Social Environmental Moderators of Long-Term Functional Outcomes of Early Childhood Brain Injury

Pediatric traumatic brain injury (TBI) contributes to impairments in behavior and academic performance. The objective of this study was to examine the long-term functional outcomes of childhood TBI, which are poorly understood. They also examined the role of the social environment defined by parent report and observational measures of family functioning and home environment. The study included 3 children’s hospitals and 1 general hospital in the Midwest. Patients were enrolled between 2003 and 2006 and follow-ups were between 2010 and 2015. 58 children who sustained a TBI and 72 children who sustained an OI (orthopedic injury) were followed up shortly after injury.

Children with moderate and severe TBI were rated as having more functional impairments than those with OI’s. Children with complicated mild TBI had greater impairments in school and with thinking than those with OI’s. Functional impairments in children with TBI were more pronounced among children from families with higher levels of permissive or authoritarian parenting or with fewer home resources. Even children with relatively mild early TBI experience long-term functional impairments, particularly in the context of less favorable home environments.

This study suggests that improving parenting skills and the quality of home environment may promote functional revovery following early TBI. This can be extremely important for the children’s well-being, especially because they are so young and have their whole life ahead of them. What do you think should be done about this? Should parents be counseled on the importance of nurturing their child after this type of injury? What role should health care professionals play in this touchy circumstance?

JAMA Pediatr. Published online February 22, 2016. doi:10.1001/jamapediatrics.2015.4485

Cognitive Decline in a Colombian Kindred With Autosomal Dominant Alzheimer

Data from autosomal dominant Alzheimer disease (ADAD) kindred were used to track the trajectory of cognitive decline associated with preclinical ADAD and look at factors that may modify the rate of decline. A study was performed from 1995 through 2012 of individuals who tested positive for the ADAD PSEN1 E280A mutation. A total of 493 carriers met the inclusion criteria and were analyzed. At the time of initial assessment, participants had a mean age of 33.4 years. They were mostly female and of low socioeconomic status.

Word list recall scores provided the earliest indicator of preclinical cognitive decline at 32 years of age. Carriers had a significant cognitive decline with a loss of 0.24 points per year for the word list recall test and 2.13 points per year for total scores. Carriers with high educational levels had an increased of 36% in the rate of cognitive decline when compared with those with low educational levels. Onset of cognitive decline was delayed by 3 years in people with higher educational levels. Overall, preclinical cognitive decline was evident in carriers 12 years before the onset of clinical impairment.

I thought this study was really interesting because it pointed out that education level was a factor in cognitive decline. Although the decline was delayed, they had an increase in the rate of decline when it happened. Do you think there is a reason for this? What could we do to better prepare these people for cognitive decline at such an early age? Is genetic testing the answer?

A National Profile of Family and Unpaid Caregivers Who Assist Older Adults With Health Care Activities

Family and unpaid caregivers commonly help older adults who are at high risk for poorly coordinated care. A total of 1739 family and unpaid caregivers of 1171 community-dwelling older adults with disabilities participated in the National Health and Aging Trends Study (NHATS). It wanted to measure the effects (emotional, physical and financial) of caregivers participating in activities.

From this study, the NHATS produced weighted estimates that accounted for the sampling designs. From these estimates, 14.7 million caregivers assisting 7.7 million older adults, 6.5 million (44.1%) provided substantial help while 4.4 million (29.8%) provided some help. Caregivers providing substantial help with health care provided more hours of assistance per week than caregivers providing some or no help. However, caregivers providing substantial help with health care were more likely to experience emotional difficulty, physical difficulty and financial difficulty. Ultimately, family caregivers providing substantial assistance with health care experience significant emotional difficulty.

This study was really interesting because you got to look at it from the caregiver side and not the patient. Not a lot of people think about the effects of taking care of someone every day. I got to see it with my mom taking care of her father when he was really sick and it really took a toll on her. Maybe some of us have seen examples with our own family. Can health care providers really take the place of a family or friend? Is the emotional connection much better with a family member?

JAMA Intern Med. Published online February 15, 2016. doi:10.1001/jamainternmed.2015.7664

Effectiveness of Sun Protection Program for Young Children

I felt this study was important and interesting because it emphasizes sun protection behaviors that may minimize sun damage and lifelong sun protection behaviors that will reduce the likelihood of developing skin cancer. This study was a randomized controlled clinical trial with a 4-week follow-up that included 300 parents who brought their child (2-6 years of age) to a Medical Group clinic. They were randomly assigned to receive a read-along book. swim shirt, and weekly text message reminders related to sun protection behaviors. 147 were randomly assigned to receive the information usually provided at a well-child visit.

Outcomes were caregiver-reported use of sun protection by the child using a 5-point Likert scale, duration of outdoor activities and number of children who had sunburn or skin irritation. Of the 300 caregiver-child pairs, the 153 children in the intervention group had significantly higher scores related to sun protection behaviors. Examination of pigmentary changes revealed that the children in the control group had significantly increased  their melanin levels, whereas the children in the intervention group did not have change.

In conclusion, this intervention was associated with increased sun protection behaviors among young children. Do you think interventions like this could be really helpful? Getting things started in early childhood could really lead to healthy behaviors as adults. This study is really interesting in pointing that out. Also, do you think this study has a flaw in that the results were self-reported? This was a really interesting study in the effects of interventions in young children that could lead to healthy behaviors later in life.

JAMA Pediatr. Published online February 08, 2016. doi:10.1001/jamapediatrics.2015.4373

BRCA Mutation Testing in Young Women With Breast Cancer

In young women diagnosed with breast cancer, BRCA testing is recommended. This study looked at the decisions surrounding testing and how results may influence treatment decisions. The study’s objective was to describe the genetic testing and evaluate how concerns about genetic risk affect treatment decisions in these young women. There were 897 women aged 40 years and younger observed that all had a breast cancer diagnosis.

A total of 780 women (87%) reported BRCA testing by 1 year after breast cancer diagnosis. This study took place from the year 2006 to the year 2014. As the years went on, a bigger percentage of women reported testing. For example, in 2006, 30 of 39 women (76.9%) reported testing. In 2008, 141 of 146 women (96.6%) tested. Among the untested women, 43 of 117 (36.8%) were thinking of testing in the future. A total of 248 of 831 women (29.8%) said that knowledge or concern about genetic risk influenced surgical treatment decisions. In conclusion, rates of BRCA mutation testing are increasing in young women with breast cancer. Given that knowledge and concern about genetic risk influences surgical decisions, all women with breast cancer should be counseled and offered genetic testing.

We have started talking a good amount about the genetic role in pharmacy and pharmacotherapy. Do you think that genetic testing, especially in cancer, should be pushed for more? Does this testing actually benefit patients or just get them worried and thinking more? I think genetic testing is a great tool for health professionals to have and we should use it to our advantage as much as possible. The problem is, however, getting the public on board with it. What is the best way to accomplish that?

JAMA Oncol. Published online February 11, 2016. doi:10.1001/jamaoncol.2015.5941

Effectiveness of Patient Monitoring After Discharge of Patients With Heart Failure

This study evaluated the effectiveness of a care transition intervention for patients suffering from heart failure. The study used monitoring in reducing 180-day readmissions among older adults suffering from HF. The intervention combined health coaching telephone calls and telemonitoring that collected daily information about BP, heart rate, symptoms and weight. Registered nurses conducted telemonitoring reviews and telephone calls. The main measure was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days, mortality at 30 and 180 days and quality of life at 30 and 180 days.

There were 1437 participants with a median age of 73 years. Overall, the intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% and 49.2% of patients, respectively. There were also no differences in 30 day readmissions or mortality between the 2 groups. However, there was a significant difference in 180-day quality of life between the intervention and usual care groups. Ultimately, though, health coaching, telephone calls and telemonitoring did not reduce readmissions.

I believe following up with patients and discussing they’re symptoms and collecting information is great for the patient. Honestly, I am not too sure why this didn’t reduce readmissions. You cannot force patients to comply with medications or the doctor’s orders. Would patients benefit from a pharmacist doing the phone calls and coaching? Do you think a lot of the problems patients have with HF at this age are medication related? Personally, I think patients could benefit greatly from a pharmacist doing the follow-ups and information collecting. It would be a great time to assess how the patient is doing with their medication regimen and to see if they can help in any way or discuss any problems.

JAMA Intern Med. Published online February 08, 2016. doi:10.1001/jamainternmed.2015.7712

Genetic Risks for Weight Gain in Early Childhood

This study looked at genetic risks and the development of obesity by accelerating weight gain in childhood. This type of research is needed to identify ways to inform intervention. Also, longitudinal studies, as this study is, are helpful in determining if appetite traits mediate genetic influences on weight gain. Participants were enrolled at age 4 (995 children) with follow-ups at ages 6 (795 children) and 8 (699 children). children at higher genetic risk for obesity had higher baseline body mass index and fat mass compared with lower genetic risk peers. They also gained weight and fat mass more rapidly during follow-up. Each standard deviation increase in genetic risk score was associated with a 0.22 point increase in BMI at age 4 baseline. Children with higher genetic risk scores gained BMI points more rapidly from ages 4 to 6.

The conclusion in this study was that genetic risk for obesity is associated with accelerated childhood weight gain. Another interesting point in this study is that children at higher genetic risk also had higher levels of obesogenic appetite trait, but these traits did not have association with weight gain.

I think there are some questions we can ask and take away from this. Is there any way to overcome genetics? Is trying to eat healthier and exercising not worth it if you have bad genetics in the first place? Most importantly, how can we as pharmacists help in educating families of overweight young children? Childhood obesity can lead to disease states such as diabetes which is a huge problem in this country. What role can we play?

JAMA Pediatr. 2016; 170(2)

End of Life Infection Care

A lot of patients in the final stages of life face complicated decisions on their medical care and what should be treated. Infections are one of the most prevalent complications that these patients experience. A lot of clinicians prescribe antimicrobials in the weeks leading up to death. According to the article, 90% of cancer patients are prescribed these medications during the week prior to death. There are risks and benefits associated with prescribing antimicrobials to these patients when they are so close to death. Risks include drug reactions and interactions, the burden of treating more symptoms when the patient is terminally ill, and contributing to drug resistance. However, these medications can contribute to prolonged survival and symptom relief.

I think pharmacists can have a huge impact in these type of situations. Pharmacists, in my opinion, may be the best suited for these decisions and can help physicians make an informed decision. Will this drug be effective enough in relieving symptoms compared to the risks it poses to the patient? Do these medications interact with any treatment the patient is currently on? Pharmacists can weigh the risks and benefits of all of these questions and help other clinicians make informed decisions. This is an excellent article in showing how pharmacists need to be part of the health care team.

JAMA. 2015;314(19):2017-2018