Brown Medical Research Articles

Cancer survivorship care plans time and effort.

146 Background: The Lifespan Cancer Institute (LCI) is one program based at three hospitals in the Lifespan healthcare system, a main teaching affiliate of Brown Medical School. All sites are ASCO QOPI certified. In 2017, 1,742 patients from radiation, surgical, and medical oncology were diagnosed and/or treated for cancer. The Commission on Cancer guidelines specify patients with a new diagnosis of cancer treated with curative intent receive a survivorship care plan (SCP) within one year of diagnosis extended to 18 months for those receiving hormone therapy. Methods: The LCI Quality team is a multidisciplinary group comprised of nursing, leadership, physicians, midlevel providers, administrative assistants, and tumor registry staff. Our Quality Improvement Project for 2017 was generation and distribution of survivorship care plans to 50% of eligible patients. Our project underwent 5 plan/do/study/act cycles (PDSA). Prior to the intervention only 271 care plans were prepared and delivered for 2016 diagnoses. Results: For the total 2017 diagnoses, 843 eligible patients were treated within the LCI (medical and radiation oncology). Survivorship Care plans completed by midlevel providers were generated and distributed to 100% of LCI patients during January -April 2018 (244 in total), a 37% increase compared to the same timeframe, one year previous. The electronic medical record provides tools for SCP preparation including auto population of demographics and chemotherapy plan. Staging, radiation, and surgery are manually entered. On average, each SCP required 1 hour to complete for approximately 244 hours of midlevel provider time for January -April 2018. This abstract’s time and effort does not include the time for patient calls, survivorship visits or administrative monitoring. Conclusions: Survivorship care plans provide patients and primary care providers a summary of the treatment plan and recommendations for follow up/survivorship goals in transitions of care. Significant time and effort is required to generate an individual SCP therefore the goal should be to increase electronic efficiencies within the medical record, and focus on the clinically relevant patient population who are most likely to survive 5 years and be impacted by diagnosis and treatment.

A model for increasing access to behavioral health services in low‐ and middle‐income countries

This month's commentary comes to you from Eldoret, Kenya, where a group of child clinical psychologists and child and adolescent psychiatry fellows from Brown Medical School are completing a rotation in global mental health. We are collaborating with Kenyan colleagues in the Psychiatry and Behavioral Sciences Department at the Moi University School of Medicine, learning about providing mental health services in resource‐poor settings, and hoping to provide some training in treatments that are more commonly provided in the United States.

Economic order quantity - a tool for inventory management - a case study

Inventory refers to the stock of the products, a firm is offering for sale and the stock of sub-components that make up the product. In this research, the economic order quantity method for inventory management is used. In inventory management, economic order quantity (EOQ) is the order quantity that minimises the order quantity, ordering cost, number of orders, total annual cost, carrying cost, order size and average inventory. The purpose of this model is to decide order quantity and reorder point. This research goes throughout the process of analyse the company's current forecasting model and recommends an inventory control model. Order quantity and reorder point was recommended to reduce product inventory. In this work, a case study has been done for optimal inventory control, applied to B. Brown Medical India Pvt. Ltd. The researcher analyses a single product inventory in which cyclic review of inventory control, where separate unsystematic demand may be satisfied. A numerical study is provided to add insight into the results.

Prozac Author Calls for Reassessment of Clinical Trial Efficacy

Clinical Researcher ’s editor-in-chief interviews Peter Kramer, author of the controversial Listening to Prozac , about his new book, Ordinarily Well: The Case for Antidepressants , in which the psychiatrist and Brown Medical School professor challenges some current thinking regarding the testing and efficacy of antidepressants.

How Important is Radiofrequency Ablation in Lung Cancer?

Terrance T Healey is the director of Thoracic Radiology at Rhode Island Hospital (RI, USA) and an Assistant Professor of Diagnostic Imaging at the Alpert Medical School of Brown University (RI, USA). Healey received his medical degree from the combined Dartmouth Medical School–Brown Medical School Program in 2003, completed his residency in radiology at Brown University in 2008 and a thoracic radiology fellowship at the Massachusetts General Hospital (MA, USA) in 2009. He joined the faculty staff at Rhode Island Hospital and Brown University in 2009. Robert C Ward is one of the chief residents within the Department of Diagnostic Imaging at Rhode Island Hospital (RI, USA) and the Alpert Medical School of Brown University (RI, USA). Ward received his medical degree from the George Washington University (Washington, DC, USA) in 2010. Damian E Dupuy is the director of Tumor Ablation at Rhode Island Hospital (RI, USA) and a Professor of Diagnostic Imaging at The Warren Alpert Medical School of Brown University (RI, USA). Dupuy received his medical degree from the University of Massachusetts Medical School (MA, USA) in 1988 and completed his residency in radiology at The New England Deaconess Hospital (MA, USA) and Harvard Medical School (MA, USA) in 1993. After residency, Dupuy joined the staff at Massachusetts General Hospital (MA, USA) where he worked in the Abdominal Imaging and Bone and Joint Divisions. In 1997, Dupuy joined the Department of Diagnostic Imaging at Rhode Island Hospital and Brown University. Dupuy, a pioneer in the use of image-guided ablation, helped broaden clinical applications to successfully combat cancer involving the kidney, liver, lung, head and neck, adrenal gland and skeleton. Other newer technologies, such as percutaneous microwave ablation, cryoablation and combination therapies using radiofrequency ablation with external radiation or brachytherapy, have been pioneered by Dupuy who has been the principal investigator of two National Cancer Institute-funded multicenter trials. Dupuy has received national awards for research and teaching from the American College of Radiology Imaging Network and the Radiological Society of North America where he is currently the Chair of the Interventional Oncology Symposium featured at the Annual Meeting of the Radiological Society of North America and a Fellow of the American College of Radiology. Dupuy is a member of the Radiological Society of North America, The New England Roentgen Ray Society, The American College of Radiology, Rhode Island Radiological Society and the Society of Interventional Radiology. Dupuy has published over 150 publications and given over 120 invited lectures in the field of radiology and image-guided ablation, both nationally and internationally.

Weight Loss Prevents Urinary Incontinence in Women With Type 2 Diabetes: Results From the Look AHEAD Trial

We determined the effect of weight loss on the prevalence, incidence and resolution of weekly or more frequent urinary incontinence in overweight/obese women with type 2 diabetes after 1 year of intervention in the Look AHEAD (Action for Health in Diabetes) trial. Women in this substudy (2,739, mean ± SD age 57.9 ± 6.8 years, body mass index 36.5 ± 6.1 kg/m(2)) were randomized into an intensive lifestyle weight loss intervention or a diabetes support and education control condition. At baseline 27% of participants reported urinary incontinence on a validated questionnaire (no significant difference by intensive lifestyle intervention vs diabetes support and education). After 1 year of intervention the intensive lifestyle intervention group in this substudy lost 7.7 ± 7.0 vs 0.7 ± 5.0 kg in the diabetes support and education group. At 1 year fewer women in the intensive lifestyle intervention group reported urinary incontinence (25.3% vs 28.6% in the diabetes support and education group, p = 0.05). Among participants without urinary incontinence at baseline 10.5% of intensive lifestyle intervention and 14.0% of diabetes support and education participants experienced urinary incontinence after 1 year (p = 0.02). There were no significant group differences in the resolution of urinary incontinence (p >0.17). Each kg of weight lost was associated with a 3% reduction in the odds of urinary incontinence developing (p = 0.01), and weight losses of 5% to 10% reduced these odds by 47% (p = 0.002). Moderate weight loss reduced the incidence but did not improve the resolution rates of urinary incontinence at 1 year among overweight/obese women with type 2 diabetes. Weight loss interventions should be considered for the prevention of urinary incontinence in overweight/obese women with diabetes.

Integrating and Evaluating Geriatrics in Medical School: A Novel Approach for the Challenge

Brown Medical School developed a comprehensive curriculum in which enriched aging content increased from 22 to 80 hours in preclerkship courses and was also added for clerkships, residencies, and nongeriatrician physicians. Innovative evaluation strategies are also described. Highlights include “treasure hunts” in the anatomy laboratory, a Scholarly Concentration in Aging, Schwartz Communication Sessions, a Website of aging-related materials, and a monthly column in the state medical journal. Evaluation includes “tracking” to compute the “dose” of aging content, and “journaling” and focus groups to evaluate students' responses. Integrating geriatrics across a broad range of courses and clinical experiences is feasible.

Psychogenic Nonepileptic Seizures (Pseudoseizures)

1. Hema Patel, MD* 2. David W. Dunn, MD*† 3. Joan K. Austin, PhD, RN§ 4. Julia L. Doss, PsyD‡ 5. W. Curt LaFrance Jr, MD, MPH** 6. Sigita Plioplys, MD§§ 7. Rochelle Caplan, MD†† 1. *Section of Child Neurology, Department of Neurology, Indiana University School of Medicine, Indianapolis, IN. 2. †Section of Child Psychiatry, Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN. 3. §Indiana University School of Nursing, Indianapolis, IN. 4. ‡Minnesota Epilepsy Group, St. Paul, MN. 5. **Department of Neuropsychiatry and Behavioral Neurology, Brown Medical School, Rhode Island Hospital, Providence, RI. 6. §§Department of Psychiatry and Behavioral Sciences, Northwestern University's Feinberg School of Medicine, Chicago, IL. 7. ††Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA. After completing this article, readers should be able to: 1. Recognize the antecedent stressors associated with psychogenic nonepileptic seizures in children. 2. Identify pediatric nonepileptic seizures clinically. 3. Distinguish psychogenic nonepileptic seizures from epileptic seizures and other paroxysmal nonepileptic events. 4. Be aware of the comprehensive assessment needed to evaluate the child who has possible psychogenic nonepileptic seizures. 5. Become familiar with the management approaches used to treat psychogenic nonepileptic seizures in children. Nonepileptic seizures are episodic behavioral events that mimic epileptic seizures but are not associated with abnormal cortical electrical discharges. Psychogenic nonepileptic seizures (PNES) are related to an underlying psychological stressor or conflict and differ from other paroxysmal nonepileptic events. A variety of terms have been used in the literature to describe these events, including hysterical epilepsy, hysteroepilepsy, psychogenic seizures, pseudoepileptic seizures, pseudoseizures, and nonphysiologic or functional seizures. The term psychogenic nonepileptic seizure is preferred because it is nonpejorative and neutral, although there is continuing discussion regarding the most appropriate terminology. PNES are common. Although population data are limited, one report suggested a prevalence of 2 to 33 per 100,000, basing the estimate on an assumption that 10% to 20% of patients seen in an epilepsy center would be found to have PNES. (1) Reviewing video-electroencephalography (EEG) monitoring records, Patel and associates (2) and Wyllie and colleagues (3) found that 3.5% and 7% of children, respectively, seen in clinic for assessment of persistent seizures had PNES. PNES occur in both elementary-age children and in adolescents as well as in all age groups of adults. (2)(3)(4)(5)(6) A female preponderance has been …

Lessons learned from a training collaboration between an Ivy League institution and a historically Black university.

The Miriam Hospital, Brown Medical School, and Jackson State University developed a joint training program for predoctoral, Black psychology students under the auspices of a training grant funded by the National Institutes of Health. The students in the program at Jackson State University had unlimited access to the clinical research resources and mentoring expertise at Brown Medical School. This innovative program began in 2001 and addresses the need for Black leaders in clinical research and academia who will focus on HIV and other infections that disproportionately affect the Black community. This collaboration has served as a bridge between an Ivy League institution and a historically Black university for training in clinical research to develop successful minority academicians.

Human arachnoid membrane: active transport of amyloid-beta

Address: 1Department of Ophthalmology, The Ohio State University, College of Medicine, Columbus, OH 43210, USA, 2Department of Biomedical Engineering Center, The Ohio State University, College of Medicine, Columbus, OH 43210, USA, 3Division of Neuropathology, Dept. of Pathology, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI 02903, USA and 4Clinical Neuroscience, Brown Medical School, Providence, RI 02903, USA

Perceptions of medical malpractice and medical malpractice reform among first- and fourth-year medical students

Comparison of first- and fourth-year medical student perceptions of the U.S. medical malpractice system and their disposition toward reform, and examination of the relationship between school year and other potential correlates of these perceptions. Data derived from 109 students at Brown Medical School who responded to a 2006 web-based survey of attitudes and background characteristics. We report student perceptions stratified by medical school year. We use Mann-Whitney U and chi2 tests to examine the correlates of perceptions and linear regression to examine these in a multivariate context. There were no significant differences in the dispositions of first- and fourth-year students toward the current system (p> or =0.05). However, fourth-year students were more likely to favor screening panels for malpractice cases (82.2% vs. 70.4%) and capping pain and suffering damages (68.9% vs. 55.2%) (both p<0.05). Multivariate results reveal greater concern about malpractice among students intending to specialize in high-risk areas (both p<0.001). Bivariate results reveal greater concern among students with lawyer relatives (p<0.05). First- and fourth-year students had overwhelmingly negative perceptions of the medical malpractice system. This implies attitudes toward malpractice are formed before medical school, with intended specialty and other background characteristics more negatively influencing students' views.

Obesity in Children Untreated for ADHD

The prevalence of overweight in children and adolescents with attention-deficit/hyperactivity was determined by cross-sectional analysis of 62,887 children aged 5 to 17 years from the 2003-2004 National Survey of Children’s Health, in a study at Brown Medical School, Providence, RI.

Reflections on Chemical Dependency in a College Setting and Its Intersection with Secondary School Programs

ABSTRACT For more than 25 years, I served Brown University as Associate Dean with Special Responsibilities in the Area of Chemical Dependency, a long title, but one in which, in those early days, each word had its own political value: the idea of this deanship was without precedent, and questions of turf were a big concern. The status of “associate,” for example, made clear that others of higher rank exercised some authority. (Happily, over the years, my supervision was always supportive, trusting and even distant.) “Special” suggested that my responsibilities did not include medical matters addressed in the Brown Medical School and that still other departments had responsibilities in the alcohol and drug area. “In the area” made clear that my own purview had considerable range—academic affairs, athletics, faculty matters, personnel, student life—and was not merely clinical. At the outset, few—locally or nationally—were paying attention to alcohol and other drug issues on campus. I was a full professor in...

Adolescent Nonsuicidal Self-Injury: Who Is Doing It and Why?

From the Department of Psychiatry and Human Behavior, Weight Control and Diabetes Research Center, Brown Medical School, The Miriam Hospital, Providence, Rhode Island. See related article on page 161. Address correspondence to: Elizabeth E. Lloyd-Richardson, Ph.D., The Miriam Hospital, Weight Control and Diabetes Research Center, 196 Richmond Street, Providence, RI 02903; e-mail: [email protected].

An International Volunteer Program for General Surgery Residents at Brown Medical School: The Tenwek Hospital Africa Experience

Surgicaltrainingprogramsprovidethestructureforyoungphysicians to become thoughtful, responsible, and awareattending surgeons; aware not only of the latest operativetechniques and equipment, but also of the profound soci-etal responsibility that comes with surgical training. Formany years, opportunities have existed for general surgeryresidentstoparticipateinmedicalvolunteerworkinAmer-icaandabroad.Inthepast,complaintsoftimeconstraints,cost, lack of volunteer site supervision, concerns for resi-dent safety, and institutional resident coverage issues werecitedasbarrierstosuchparticipation.Now,thereisagrow-ing call for surgical residents to volunteer in developingcommunities, not only because it benefits the community,but also because it enriches the residents’ learningexperience.

Severe community acquired pneumonia update: mortality, mechanisms and medical intervention

Severe community-acquired pneumonia (CAP) in the intensive care unit (ICU) is associated with a high mortality rate of about 30% [1], and this rate has remained largely unaltered since the discovery of antibiotics in the 1950s [2]. Until now, no therapies have been designed specifically as adjunct agents for the treatment of severe CAP. In the majority of cases, broad-spectrum antibiotics or pathogen-directed therapies are effective in eradicating the causative organism(s), but they do not address causative effects from pathways of inflammation and coagulation, which are characteristic of the host response to infection. Initially activated as a protective host response, these inflammatory and coagulation pathways may become unregulated and paradoxically may cause tissue damage in the setting of severe CAP. A major component of both of these pathways is tissue factor (TF), a microvascular endothelial glycoprotein that becomes exposed to the systemic circulation after tissue damage. TF is an attractive therapeutic target for adjunctive treatment in severe CAP because it is the initiating factor in the TF coagulation pathway (which ultimately results in thrombin generation and fibrin deposition) [3] and has been shown to stimulate directly the production and release of proinflammatory cytokines (through the protease-activated receptor system) [4]. The largest phase III randomized, placebo-controlled study ever undertaken in patients with severe CAP is currently underway to investigate whether targeting the TF pathway with a specific TF pathway inhibitor can significantly reduce 28-day all-cause mortality in the primary target population. The objective of this symposium is to review the epidemiology of severe CAP, examine current clinical practice and treatment guidelines, and investigate the evidence supporting the potentially central role of TF in the pathophysiology of severe CAP. Jordi Rello MD, PhD is Chief of the Critical Care Department at the Joan XXIII University Hospital in Tarragona, Spain. Professor Rello has been actively involved in clinical research for the past 20 years, focusing on the prevention and control of hospital-acquired infections, severe CAP and treatment of infections in critically ill patients. His presentation focused on the epidemiology, diagnosis and severity scoring of severe CAP, and the impact that treatment guidelines have had [5]. Tom van der Poll MD, PhD is Head of the Centre for Experimental and Molecular Medicine in the Academic Medical Centre in Amsterdam. His research is based in the Centre for Infection and Immunity Amsterdam (CINIMA) and focuses on innate immune responses to bacterial and myco-bacterial infection. He also serves on the Steering Committee of the International Sepsis Forum. His presentation focused on the pathogenesis of severe CAP, in particular covering the roles played by TF as a critical component of the infectious, inflammatory and coagulation pathways [6]. Pierre-Francois Laterre MD is Head of the Intensive Care Unit at St. Luc University Hospital, Universite Catholique de Louvain in Brussels, Belgium. Professor Laterre's professional and scientific activities have focused on the diagnosis, investigation and treatment of sepsis, particularly its interaction with the coagulation cascade. As Co-Chair for the symposium, his presentation focused on the rationale for TF as a therapeutic target in severe CAP and reviewed the design of the ongoing phase III CAPTIVATE study of tifacogin [7]. Jean-Paul Mira MD is Professor of Critical Care Medicine and Chair of the Medical Intensive Care Unit at the Cochin University Hospital; he is also Head of the Variability of Innate Immunity Research Laboratory at the Cochin Institute, both in Paris, France. His research interests are cellular responses to micro-organisms, Toll-like receptor signalling, functional genomics, genetic predisposition to sepsis and sepsis-induced immunosuppression. His presentation focused on the potential for biomarkers to assist physicians in the diagnosis of severe CAP and their possible future role in directing appropriate treatment [8]. The second Co-Chair, Steve Opal MD, who is Professor of Medicine from the Brown Medical School, Pawtucket, Rhode Island, USA, hosted the questions from the audience and directed responses from faculty.

A tailored internet intervention did not increase physical activity more than a tailored print intervention or publicly available web sites

B H Marcus Correspondence to: Dr B H Marcus, Miriam Hospital and Brown Medical School, Providence, RI, USA; bmarcus@lifespan.org In sedentary adults, does a tailored, internet-based intervention (TII) increase physical...

Comparison of Outcomes of Vasovasostomy Performed in the Convoluted and Straight Vas Deferens

We compared postoperative semen analysis parameters and patency rates of vasovasostomy performed in the convoluted vs straight portion of the vas deferens. Records of patients that underwent bilateral vasovasostomy in the straight and convoluted vas deferens by a single surgeon were retrospectively analyzed. Patient age, partner age, obstructive interval, gross and microscopic appearance of the intraoperative fluid aspirated from the testicular portion of the vas deferens, and postoperative semen analysis results were examined. Patency was defined as any sperm in the postoperative ejaculate and was compared for the 2 groups. A total of 42 and 64 patients underwent bilateral straight vasovasostomy and convoluted vasovasostomy, respectively. Mean patient age for straight and convoluted vasovasostomy was 38.5 and 40.3 years, respectively. Mean obstructive interval for straight vasovasostomy and convoluted vasovasostomy was 7.7 and 8.6 years, respectively. No significant differences in the postoperative semen analysis parameters of volume, total count, sperm density, motility or total motile count were found between the 2 groups. The patency rate was 98.1% and 97.3% for convoluted vasovasostomy and straight vasovasostomy, respectively, and was not statistically different. Although vasovasostomy in the convoluted vas deferens is considered technically more challenging than in the straight vas deferens, patency rates and postoperative semen analysis parameters for convoluted vasovasostomy and straight vasovasostomy are comparable.

Type B Lactic Acidosis As a Severe Metabolic Complication in Lymphoma and Leukemia

Type B lactic acidosis is a rare complication of hematologic malignancies. The exact mechanism of this process is not well understood. Because caregivers may not be aware of the association of type B lactic acidosis with hematologic malignancies, it may go unrecognized as a cause of acidosis in these patients. We report the cases of 7 patients with type B lactic acidosis who were cared for by members of the Brown Medical School Hematology/Oncology Division. Of the 7 patients reported, 5 had lymphomas and 2 had chronic lymphocytic leukemia. One of the lymphomas was a T-cell lymphoma. Of the patients we were able to evaluate, there did not seem to be a unique cluster of differentiation marker in association with type B lactic acidosis. We also review 14 additional cases, most reported since 2001. From our review of the literature, we suggest that a deficiency of thiamine or riboflavin may play a more pivotal role than previously recognized in the development of type B lactic acidosis associated with malignancy. Further investigation should be undertaken to learn if thiamine or riboflavin replacement might be useful in treating this disorder.

Timing of Referral to Hospice and Quality of Care: Length of Stay and Bereaved Family Members' Perceptions of the Timing of Hospice Referral

Previous research has noted that many persons are referred to hospice in the last days of life. The National Hospice and Palliative Care Organization collaborated with Brown Medical School to create the Family Evaluation of Hospice Care (FEHC) data repository. In 2005, 106,514 surveys from 631 hospices were submitted with complete data on the hospice length of stay and bereaved family member perceptions of the timing of hospice care. Of these surveys, 11.4% of family members believed that they were referred “too late” to hospice. This varied from 0 to 28.1% among the participating hospice programs with 30 or more surveys. Among those with hospice lengths of stay of less than a month, only 16.2% reported they were referred “too late.” Although the bereaved family member perceptions of the quality of end-of-life care did not vary by length of stay for each of the FEHC domains, the perception of being referred “too late” was associated with more unmet needs, higher reported concerns, and lower satisfaction. Our results suggest that family members' perception of the timing of hospice referral—not the length of stay—is associated with the quality of hospice care. This perception varies substantially among the participating hospice programs. Future research is needed to understand this variation and how hospice programs are delivering high quality of care despite short length of stay.