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Patients who are 90+ years of age are a growing - but understudied - group at risk for cancer. Because many of these patients are undertreated (with no tissue/cytologic diagnosis), we sought to better understand how such decisions are arrived upon.This study focused on patients between 2007 and 2017. None had received cancer therapy. Medical records were reviewed for quotations relevant to decision-making and analyzed qualitatively.Ninety-four patients (median age 93 years) with a cancer diagnosis/presumed diagnosis were identified; most were women (82%) with an average of six co-morbidities (dementia occurred in approximately one-third). The primary qualitative theme was a keen appreciation on the part of all stakeholders of the gravity of the decision to forgo a cancer work-up/therapy, with four subthemes: 1) substantial, detailed medical information about the patient's medical condition ("600 mL of yellow, hazy fluid with an LDH [lactate dehydrogenase] level greater than 450 …"); 2) complex discussions about the risks and benefits of no biopsy and/or no cancer treatment ("[the patient] would not prefer to have the quality of any remaining time ruined with salvage chemo and radiation"); 3) the inclusion of multiple individuals in decision-making ("I had a lengthy discussion with the patient and her daughter;" "I spoke by phone with one of my pathology colleagues"); and 4) patient-voiced decision-making ("I want to die.").Healthcare providers appear to understand the seriousness of no cancer-directed therapy and no work-up in patients 90 years of age and older. Neither ageism nor nihilism was observed.

Background Despite the high burden of Staphylococcus aureus infections among persons who use drugs, limited data exist comparing outcomes of patient-directed discharge (known as discharge against medical advice) compared with standard discharge among persons who use drugs hospitalized with S. aureus infection. Methods We conducted a retrospective study of hospitalizations among adults with S. aureus bacteremia, endocarditis, epidural abscess, or vertebral osteomyelitis at 2 San Francisco hospitals between 2013 and 2018. We compared odds of 1-year readmission for infection persistence or recurrence and 1-year mortality via multivariable logistic regression models adjusting for age, sex, Charlson comorbidity index, and homelessness. Results Overall, 80 of 340 (24%) of hospitalizations for invasive S. aureus infections among persons who use drugs involved patient-directed discharge. More than half of patient-directed discharges 41 of 80 (51%) required readmission for persistent or recurrent S. aureus infection compared with 54 of 260 (21%) patients without patient-directed discharge (adjusted odds ratio 3.8, 95% confidence interval [CI] 2.2-6.7). One-year cumulative mortality was 15% after patient-directed discharge compared with 11% after standard discharge (P = .02); however, this difference was not significant after adjustment for mortality risk factors. More than half of deaths in the patient-directed discharge group (7 of 12, 58%) were due to drug overdose; none was due to S. aureus infection. Conclusions Among persons who use drugs hospitalized with invasive S. aureus infection, odds of hospital readmission for infection were almost 4-fold higher following patient-directed discharge compared with standard discharge. All-cause 1-year mortality was similarly high in both groups, and drug overdose was a common cause of death in patient-directed discharge group.

Emergency department (ED) patients may elect to refuse any aspect of medical care. They may leave prior to physician evaluation, elope during treatment, or leave against medical advice during treatment. This study was undertaken to identify patient perspectives and reasons for refusal of care.This prospective study was conducted at an urban Level 1 Trauma Center. This study examined ED patients who left without being seen (LWBS), eloped during treatment, or left against medical advice during September to December 2018. This project included both chart review and a prospective patient survey.Among 298 participants, the majority were female (54%). Most participants were White (61%) or African American (36%). Thirty-eight percent of participants left against medical advice, 23% eloped, and 39% left without being seen by a provider. When compared to the general ED population, patients who refused care were significantly younger (p 0.001). When comparing by groups, patients who left AMA were significantly older than those who eloped or left without being seen (p 0.001). Among 68 patients interviewed by telephone, the most common stated reasons for refusal of care included wait time (23%), unmet expectations (23%), and negative interactions with ED staff (15%).ED patients who refused care were significantly younger than the general ED population. Common reasons cited by patients for refusal of care included wait time, unmet expectations, and negative interactions with ED staff.

Background We aimed to identify factors associated with refusal of surgery among patients with colon cancer. Methods This 2004–2016 NCDB retrospective study identified AJCC stage I-III colon cancer patients who were recommended surgery. Multivariable logistic regression defined adjusted odds ratios of refusing treatment, with sociodemographic and clinical covariates. Treatment propensity-adjusted Cox proportional hazard ratios defined differential survival stratified by clinical stage, controlling for potential confounders. Results Of 170,594 patients recommended surgery, 1116 refused. Increased rates of surgery refusal were associated with older age, African American race, CDCC>3, and female sex. Decreased rates of surgery refusal were associated with higher income and private insurance. Stratifying by stage, refusal rates among African Americans remained disparately high. Refusal of surgery was associated with worse overall survival. Conclusions Disparate rates of refusal of surgery for resectable colon cancer by race and other sociodemographic factors highlight potential treatment adherence reinforcement beneficiaries, necessitating further study of shared decision-making.

Objectives: Alcohol and substance misuse has been under-acknowledged and underidentified in older adults. However, promising treatment approaches exist (e.g., brief interventions) that can support older adults with at-risk alcohol and substance use. Postacute rehabilitation settings of Skilled Nursing Facilities (SNFs) can offer such programs, but little is known about patient characteristics that are associated with the likelihood of participating in interventions offered in postacute rehabilitation care. Thus, the objective of this study was to identify individual patient characteristics (predisposing, enabling, and need-related factors) associated with participation in a brief alcohol and substance misuse intervention at a SNF. Methods: This cross-sectional study analyzed medical record data of postacute care patients within a SNF referred to a substance misuse intervention. Participants were 271 patients with a history of substance misuse, 177 of whom enrolled in the intervention and 94 refused. Data collected upon patient admission were used to examine predisposing, enabling, and need-related factors related to likelihood of program participation. Results: Older age and ethnic minority status were associated with a reduction in likelihood to participate, while widowhood increased the likelihood of participation. Conclusion: Upon referral to a substance misuse intervention, clinicians in SNFs should be cognizant that some patients may be more likely to refuse intervention, and additional efforts should be made to engage patients at-risk for refusal.

The objective of this study was to determine the demographics and subjective rationale for failure to present for retrieval of patients who had an inferior vena cava (IVC) filter placed.Between January 1, 2010, and September 12, 2017, there were 242 patients who had retrievable IVC filters placed. Demographics and indications for filter placement were retrospectively analyzed. All patients who failed to have the filter retrieved were contacted by Institutional Review Board-approved telephone survey to delineate the reason that the filter was not removed.Of 242 patients with IVC filters placed, 53 (22%) patients presented for filter retrieval at Abington-Jefferson Health. Patients who presented for filter retrieval were statistically younger (46 years vs 65 years; P .001). The most common indication for filter placement in both groups was preoperative placement for bariatric surgery, but this percentage was higher in the group that presented for filter retrieval (70% [37/53] in the retrieved group vs 47% [88/189] in the nonretrieved group; P = .018). After telephone survey that reached 146 patients, it was determined that 46 (32%) patients who did not return for filter retrieval were told to keep the filter in place secondary to comorbidities, 28 (19%) did not remember being instructed to follow up for retrieval, and 18 (12%) did not want another procedure. Twenty-four patients were deceased at the time of telephone survey (16%). The remainder of the patients had the filter removed at an outside institution or gave another reason.Our study documented a disappointingly low rate of filter retrieval. Patients with IVC filters who failed to present for retrieval were more likely to be older and frequently did not understand the complications of leaving a filter in place and the need to have the filter retrieved. Patient education should be increased to better capture patients with IVC filters and to improve retrieval rates, but our study showed that a significant percentage of patients do not have filters retrieved because of comorbidities or they do not want another procedure.

Homeless individuals suffer a greater burden of health problems than the general population. This study aimed to describe the epidemiology of physical trauma among homeless patients presenting to an urban major trauma center and to ascertain any differences in the nature, injury severity and outcomes among homeless compared to domiciled patients.A retrospective matched cohort study that included adults who met inclusion criteria for The Alfred Hospital Trauma Registry between 01 July 2010 and 31 March 2017 was conducted. Primary homelessness was identified using the International Statistical Classification of Diseases, 10th Revision Coding Z59.0 and/or 'No fixed abode' address data. Homeless and domiciled patients were matched at a 1:2 ratio on age, sex, month and year of injury. The primary outcome variable was the Injury Severity Score (ISS). Secondary outcomes were hospital length of stay (LOS), mortality, emergency department (ED) disposition, hospital disposition, discharge processes and trauma registry recidivism.Of 25,920 cases in the trauma registry, 147 (0.6%) were identified as homeless, comprising 131 unique homeless individuals who were matched with 262 domiciled patients. The median (Inter-Quartile Range) ISS among homeless patients was 5(2-10), compared to 9(4-17) for domiciled patients (p 0.001). Homeless patients had significantly lower odds of sustaining an injury with ISS12 (OR 0.5, 95% CI: 0.3-0.8, p = 0.001). Homeless patients were treated more often than domiciled patients for assault (32.1% vs 9.5%), intentional self-harm (10.7% vs 2.7%), and penetrating injury (16.0% vs 6.5%). Homeless patients had higher rates of psychiatry admissions (9.2% vs 0.8%), positive blood alcohol concentration (30.5% vs 13.7%), and higher odds of discharging against medical advice (DAMA)(OR 2.0, 95% CI: 1.1-3.6 p = 0.02). There were no differences in LOS (p = 0.51), mortality (p = 0.19), ED disposition (p = 0.64) or trauma registry recidivism (p = 0.09).Among injured patients who presented at an urban trauma center, homelessness was associated with higher odds of assault, intentional self-harm, penetrating injury, psychiatry admissions, DAMA but lower ISS than domiciled patients. Variable definitions of homelessness and lack of standardized documentation in the medical record should be addressed to ensure these vulnerable patients are identified and linked with peripheral services.

Background Despite a higher prevalence of sudden cardiac death (SCD), black individuals are less likely than whites to have an implantable cardioverter defibrillator (ICD) implanted. Racial differences in ICD utilization is in part explained by higher refusal rates in black individuals. Decision support can assist with treatment-related uncertainty and prepare patients to make well-informed decisions. Methods The Videos to reduce racial disparities in ICD therapy Via Innovative Designs (VIVID) study will randomize 350 black individuals with a primary prevention indication for an ICD to a racially concordant/discordant video-based decision support tool or usual care. The composite primary outcome is (1) the decision for ICD placement in the combined video groups compared with usual care and (2) the decision for ICD placement in the racially concordant relative to discordant video group. Additional outcomes include knowledge of ICD therapy and SCD risk; decisional conflict; ICD receipt at 90 days; and a qualitative assessment of ICD decision making in acceptors, decliners, and those undecided. Conclusions In addition to assessing the efficacy of decision support on ICD acceptance among black individuals, VIVID will provide insight into the role of racial concordance in medical decision making. Given the similarities in the root causes of racial/ethnic disparities in care across health disciplines, our approach and findings may be generalizable to decision making in other health care settings.

Background: Vaccine-related diseases are increasing in developing countries. This study aimed to explore parents’ reasons for refusal of childhood vaccinations in Malaysia and their recommendations on addressing their concerns. Methods: A qualitative study design involving individual both face-to-face and online in-depth interview was used. The topic guide was developed from the Health Belief Model theoretical framework. Seven face-to-face and seven online interviews were conducted with parents in the Klang Valley (an urban area) who had refused childhood vaccination. All interviews were audio-recorded, transcribed verbatim and checked. Thematic approach was used to analyze the data. Data was collected until data saturation was reached. Results: Findings were summarized into two main categories: Personal Health Beliefs and Vaccine Related Concerns. Six personal health beliefs were identified: lack of confidence in modern medicine and health care personnel, pharmaceutical conspiracy to sell medicines, preference to a natural approach to health, personal instincts, religious beliefs and having a partner with similar beliefs. Four main vaccine-related concerns were identified: negative effects and content concerns, doubts of necessity and lack of information and knowledge regarding vaccines. Parents recommended that more empathy from healthcare professionals and evidence on safety and content purity would help them reconsider vaccination. Conclusion: Parents had multiple reasons for refusing childhood vaccinations but felt that communication and empathy from healthcare professionals was lacking. Besides individual consultations with parents, addressing these concerns at multiple levels in the health care system and society may help to increase the uptake of childhood vaccinations in the future. Keywords: Primary health care, Vaccines, Treatment refusal

Background: There are still oral cancer patients without surgery. To improve the survival, it is necessary to know the causes of the oral cancer patients without surgery. Methods: 23,217 patients with a newly-diagnosed oral cancer in Taiwan Cancer Registry (TCR) database between 2011 and 2015 were enrolled. Data from TCR database named “Reason for No Surgery of Primary Site” were extracted for analysis of the causes of those without surgery. Overall survival plots were presented using the Kaplan–Meier method with log-rank test. Results: 3263 (14%) patients did not received surgery. Among them, there were 720 patients (group 3) without surgery although surgery was advised, 154 patients (group 2) because of poor condition or death before surgery, and 2389 patients (group 1) because of other causes. Twenty-four percent of the patients with surgery were treated one month and more after diagnosis. The 5-year overall survival rates were 68.7%, 25.2%, 9.1% and 17.3% for surgery group, group 3, 2 and 1, respectively (p

BackgroundThere is little research examining resistance, refusal or rejection of care by people living with dementia within acute hospital wards despite the prevalence of dementia in adult hospital populations.ObjectivesTo explore the ways in which resistance to care manifests within the acute setting and is understood, classified and subsequently managed by ward staff.DesignEthnographySettingAcute medical units and trauma and orthopaedic wards in five NHS hospitals in England and Wales.ParticipantsPeople living with dementia and nursing team members (registered nurses and healthcare assistants) on participating wards.MethodsObservational fieldwork and ethnographic interviews collected over a period of 20 months (155 days of non-participant observation (minimum 2 h, maximum 12 h, total hours: 680) focusing on staff delivering care to patients with dementia. Interviewees included patients, visitors, and staff working on and visiting the ward. Data collection and analysis drew on the theoretical sampling and constant comparison techniques of grounded theory.ResultsWe found that resistance to care by people living with dementia was a routine and expected part of everyday care in the participating acute hospital settings. The timetabled rounds of the ward (mealtimes, medication rounds, planned personal care) significantly shaped patient and staff experiences and behaviours. These routinized ward cultures typically triggered further patient resistance to bedside care. Institutional timetables, and the high value placed on achieving efficiency and reducing perceived risks to patients, dictated staff priorities, ensuring a focus on the delivery of essential everyday planned care over individual patient need or mood in that moment. Staff were thus trapped into delivering routines of care that triggered patterns of resistance.ConclusionsNursing staff struggle to respond to the needs of people living with dementia in acute care settings where the institutional drivers of routines, efficiency and risk reduction are not mediated by clinical leadership within the ward. Cycles of resistance in response to organisationally mandated timetables of care can result in poor care experiences for patients, and emotional and physical burnout for staff. More research is needed into how institutional goals can be better aligned to recognise the needs of a key hospital population: people living with dementia.

Background Family caregivers (FCGs) often participate in the decision for their loved one to receive a left ventricular assist device (LVAD). Little is known about the contribution of FCGs to this complex decision. Objectives To investigate family caregiver-reported outcomes related to decision-making for LVAD implantation and their experiences post-implantation. Methods Descriptive thematic analysis was used to analyze longitudinal data. Thematic saturation was achieved. Results Three key themes emerged from the data. The main theme in the pre-implantation period was: Not a decision. The two themes in the post-implantation period were: More satisfaction than regret and Unanticipated situational change. Conclusions Family caregiver-reported outcomes inform clinical practice and future research. FCGs of LVAD recipients did not see viable alternatives to LVAD implantation, were generally satisfied with post-implantation outcomes, and experienced unexpected life changes in the post-implantation period despite feeling prepared preoperatively. Education of both LVAD recipients and their FCGs must be optimized.

This article critically assesses the way a certain court has determined the capacity of a person diagnosed with anorexia to refuse medical treatment. It is shown that when making this determination, the court has adopted a process of circular reasoning, meaning anyone with the diagnosis will be found to lack capacity to refuse its treatment. This circular reasoning means that indicia of capacity that ought to be considered by the court is ignored. The result is a procedure in which the anorexic patient has no voice, and an outcome against which he or she has no effective legal recourse. This problem, it is argued, can be overcome in two ways. Firstly, courts must make sure that the 'functional' test of capacity is properly applied, meaning any finding of incapacity must rest on evidenced deficits in decision-making ability. Secondly, courts must properly engage with the subjective reasoning of the person making the treatment refusal.

In everyday clinical practice, health professionals and parents of chronically ill children often rely on the principle of 'best interest' in the development of medically oriented treatment plans. In most cases, such processes are done collaboratively; however, 'best interest' as a standard for decision-making becomes ambiguous in situations wherein parents and health professionals fail to agree on the course of treatment. This paper will explore the potential tensions that can exist in clinical practice when 'best interest' is used for making health care decisions. The discussion will be framed within the case of baby M, a newborn child of Mennonite descent diagnosed at birth with end-stage kidney disease (ESKD). M's parents refused medically-prescribed therapy on behalf of their child because of the uncertainty of the treatment and beliefs regarding quality of life. This case highlights that the application of the 'best interest' principle in the clinical domain can be ambiguously interpreted and subjectively operationalized along a narrowly defined medical understanding of what is in the patient's best interest. In addition, this case serves as an example of how power within the health care system can be used to operationalize a medically-sanctioned definition of 'best interest', often at the expense of the values, beliefs and interests of parental caregivers.

AIM: The prevalence of hysterectomy is decreasing worldwide. It is not clear whether changes in the population at risk (women with intact uteruses) have contributed to an increased uterine cancer incidence. This study aims to assess the effect of changing trends in hysterectomy prevalence on uterine cancer incidence in Scotland.METHODS: The population of women aged ≥25 years with intact uteri was estimated using the estimated hysterectomy prevalence in 1995 and the number of procedures performed in Scotland (1996-2015). Age-standardized uterine cancer incidence was estimated using uncorrected (total) or corrected (adjusted for hysterectomy prevalence) populations as denominators and the number of incident cancers as numerators. Annual percentage change in uterine cancer was estimated.RESULTS: Hysterectomy prevalence fell from 13% to 10% between 1996-2000 and 2011-2015, with the most marked decline (from 20% to 6%) in the 50-54-year age group. After correction for hysterectomy prevalence, age-standardized incidence of uterine cancer increased by 20-22%. Annual percentage change in incidence of uterine cancer remained stable through the study period and was 2.2% (95%CI 1.8-2.7) and 2.1% (95%CI 1.7-2.6) for uncorrected and corrected estimates, respectively.CONCLUSION: Uterine cancer incidence in Scotland corrected for hysterectomy prevalence is higher than estimates using a total female population as denominator. The annual percentage increase in uterine cancer incidence was stable in both uncorrected and corrected populations despite a declining hysterectomy prevalence. The rise in uterine cancer incidence may thus be driven by other factors, including an ageing population, changing reproductive choices, and obesity.

Pediatric heart transplant waitlist mortality remains significant but allograft offer refusals are common and allografts continue to be discarded. Our aim in this study was to assess the impact of donor organ refusals on mortality after listing using a multi-institutional data set.In this study we conducted a retrospective review of donor offers made to pediatric (18 years) recipients in the United States in the period from 2007 to 2017. Candidates were stratified by whether they refused an acceptable donor offer (ADO). Acceptance was defined as an offer from a donor40 years old and within 1,000 miles that was ultimately accepted by a waitlist candidate. Candidate survival after an offer was assessed.There were 12,447 hearts offered at least once to a pediatric candidate. Most candidates (n = 4,282, 84.4%) refused the first offer, and 677 (15.4%) of these subsequently died or were removed from the list for deterioration. Refusal of an ADO was associated with higher mortality after listing, independent of transplant, in both univariate (1 year: 92% vs 87%, p = 0.002) and multivariate (hazard ratio 1.5, 95% CI 1.2 to 1.7, p0.0001) Cox regression analyses. ADO refusals were not correlated with improved post-transplant survival and8 ADO refusals was associated with higher risk-adjusted post-transplant mortality (odds ratio 1.7, 95% confidence interval 1.0 to 2.9, p = 0.04).Refusal of ADOs is associated with higher risk-adjusted mortality after listing (independent of transplantation), without improvement in post-transplant outcomes. So, although a "perfect" organ would be ideal, acceptance of one that is "good enough" has the potential to improve survival among pediatric candidates for heart transplantation.

Objective To determine the rate and determinants of neoadjuvant chemotherapy noncompletion in patients with muscle-invasive bladder cancer. Methods Using Surveillance, Epidemiology, and End Results-Medicare data, we identified all patients who underwent cystectomy between 2008-2013 and received chemotherapy within 6 months. Of these, 594 patients received neoadjuvant chemotherapy, defined as the presence of a claim for chemotherapy within the 180 days preceding cystectomy. Our primary outcome was noncompletion of neoadjuvant chemotherapy. We determined regimen-specific cut points for noncompletion based on clinical trials and national guidelines. Results Over the study period, 174 of 594 patients (29%) did not complete neoadjuvant chemotherapy. Noncompleters and completers received a median interquartile range of 4.4 (3.0-8.0) and 10.0 (7.7-11.2) weeks of chemotherapy, respectively. A total of 391 (66%) patients received a cisplatin-based regimen and 203 (34%) patients received an alternative regimen, with 27% and 33% not completing chemotherapy, respectively. After adjusting for covariates, age and geographic region were independently associated with failing to complete chemotherapy. Conclusion Nearly 30% of patients who received neoadjuvant chemotherapy did not complete their regimen. Advanced age and nonclinical factors, such as practice patterns in certain geographic regions, may influence a patient's likelihood of successfully completing chemotherapy.

Summary The Canadian Supreme Court's decision in Carter v. Canada conceivably allows depressed psychiatric patients without a terminal physical illness to claim that they meet the criteria for physician-assisted death. Bill C-14, aka the Medical Assistance in Dying Act (MAiD), conceivably does not: patients suffering from mental illness are supposedly not facing an impending death from their disorder that is reasonably foreseeable. Specific concerns have been raised about major depression as hopelessness and suicidal thinking are symptoms. If psychiatric patients are candidates for MAiD, then concerns about incurability, appreciation, and voluntariness could be met by a “conservative” oversight regime that requires extra safeguards and sufficient evidence to offset them. It should require: 1) substantive clinical evidence that treatments have failed, and 2) substantive narrative evidence of how patients evaluate the risk of premature death. As per 1), it is argued that treatment refusal will not by itself determine incurability. An approach for 2) is proposed that uses methods derived from narrative psychotherapy. This narrative approach uses therapeutic techniques to inform assessments of suicidal risk, but in collaborative ways that can sustain hope. Aside from adding first-person evidence to the clinical file, it might better enable patients to articulate the extent to which they appreciate the risk of premature death. It might also enable patients to re-evaluate their wish for MAiD. More to the point, it affords patients who profess a wish to die an opportunity to express themselves and be listened to that many of them claim they want to have.

Background Human papillomavirus (HPV) vaccination is expected to reduce HPV-related disease and cancer in the US. However, many parents are hesitant to obtain the vaccine for their children. The purpose of this study is to examine how the reasons for refusing the HPV vaccine vary across regions of the US, across time, and by race/ethnicity. Methods This study used data on 13–17 year old adolescents collected by the National Immunization Survey – Teen (NIS-Teen) annually between 2008 and 2016. We evaluated the frequencies of parents who did not intend to vaccinate their children in the next year among unvaccinated children. Among these non-intenders, we evaluated how reasons for HPV vaccine hesitancy changed across time, by region of the US, and race/ethnicity. Results The proportion of non-intenders among unvaccinated decreased from 72% in 2010 to 58% in 2016. The most frequent reason for vaccine hesitancy was that parents felt HPV vaccination was not necessary (22.4%), followed by lack of provider recommendation (16.2%), and lack of knowledge (15.6%). Lack of provider recommendation increased in frequency as a reason for HPV vaccine hesitancy until 2012, then decreased in frequency through 2016. Cost was one reason that was elevated in all regions compared to the Northeast. Black non-intenders were less likely to report safety, costs, or their children’s fear as reasons for not intending to vaccinate their children compared to white non-intenders. Hispanic non-intenders were more likely to report lack of knowledge and that the vaccine is not a school requirement as reasons not to vaccinate their children compared to white non-intenders. Conclusions National advocacy for improving provider recommendation for HPV vaccination likely contributed to a sharp decline in HPV vaccine hesitancy due to lack of provider recommendation. Results indicate the need for multifaceted interventions to increase HPV vaccination.

Aim\ud \ud To estimate treatment refusal and treatment dropout rates for cognitive analytic therapy (CAT) and then benchmark these rates against other psychotherapies.\ud \ud \ud \ud Method\ud \ud PROSPERO registration CRD4202017081. Systematic searches found CAT treatment studies reporting treatment refusal and dropout rates. Studies were narratively and quantitatively synthesised in a proportional random-effects meta-analysis and moderator analyses were performed. Secondary analyses compared refusal and dropout rates for CAT versus other psychotherapies via direct comparisons in the original studies and via benchmarking these rates against other acceptability meta-analyses for other psychotherapies.\ud \ud \ud \ud Results\ud \ud Thirty-four CAT studies were included in the review. The treatment refusal rate was 15.35% (k = 9, 95% CIs 8.78–23.21). The treatment dropout rate was 18.69% (k = 34, 95% CI's 15.02–22.62). CAT generated significantly lower dropout rates relative to treatment comparators in the original studies (OR = 0.67; 95% CI 0.48–0.93). Country and younger age were significant moderators of dropout rates. CAT had a comparable treatment refusal rate and was towards the lower end of the dropout range when benchmarked against other psychotherapies.\ud \ud \ud \ud Conclusions\ud \ud CAT as a brief and integrative psychotherapy for individuals presenting with typically complex psychological disorders appears a relatively acceptable intervention to patients.

Purpose: \ud The study aims to analyse the reasons underpinning women's refusal to undertake Down's syndrome screening (DSS) by maternal serum testing (MST).\ud \ud Methods: \ud A retrospective, mixed methods sequential approach was used. An online survey on women's experience of prenatal testing followed by in-depth interviews were conducted, with women over 18 years old, who had been pregnant within five years prior to the study. Altogether, 1726 responses were gathered, of which 217 related to women who had refused MST. The study compares the women who refused MST with women who accepted it on sociodemographic characteristics, the evolution and experience of the pregnancy, their knowledge about Down's syndrome (DS). It also utilises survey comments and five in-depth interviews to explore, using Thematic Analysis, the reasons for refusing MST.\ud \ud Results: \ud To refuse MST is cognitively demanding. Indeed, women who refused MST were better educated, knew more about prenatal diagnosis sequences and DS than women who accepted it. This position is also emotionally challenging as women's interactions with practitioners can put them in difficult situations, where they have to defend their point of view. Reasons for refusing MST go beyond religious beliefs, negative attitudes towards abortion and/or medicalisation of pregnancy. Rather, women's position appears to be driven by a holistic conception of care-based monitoring, values of inclusivity and a desire to remain in control of their pregnancy.\ud \ud Conclusions: \ud It is essential that women feel accepted and supported in their choice to refuse MST. Consequently, it is important for professionals to remain cognisant of the diversity of factors underpinning women's decision, the pressure this position generates and the challenges that come with it.

Alveolar bone grafting (ABG) delay can lead to suboptimal outcomes. This study seeks to categorize reasons patients with cleft lip and palate have no record of ABG or who underwent later than typical ABG (≥13 years).At a single tertiary care center, a retrospective review was performed of all patients with unilateral, complete cleft lip and palate, born 1998-2005. Database query identified which patients had timely, late, or no record of ABG. The retrospective cohort study was performed to categorize ABG delay or absence of recorded ABG.Of 135 participants, 82 (61%) had timely, 8 (6%) had late, and 45 (33%) had no record of ABG. The primary factor for late ABG was noncompliance or refusal (n = 5 of 8, 63%), comorbidity or medical complexity (n = 1 of 8, 13%), orthodontic unpreparedness (n = 1 of 8, 13%), or inaccurate prior assessment of alveolar sufficiency (n = 1 of 8, 13%). The primary factor for ABG record absence was loss to follow-up (n = 40 of 45, 89%), noncompliance or refusal (n = 3 of 45, 7%), comorbidity or medical complexity (n = 1 of 45, 2%), or orthodontic unpreparedness (n = 1 of 45, 2%). Racial majority (White, Asian) patients received preferred care (timely ABG or medically appropriate absence or delay) at a significantly higher rate (67%) than underrepresented minorities (African American, Hispanic, Native American, other) (35%, P = 0.016). Families with private insurance and those who were self-pay received preferred care at a significantly higher rate (77%) than families with Medicaid (42%) (P 0.001).The high number of patients lost to follow-up highlights the impact of poor retention on ABG completion. Possible health disparities based on race and insurance status warrant clinical focus.

Behavioral problems decrease quality of life of people with dementia and their care providers. Three main consequences of dementia are functional impairment and in some cases also mood disorders and psychosis. These consequences, alone or in combination, result in 3 main behavioral problems: apathy, agitation, and rejection of care/aggression. Nonpharmacologic management strategies include meaningful activities and individualized comfort care, for example, Namaste Care. If needed, pharmacologic management should concentrate on treatment of main dementia consequences, especially depression, instead of treating secondary symptoms, for example, insomnia. Use of antipsychotics should be minimized but antipsychotics may be necessary for augmentation of antidepressants.

To determine the readmission rate in patients with acute heart failure (AHF) discharged against medical advice (AMA).We performed a retrospective analysis using the 2014 National Readmission Database. Patients admitted with a primary diagnosis of AHF were selected. Only those discharged to home and who left AMA were included in the study. The primary outcome was 30-day readmission. We compared the readmission rates among those discharged AMA vs routinely discharged patients using propensity score matching (PSM) to address imbalance in variables between the 2 groups. We matched 3 routinely discharged patients to 1 patient who left AMA.We identified 273,489 patients with AHF, of whom 116,869 qualified for further study analysis. A total of 2014 patients (1.7%) were in the AMA group and 114,855 (98.3%) were in the routinely discharged group. After PSM, 6042 routinely discharged patients were matched with 2014 patients from the AMA group. The standard mean difference for each variable was less than 10% postmatching. The 30-day readmission rate among those who left AMA was higher than among those routinely discharged (33% vs 20.1%; P.001). Heart failure (44.8%) was the most common cause of readmission in the AMA group. Patients who left AMA were more likely to be readmitted to a different hospital compared with those routinely discharged (37.4 vs 23.1%; P.001). They also had a high rate of leaving AMA during the readmission (18 vs 2%; P.001).Patients with AHF discharged AMA had a significantly higher 30-day readmission rate than did the routinely discharged group.

Background Despite safe and effective childhood immunizations, decreased acceptance of vaccines has become an emerging global problem. The WHO SAGE Working Group on Vaccine Hesitancy developed a common diagnostic tool, the Vaccine Hesitancy Scale (VHS), to identify and compare hesitancy in different global settings. We field tested the VHS in rural and urban Guatemala. Methods We analyzed data from the enrollment visit of a study conducted at four public health clinics in Guatemala. Infants ages 6 weeks-6 months presenting for their first wellness visit were enrolled March-November 2016. Parents completed a demographic survey that included the 10 dichotomous and 10 Likert scale VHS questions. Chi-square or Fisher’s exact for categorical and ANOVA test for continuous variables were used to assess significance levels in survey differences. We conducted a factor analysis to assess the Likert scale questions. Results Of 1088 families screened, 871 were eligible and 720 (82.7%) participated. No parent had ever refused a vaccination, and only eight parents (1.1%) had been reluctant or hesitated to get a vaccination for their children. However, only 40.8% (n = 294) of parents said that they think most parents like them have their children vaccinated with all the recommended vaccines. Factor analysis identified two underlying constructs that had eigenvalues of 1.0 or greater and a substantive lack of variability in response across the Likert scale. There were consistent differences between how study clinics responded to the ordinal scaling. Conclusion Our results suggest problems with interpretation of the VHS, especially in the presence of vaccine shortages and using a Likert scale that does not resonate across diverse cultural settings. Our factor analysis suggests that the Likert scale items are more one-dimensional and do not represent the multiple constructs of vaccine hesitancy. We suggest more work is needed to refine this survey for improved reliability and validity. Clinical Trial Registry: NCT02567006 .

It has been reported that some patients with breast cancer may refuse cancer-directed surgery, but the incidence in the United States is not currently known. The purpose of this study was to identify the incidence, trends, risk factors, and eventual survival outcomes associated with refusal of recommended breast cancer-directed surgery.A retrospective review of the Surveillance Epidemiology and End Results (SEER) database between 2004 and 2013 was performed. Patients who underwent cancer-directed surgery were compared with patients in whom cancer-directed surgery was refused, even though it was recommended.Of 531,700 patients identified, 3389 (0.64%) refused surgery. An increasing trend was observed from 2004 to 2013 (P = .009). Older age (50-69: odds ratio [OR] 4.96; 95% confidence interval, 1.23-19.96; P = .024, ≥ 70 years: OR 17.27; 95% CI, 4.29-69.54; P .001), ethnicity (P .001), marital status (single: OR 2.28; 95% CI, 1.98-2.62; P .001, separated/divorced/widowed: OR 2.26; 95% CI, 2.01-2.53; P .001), higher stage (II: OR 2.05; 95% CI, 1.83-2.3; P .001, III: OR 2.2; 95% CI, 1.87-2.6; P .001, IV: OR 13.3; 95% CI, 11.67-15.16; P .001), and lack of medical insurance (OR 2.11; 95% CI, 1.59-2.8; P .001) were identified as risk factors associated with refusal of surgery. Survival analysis showed a 2.42 higher risk of mortality in these patients.There has been an increasing rate of patients refusing recommended surgery, which significantly affects survival. Age, ethnicity, marital status, disease stage, and lack of insurance are associated with higher risk of refusal of surgery.

BACKGROUND: Chemotherapy preference refers to a patient’s interest in receiving chemotherapy. This study examined whether chemotherapy preference was associated with toxicity, efficacy, quality of life (QoL), and functional outcomes during and after completion of adjuvant chemotherapy in older women with breast cancer. METHODS: This study is a secondary analysis of CALGB 49907, a randomized trial that compared standard adjuvant chemotherapy versus capecitabine in patients age 65 years or older with breast cancer. A subset of 145 patients completed a questionnaire to describe chemotherapy preference pre-treatment. The association of this pre-treatment preference with the patient’s perception of self-health, predicted and actual QoL, patient- and professional-reported toxicity, mental health, self-rated function, and survival was studied during and after treatment. RESULTS: The median age of patients was 71 years and 47% had a high preference for chemotherapy. On baseline demographics, the low preference group had a higher proportion of white patients (95% vs. 78%, p=0.004). Before treatment, low chemotherapy preference was associated with greater nausea/vomiting (p=0.008). Mid-treatment, low preference was associated with lower QoL, worse social, emotional and physical function (all p≤0.02) and worse nausea/vomiting, cancer symptoms and financial worries (all p

Background Medically hospitalized patients who lack decisional capacity may request, demand, or attempt to leave the hospital despite grave risk to themselves. The treating physician in this scenario must determine how to safeguard such patients, including whether to attempt to keep them in the hospital. However, in many jurisdictions, there are no laws that address this matter directly. In this absence, psychiatrists are often called upon to issue an involuntary psychiatric hold (civil commitment) to keep the patient from leaving. Yet, civil commitment statutes were not intended for, and generally do not address, the needs of the medically ill patient without psychiatric illness. Civil commitment is permitted for patients who pose a danger to themselves or others, or who are gravely disabled, specifically as the result of a mental illness, and allows the transport of such individuals to facilities for psychiatric evaluation. It does not permit detention for medical illnesses nor the involuntary administration of medical treatments. Therefore, the establishment of hospital policies and procedures may be the most appropriate means of detaining medically hospitalized patients who lack capacity to understand the risks of leaving the hospital, in addition to mitigating the potential tort risk faced by the physician for acting in a manner that protects the patient. Objective The purpose of this article is to identify the array of clinical and medical-legal concerns in these scenarios, and to describe the development of a "medical incapacity hold" policy as a means of addressing this unresolved issue.

Objectives In 2004, Lithuania started the Nationwide Cervical Cancer Screening Programme. The aim of the study was to estimate the trend in the uptake of cervical cancer (CC) screening in Lithuania during 2006–2014 and to identify sociodemographic and lifestyle factors associated with non-attendance for screening. Study design Cross-sectional studies. Methods The data of 4248 women aged 25–60 years who participated in population-based cross-sectional surveys of Lithuanian Health Behaviour Monitoring were analysed. The postal surveys of independent random samples were conducted every second year. Participation in screening was determined by asking women whether they have had a Pap smear test within the last 3 years. Associations of non-attendance with sociodemographic characteristics and lifestyle factors were assessed by multivariate logistic regression analysis. Results The proportion of women who reported taking a test for CC within 3 years was continuously increasing from 60.0% in 2006 to 74.2% in 2014. The likelihood of not being screened was lower among older as compared to younger women (odds ratio = 0.70; 95% confidence interval = 0.61–0.82). Non-attendance was associated with lower education, being single, having rare contacts with a doctor, low physical activity, and obesity. In addition, older women who smoked and consumed alcohol at least once a week were more likely to have never been screened. Conclusions Established social and behavioural determinants of non-attendance for CC screening should be used for optimising CC prevention in Lithuania. The implementation of organised screening programme using innovative screening methods might increase attendance and reduce inequalities.

Objective To investigate survival outcomes of patients with muscle-invasive bladder cancer (MIBC) that demonstrate complete clinical response (cT0) to neoadjuvant chemotherapy (NAC) and then reject subsequent radical cystectomy (RC). Methods A retrospective chart review identified patients with MIBC who were cT0 after platinum-based NAC. cT0 was defined as negative cytology, cystoscopy with transurethral resection of bladder tumor, and imaging. cT0 patients refusing for RC were followed up with cytology, cystoscopy with biopsy, and cross-sectional imaging. Results Forty-eight patients were identified with MIBC that were cT0 after NAC. Seven patients underwent immediate RC, whereas 41 elected bladder preservation with close surveillance. Of those remaining 41 patients, mean age was 68 ± 11 years with median follow-up of 35 months. NAC regimens were 46% methotrexate/vinblastine/doxorubicin/cisplatin, 39% gemcitabine/cisplatin, and 15% other platinum-based therapies. Five-year cancer-specific survival was 87%, disease-free survival was 58%, and cystectomy-free survival was 79%. A total of 19 patients (46%) relapsed with 5.4-month median recurrence time. Conclusion Bladder preservation may be a reasonable option in a highly select subset of patients with MIBC who are complete clinical responders after NAC. For those patients that were cT0 after NAC and refused or were ineligible for RC, 5-year disease-free survival was nearly 60% and cancer-specific survival was nearly 90%. Future studies should focus on identifying clinical and molecular factors associated with a durable pathologic complete response after NAC.

Objectives The objective of this study was to determine the applicability of utilizing the N-of-1 method for deprescribing trials in older adults. Study Design and Setting Systematic review of any human studies conducted in older adults (≥50 years), deprescribing any long-term treatment over less than a year using the N-of-1 trial method was performed. Two authors independently reviewed all articles for eligibility and extracted data. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quality assessment of trials was carried out using the Physiotherapy Evidence Database scale. Results Six studies were identified and extracted. Trials investigated the efficacy of pharmacological and non-pharmacological therapies for treating diseases. Four trials demonstrated non-significant benefits of treatment, with a significant number of patients discontinuing their medications in two trials where follow-up data was collected (N = 8/18, 9/14 [44.4--64.3%]). In two studies, where treatment was beneficial, all participants were found to be maintaining regimen at follow-up. Conclusion The N-of-1 trial methodology can be used to generate patient-specific evidence of medication and inform prescribing decisions. Future studies are required to assess the feasibility of using the N-of-1 method to determine the effects of deprescribing medications on short-term outcomes.

Objective While the study of suicide on mental health units has a long history, the study of patient safety more generally is relatively new. Our objective was to determine the type and relative frequency of adverse events occurring on Veterans Health Administration (VHA) mental health units; the primary root causes for these events; and make recommendations for abating or mitigating these events. Methods We searched our national database for any reported adverse event that occurred on an inpatient mental health unit between January 1, 2015 and December 31, 2016. We found 87 Root Cause Analysis (RCA) reports and 9780 safety reports. The safety reports were coded for type of event and the RCAs were further coded for underlying causes and severity. Results Of the 87 RCA reports, there were 31suicide attempts, 16 elopements, 10 assaults, 8 events involving hazardous items on the unit, 7 falls, 6 unexpected deaths, 3 overdoses and 6 cases coded as “other”. For the 9780 safety reports falls were the most common event, followed by medication events, verbal assaults, physical assaults, medical problems and hazardous items on the unit. Conclusions As with medical units, patients on mental health units are at risk for many types of adverse events. The same focus on patient safety is just as important for our mental health patients as for our medical patients. Mental health unit staff should undertake a structured assessment of all risk on their units. This broad approach may be more successful than focusing on a particular event type.

In this article, we elucidate a symbiotic relationship between complementary and alternative medicine (CAM) and rejection of, or hesitancy towards, vaccination. In Fremantle, Western Australia, and Adelaide, South Australia, we conducted in-depth interviews from September 2013-December 2015 with 29 parents who had refused or delayed some or all of their children's vaccines. Our qualitative analysis found that for many, their do-it-yourself ethic and personal agency was enhanced by self-directed CAM use, alongside (sometimes informal) CAM practitioner instruction. Reifying 'the natural,' these parents eschewed vaccines as toxic and adulterating, and embraced CAM as a protective strategy for immune systems before, during and after illness. Users saw CAM as harm-free, and when it came to experiences that non-users might interpret as demonstrating CAM's ineffectiveness, they rationalised to the contrary. They also generally glossed over its profit motive. CAM emerged as part of an expert system countering Western medicine. CAM's faces were trusted and familiar, and its cottage capitalism appeared largely free from the taint of "Big Pharma." A few parents employed a scientific critique of CAM modalities - and a minority were dubious of its profit motive - but others rejected the epistemology underpinning biomedicine, framing CAM as a knowledge not poisoned by avarice; a wisdom whose very evidence-base (anecdote and history) was demeaned by an arrogant scientific process only permitting belief in that which could be quantified. However, all parents engaged with Western medicine for broken bones and, sometimes, medical diagnoses. Our analysis suggests that pro-vaccination health professionals, policymakers and information-providers seeking to address the role of CAM in vaccine rejection face significant challenges due to the epistemic basis of some parents' decisions. However, we make some suggestions for professional practice and policy to enhance trust in vaccination.

Cancer patients are at increased risk for morbidity and mortality from seasonal influenza but are known to respond poorly to influenza vaccination. This single-center survey suggests that approximately one-third of cancer patients and their caregivers and family did not receive the vaccine in the prior season. Patients felt strongly that caregiver vaccination was important, whereas caregivers' decisions did not appear to be affected by the patients' disease.

Using conversation analysis, this paper investigates when patients exercise their right to refuse treatment in neurology outpatient consultations recorded in the UK's National Health Service in 2012 (n = 224). NHS patients have a right to refuse treatment. However, there are good reasons to suppose that this may be difficult to exercise in practice. We know that clinicians tend to pursue acceptance if it's not forthcoming and those studies that have tracked decision-making trajectories through to their outcomes have shown that clinicians typically convert resistance to acceptance. By contrast, I show that, in 35/40 (87.5 %) cases in which patients sought to refuse treatments made available by a neurologist, they left without a prescription or referral. This paper seeks to explain this apparently anomalous finding. Starting with an example of what I expected to find – a ‘duel’ that ends with the neurologist persuading the patient to accept treatment – I show that this is, in fact, the exception. By contrast, most of the (attempted) refusals are collaborative, occurring after the neurologist has initiated decision-making in a way that designedly foregrounds the patients' views as the basis for deciding. I show also that, having done so, the neurologists typically continue to treat the decision as subject to the patient's preferences. Thus, the trajectories in my collection – despite including attempts to refuse treatment – do not typically become duels. Rather, patients are refusing treatment in a sequential context that facilitates making their own decision.

Objectives: Disparities in adjuvant treatment between Black and White women with endometrial cancer (EC) are well documented and contribute to worse outcomes among Black women. However, factors leading to disparate treatment patterns are understudied. We examined whether patient refusal of adjuvant treatment (chemotherapy or radiation) differed between Black and White women and whether refusal differences mediate racial disparities in EC survival. Methods: We used the National Cancer Database (NCDB), a hospital-based registry covering ~70% of U.S. cancer diagnoses, to identify non-Hispanic Black (NHB) and non-Hispanic White (NHW) women diagnosed with EC from 2004 to 2015 who either received or refused chemotherapy or radiation. NCDB data are abstracted from medical records by tumor registrars. We used logistic regression to estimate adjusted odds ratios (aOR) of patient refusal of treatment associated with race, and accelerated failure time models to estimate differences in overall survival (OS) by race. We used causal mediation analysis to estimate how much of the difference in OS by race could be attributed to racial differences in treatment refusal. We considered the overall study populations as well as strata defined by histology, and adjusted for factors assessed at diagnosis, including age, comorbidity burden, insurance, hospital characteristics, stage, histology, and zip code-level income and education. Results: We identified 49,518 women (83% NHW, 17% NHB) who received adjuvant chemotherapy and 12,710 women with documented refusal (90% NHW, 10% NHB). After adjusting for covariates, NHB women were more likely to refuse chemotherapy than NHW women (aOR=1.12, p=0.005), particularly among those with low-grade endometrioid (aOR = 1.22, p=0.02) or serous (aOR = 1.38, p Conclusions: We observed differences in treatment refusal by race, and those differences may be responsible for up to 1 month of the OS disparity between NHW and NHB women. This represents a small fraction of the dramatic racial disparity in EC survival. While a better understanding of the reasons for patient treatment refusal and subsequent intervention may help improve outcomes for some women, other causes of disparate outcomes warrant further investigation.

Informed consent is an important component of emergency medical treatment. Most emergency department patients can provide informed consent for treatment upon arrival. Informed consent should also be obtained for emergency medical interventions that may entail significant risk. A related concept to informed consent is informed refusal of treatment. Patients may refuse emergency medical treatment during their evaluation and treatment. This article addresses important considerations for patients who refuse treatment, including case studies and discussion of definitions, epidemiology, assessment of decisional capacity, information delivery, medicolegal considerations, and alternative care plans.

Objective The Advisory Committee on Immunization Practices recommends routine human papillomavirus (HPV) vaccination for female adolescents aged 11 to 12 years, yet vaccination rates remain low. We conducted a qualitative study to understand English- and Spanish-speaking parents' reasons for noninitiation or noncompletion of the HPV vaccine series for their daughters. Methods Parents of female adolescents aged 12 to 15 years who had not initiated or not completed the HPV vaccine series were identified through administrative data in 2 large urban safety net health care systems in Colorado. Focus groups and in-depth interviews were conducted with English-speaking parents and in-depth interviews were conducted with Spanish-speaking parents. All data were recorded, transcribed, and analyzed for thematic content by experienced analysts using established qualitative content analysis techniques. Results Forty-one parents participated in the study. Thirty parents participated in individual interviews and 11 parents participated in 1 of 2 focus groups. The most common reasons for noninitiation and noncompletion among English-speaking parents included a low perceived risk of HPV infection, vaccine safety concerns, and distrust of government and/or medicine. In contrast, Spanish-speaking parents most often reported that providers had either not encouraged initiation of the HPV vaccine series or had not explained the necessity of completing the series. Some noninitiating parents, particularly Spanish-speaking ones, also cited concerns that vaccination would encourage sexual activity. Conclusions The reasons for noninitiation and noncompletion of the HPV vaccine series differed substantially between English- and Spanish-speaking parents. To maximize uptake of HPV vaccine, varying approaches might be needed to effectively target specific populations.

© 2017 Elsevier Ltd Background pregnant women, like all competent adults, have the right to refuse medical treatment, although concerns about maternal and fetal safety can make doing so problematic. Empirical research about refusal of recommended maternity care has mostly described the attitudes of clinicians, with women's perspectives notably absent. Design feminist thematic analysis of in-depth, semi-structured interviews with women's (n=9), midwives’ (n=12) and obstetricians’ (n=9) about their experiences of refusal of recommended maternity care. Findings three major interrelated themes were identified. “Valuing the woman's journey”, encapsulated care experiences that women valued and clinicians espoused, while “The clinician's line in the sand” reflected the bounded nature of support for maternal autonomy. When women's birth intentions were perceived by clinicians to transgress their line in the sand, a range of strategies were reportedly used to convince the woman to accept recommended care. These strategies formed a pattern of “Escalating intrusion”. Key conclusions and implications for practice declining recommended care situated women at the intersection of two powerful normative discourses: medical dominance and the patriarchal institution of motherhood. Significant pressures on women's autonomy resulted from an apparent gap between clinicians’ espoused and reported practices. Implications for policy and practice include a need for specific guidance for clinicians providing care in situations of maternal refusal, the potential value of an independent third-party for advice and advocacy, and the development of models that support reflexive practice amongst clinicians.

Purpose Vaccines represent one of the most important aspects of pediatric preventive care. However, parents are increasingly questioning the safety of and need for vaccines, and as a result, vaccination rates have fallen to dangerously low levels in certain communities. The effects of vaccine hesitancy are widespread. Community pediatricians who interact regularly with vaccine-hesitant parents report higher levels of burnout and lower levels of job satisfaction. Not surprisingly, vaccine hesitancy has also had direct influence on vaccination rates, which in turn are linked to increased emergency department use, morbidity, and mortality. Methods Literature from 1999 to 2017 regarding vaccines and vaccine hesitancy was reviewed. Findings Few evidence-based strategies exist to guide providers in their discussions with vaccines-hesitant parents. Recent research has shown a presumptive approach (ie, the provider uses language that presumes the caregiver will vaccinate his or her child) is associated with higher vaccination uptake. Motivational interviewing is a promising technique for more hesitant parents. Implications At the community level, evidence-based communication strategies to address vaccine hesitancy are needed. The practice of dismissing families from pediatric practices who refuse to vaccinate is common, although widely criticized. Other controversial and rapidly evolving topics include statewide vaccination mandates and school exemption policies. Electronic interventions, such as text-messaging services and social media, have recently emerged as effective methods of communication and may become more important in coming years.

Purpose Research demonstrates a negative psychosocial impact of infertility among otherwise healthy adults, and distress among adolescents facing the prospect of future infertility due to various medical conditions and treatments that impair reproductive health. Guidelines state that providers should counsel transgender youth about potential infertility and fertility preservation (FP) options prior to initiation of hormone therapy. The purpose of this study was to examine the rates of fertility counseling and utilization of FP among a cohort of adolescents with gender dysphoria seen at a large gender clinic. Methods An Institutional Review Board–approved retrospective review of electronic medical records was conducted of all patients with ICD-9/10 codes for gender dysphoria referred to Pediatric Endocrinology for hormone therapy (puberty suppression and/or cross-sex hormones) from January 2014 to August 2016. Results Seventy-eight patients met inclusion criteria. Five children were prepubertal, no hormone therapy was considered, and they were therefore excluded. Of the remaining 73 patients, 72 had documented fertility counseling prior to initiation of hormone therapy and 2 subjects attempted FP; 45% of subjects mentioned a desire or plan to adopt, and 21% said they had never wanted to have children. Conclusions Utilization rates of FP are low among transgender adolescents. More research is needed to understand parenthood goals among transgender youth at different ages and developmental stages and to explore the impact of gender dysphoria on decision-making about FP and parenthood. Discussions about infertility risk, FP, and other family building options should be prioritized in this vulnerable adolescent population.

In the early 1900s, Frederick McKay discovered the oral health benefits of fluoride when he observed that individuals exposed to naturally fluoridated drinking water in Colorado Springs, Colorado were significantly less likely to develop tooth decay.1 Laboratory studies later confirmed his clinical observations. Since then, topical fluorides have become the cornerstone of prevention in dentistry. Fluoride is available in a variety of modalities each with varying concentrations: drinking water fluoridated at 0.7ppm; over-the-counter toothpastes and mouthwashes; foams, gels, and varnishes provided by health providers during dental and medical visits; and prescription-strength toothpastes, drops, or tablets. Fluorides prevent tooth decay by promoting remineralization and inhibiting demineralization of enamel.2–5 Fluoride is recommended as part of a comprehensive tooth decay prevention program.6–8 Regular exposure to fluoride is safe, even for young infants.9,10 Even though fluoride is effective and safe, recent data showed that 13% of parents refused fluoride treatments for their child during a preventive dental or medical visit.11 Even more parents are fluoride hesitant, meaning that they may accept fluoride for their children but have unresolved concerns. These findings, which are the only published data specifically on fluoride refusal behaviors, are of concern from an evidence-based perspective because fluoride is one of the only preventive treatments we have available for caries prevention. The growing phenomenon of fluoride refusal has implications for the way in which clinicians communicate with parents about fluoride so that parents can make optimal preventive health care decisions for their children. This article will include a discussion of conceptual issues related to fluoride refusal, including definitions and measurement-related gaps. Next, I will review the relevant scientific literature to identify potential factors related to fluoride refusal. This information will form the basis for recommendations on clinical strategies that can be incorporated into practice and future research priorities related to building on stronger scientific evidence base to manage and address fluoride refusal in clinical settings. Defining and Conceptualizing Fluoride Refusal I defined fluoride refusal as any instance in which a parent has refused, attempted to refuse, or considered refusing professional fluoride treatment for their child in a health care setting because of concerns about the necessity, safety, or consequences of fluoride. I emphasize the behavioral, cultural, or social origins of fluoride refusal behaviors rather than developmental or economic etiologies. Thus, fluoride refusal excludes reasons like a parent refusing because their young child does not like the taste (developmental) or the inability to pay for fluoride treatment when a parent would otherwise accept it (economic).12,13 Fluoride refusal is typically conceptualized as a binary behavior. A parent brings their child into clinic, is presented with the option of fluoride, and makes a decision to either accept or refuse fluoride. However, similar to the continuum-of-addiction model used to describe smoking14, fluoride refusal is positioned at one end of a continuum that ranges from complete acceptance of fluoride with no reservations to complete refusal with no desire to change one’s mind (Figure 1). Somewhere in the middle of this continuum are hesitant parents, regardless of whether they accept fluoride, with some degree of concern. Parents who refuse fluoride are considered hesitant, but not all hesitant parents refuse fluoride. Studies on parent preferences regarding preventive care have reported that most parents accept fluoride, but there are some parents with concerns.15,16 These findings support the continuum model. For simplicity, when I use the term “fluoride refusal” in this paper, it incorporates the concept of hesitancy Open in a separate window Figure 1 Continuum of fluoride hesitancy behaviors.

Pregnancy is a period of psychological change which may lead to difficulties of adaptation and psychological suffering and give rise to high-risk behaviours for the fœtus in pregnant women. These risk behaviours, which are defined by certain authors as a form of "maltreatment" of the fœtus, usually spring from the psychological distress of the pregnant woman but are not recognised as a specific medical disorder. We illustrate the difficulties encountered in the identification of, and the specific intervention in, these situations through the clinical case of a pregnant drugs-dependent patient subjected to several stress factors who, in addition to consuming substances, developed high-risk behaviours for herself and her pregnancy: self-endangerment under the influence of substances, falls or refusals of treatment. In our first part, we discuss the medicolegal possibilities afforded by French law to protect the fœtus in the event of the future mother's high-risk behaviours. In our second part, we discuss the successive evolutions of the legal status of the fœtus and pregnancy, and their consequences for medical practice and the clinical situations concerned. The lack of an answer concerning the designation of these behaviours, as either medical, legal or social acts, will prompt perinatal practitioners to a certain medicolegal prudence.