN Mail and Internet-based survey, designed through an iterative process and conceptually based on the Health Belief Model. SETTING National survey conducted from July to September 2008. PARTICIPANTS General internists and family medicine physicians. MEASUREMENTS Survey responses on current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination. RESULTS Response rates were 72% in both specialties (301 general internists and 297 family medicine physicians). Physicians in both specialties reported similar methods for delivering vaccine, which included stocking and administering the vaccine in their offices (49%), referring patients to a pharmacy to purchase the vaccine and bring it back to the office for administration (36%), and referring patients to a pharmacy for vaccine administration (33%). Eighty-eight percent of providers recommend herpes zoster vaccine and 41% strongly recommend it, compared with more than 90% who strongly recommend influenza and pneumococcal vaccines. For physicians in both specialties, the most frequently reported barriers to vaccination were financial. Only 45% of respondents knew that herpes zoster vaccine is reimbursed through Medicare Part D. Of respondents who began administering herpes zoster vaccine in their office, 12% stopped because of cost and reimbursement issues. LIMITATIONS Survey results represent reported but not observed practice. Surveyed providers may not be representative of all providers. CONCLUSION Physicians are making efforts to provide herpes zoster vaccine but are hampered by barriers, particularly financial ones. Efforts to facilitate the financing of herpes zoster vaccine could help increase its use. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention.