Surface color spectrophotometry in a murine model of steatosis: an accurate technique with potential applicability in liver procurement.

Steatosis is the most important prognostic histologic feature in the setting of liver procurement. The currently utilized diagnostic methods, including gross evaluation and frozen section examination, have important shortcomings. Novel techniques that offer advantages over the current tools could be of significant practical utility. The aim of this study is to evaluate the accuracy of surface color spectrophotometry in the quantitative assessment of steatosis in a murine model of fatty liver. C57BL/6 mice were divided into a control group receiving normal chow (n = 19), and two steatosis groups receiving high-fat diets for up to 20 weeks-mild steatosis (n = 10) and moderate-to-severe steatosis (n = 19). Mouse liver surfaces were scanned with a hand-held spectrophotometer (CM-600D; Konica-Minolta, Osaka, Japan). Spectral reflectance data and color space values (L*a*b*, XYZ, L*c*h*, RBG, and CMYK) were correlated with histopathologic steatosis evaluation by visual estimate, digital image analysis (DIA), as well as biochemical tissue triglyceride measurement. Spectral reflectance and most color space values were very strongly correlated with histologic assessment of total steatosis, with the best predictor being % reflectance at 700 nm (r = 0.91 [0.88-0.94] for visual assessment, r = 0.92 [0.88-0.95] for DIA of H&E slides, r = 0.92 [0.87-0.95] for DIA of oil-red-O stains, and r = 0.78 [0.63-0.87] for biochemical tissue triglyceride measurement, p < 0.0001 for all). Several spectrophotometric parameters were also independently predictive of large droplet steatosis. In conclusion, hepatic steatosis can accurately be assessed using a portable, commercially available hand-held spectrophotometer device. If similarly accurate in human livers, this technique could be utilized as a point-of-care tool for the quantitation of steatosis, which may be especially valuable in assessing livers during deceased donor organ procurement.

Concurrence of the strengths and difficulties questionnaire and developmental behaviour checklist among children with an intellectual disability.

BACKGROUND: The Strengths and Difficulties Questionnaire (SDQ) is widely used to measure emotional and behavioural problems in typically developing young people, although there is some evidence that it may also be suitable for children with intellectual disability (ID). The Developmental Behaviour Checklist - Parent version (DBC-P) is a measure of emotional and behavioural problems that was specifically designed for children and adolescents with an ID. The DBC-P cut-off has high agreement with clinical diagnosis. The aim of this study was to estimate the relationship between DBC-P and SDQ scores in a sample of children with ID. METHOD: Parents of 83 young people with ID aged 4-17 years completed the parent versions of the SDQ and the DBC-P. We evaluated the concurrent validity of the SDQ and DBC-P total scores, and the agreement between the DBC-P cut-off and the SDQ cut-offs for 'borderline' and 'abnormal' behaviour. RESULTS: The SDQ total difficulties score correlated well with the DBC-P total behaviour problem score. Agreement between the SDQ borderline cut-off and the DBC-P cut-off for abnormality was high (83%), but was lower for the SDQ abnormal cut-off (75%). Positive agreement between the DBC-P and the SDQ borderline cut-off was also high, with the SDQ borderline cut-off identifying 86% of those who met the DBC-P criterion. Negative agreement was weaker, with the SDQ borderline cut-off identifying only 79% of the participants who did not meet the DBC-P cut-off. CONCLUSION: The SDQ borderline cut-off has some validity as a measure of overall levels of behavioural and emotional problems in young people with ID, and may be useful in epidemiological studies that include participants with and without ID. However, where it is important to focus on behavioural profiles in children with ID, a specialised ID instrument with established psychometric properties, such as the DBC-P, may provide more reliable and valid information.

Profiles of children with Down syndrome who meet screening criteria for autism spectrum disorder (ASD): a comparison with children diagnosed with ASD attending specialist schools.

BACKGROUND: Recent research suggests that around 16% to 18% of children with Down syndrome (DS) also meet diagnostic criteria for autism spectrum disorder (ASD). However, there are indications that profiles of autism symptoms in this group may vary from those typically described in children with ASD. METHOD: Rates of autism symptoms and emotional and behavioural problems among children with DS who screened positive for ASD on the Social Communication Questionnaire (SCQ) (n = 183) were compared with a group of children with clinical diagnoses of ASD (n = 189) attending specialist schools in the UK. Groups were matched for age and approximate language level (use of phrase speech). RESULTS: Profiles of autistic symptoms in the two groups were generally similar, but children with DS meeting ASD cut-off on the SCQ tended to show fewer problems in reciprocal social interaction than those in the ASD group. They also showed slightly lower rates of emotional and peer-related problems. The results mostly confirm findings from a previous study in which the original validation sample for the SCQ was used as a comparison group. CONCLUSION: Findings suggest that children with DS who meet screening criteria for ASD show similar profiles of communication and repetitive behaviours to those typically described in autism. However, they tend to have relatively milder social difficulties. It is important that clinicians are aware of this difference if children with DS and ASD are to be correctly diagnosed and eligible for specialist intervention and education services.

Age and gender-related differences in emotional and behavioural problems and autistic features in children and adolescents with Down syndrome: a survey-based study of 674 individuals.

BACKGROUND: Recent studies have indicated an increased risk of autism, behavioural and emotional problems and attention-deficit/hyperactivity disorder in individuals with Down syndrome. METHOD: In a large-scale survey-based study, we examined the rates of these problems and their relationship to age and gender, in a sample of 674 individuals (4-18 years) with Down syndrome. The relationship with IQ level was also explored in a subsample (n = 175). The Strengths and Difficulties Questionnaire and the Social Communication Questionnaire were used to assess behavioural and emotional problems and autism traits. RESULTS: On the Strengths and Difficulties Questionnaire, peer problems were the most frequently reported difficulty (48% > cut-off), followed by hyperactivity/inattention (34% > cut-off). On the Social Communication Questionnaire, 37% scored at or above cut-off (≥15) for autism spectrum disorder; 17% were at or above the suggested cut-off (≥22) for autism. Little association between age and behavioural or emotional problems or with severity of autistic symptomatology was found. However, peer problems were more common in adolescents than in junior school children (P < 0.001); Hyperactivity/inattention was less prevalent among adolescents (P < 0.001). CONCLUSIONS: High rates of autistic features, emotional and behavioural problems are documented. These problems are related to age, gender and degree of intellectual disability.

Post-hoc comparison of vitamin D status at three timepoints during pregnancy demonstrates lower risk of preterm birth with higher vitamin D closer to delivery.

There have been observational reports that maternal vitamin D status at baseline and not closest to delivery is a better predictor of pregnancy outcomes, suggesting that a cascade of events is set into motion that is not modifiable by vitamin D supplementation during later pregnancy. To address this issue, in this exploratory post-hoc analysis using correlation and logistic regression, we sought to measure the strength of the association between serum 25(OH)D concentrations at 3 timepoints during pregnancy: baseline, 1st trimester (<16 weeks); 2nd trimester (16-26 weeks); and 3rd trimester (≥27 weeks) and preterm birth. It was hypothesized that the 25(OH)D value closest to delivery would be most significantly associated with preterm birth. To accomplish this objective, the datasets from NICHD (n=333) and Thrasher Research Fund (n=154) vitamin D supplementation pregnancy studies were combined. The results of this analysis were that 25(OH)D values closer to delivery were more strongly correlated with gestational age at delivery than earlier values: 1st trimester: r=0.11 (p=0.02); 2nd trimester: r=0.08 (p=0.09); and 3rd trimester: r=0.15 (p=0.001). When logistic regression was performed with preterm birth (<37 weeks) as the outcome and 25(OH)D quartiles as the predictor variable, adjusting for study and participant race/ethnicity, as with the correlation analysis, the measurements closer to delivery were more significantly associated and had a higher magnitude of effect. That is, at baseline, those who had serum concentrations <50nmol/L (20ng/mL) had 3.3 times of odds of a preterm birth compared to those with serum concentrations ≥100nmol/L (40ng/mL; p=0.27). At 2nd trimester, the odds were 2.0 fold (p=0.21) and at the end of pregnancy, the odds were 3.8 fold (p=0.01). The major findings from this exploratory analysis were: (1) maternal vitamin D status closest to delivery date was more significantly associated with preterm birth, suggesting that later intervention as a rescue treatment may positively impact the risk of preterm delivery, and (2) a serum concentration of 100nmol/L (40ng/mL) in the 3rd trimester was associated with a 47% reduction in preterm births. This article is part of a Special Issue entitled '17th Vitamin D Workshop'.

Yunis-varon syndrome: further delineation of cardiovascular and endocrine outcome.

Yunis-Varon syndrome is a rare autosomal recessive condition initially characterized by specific skeletal and ectodermal abnormalities, and a poor prognosis, due to neurological and cardiovascular involvement. We describe the cardiovascular and endocrine complications in a 26-year-old man who had been reported previously, adding dilated cardiomyopathy to the clinical features consistent with Yunis-Varon syndrome. Short stature, successfully treated with growth hormone, and hypertension secondary to bilateral renal artery stenosis expand the phenotype.

Increased incidence of domestic animal bites following a disaster due to natural hazards.

INTRODUCTION: During deployment following Hurricane Ike in September 2008, bites from domestic animals were among the top three trauma complaints seen at the National Disaster Medical System (NDMS) Disaster Medical Assistance Team (DMAT) base of operations. PROBLEM: Unlike previous reports of frightened, misplaced dogs and cats biting strangers and rescue workers, there was an increase in bites associated with presumed non-rabid pets who were known to the bite victim. METHODS: This was an observational sampling of all patients presenting for medical care during deployment to the AL-3 DMAT base of operations in Webster, Texas, following Hurricane Ike. Findings were compared with unofficial local norms and observations from the literature. RESULTS: Of the people with animal bites presenting to the field hospital, dog bites accounted for 55%, cat bites, 40%, and snake bites, 5%. Most of the wounds required suturing and were not simple punctures. Most bites (70%) involved the hand(s). Some patients presented >24 hours after the bite, and already had developed cellulitis. One patient required transfer and inpatient admission for intravenous antibiotics and debridement of a hand injury with spread into the metacarpophalangeal space. CONCLUSIONS: Most of the bites were severe and occurred within the first 72 hours after the hurricane, and waned steadily over the following weeks to baseline levels. No animal bites caused by misplaced dogs and cats biting strangers were seen. There was an increase in bites associated with domesticated pets known to the bite victim. The current NDMS cache is stocked adequately to care for most wounds caused by animal bites. However post-exposure rabies treatment is not part of the routine medications offered. For future disaster preparedness training, pet owners should be aware of the increased potential for dog and cat bites.

Evaluation of the effect of prehospital application of continuous positive airway pressure therapy in acute respiratory distress.

OBJECTIVE: The impact of the use of mask continuous positive airway pressure (CPAP) on patients with acute respiratory distress in the prehospital, rural setting has not been defined. The goal was to test the use of CPAP using the Respironics WhisperFlow CPAP in patients presenting with acute respiratory distress. This was a collaborative evaluation of CPAP involving a rural EMS agency and the regional medical center. Patient outcomes including the overall rate of intubation-both in the field and in the emergency department (ED), and length of stay in the hospital and Intensive Care Unit (ICU) were tracked. METHODS: The study was an eight-month, crossover, observational, non-blinded study. RESULTS: During the four months of baseline data collection, 7.9% of patients presenting with respiratory distress were intubated within the first 48 hours of care. Their average ICU length of stay was 8.0 days. During the four months of data collection when CPAP was available in the prehospital setting, intubation was not required for any patients in the field or in the ED. Admissions to the ICU decreased. Those patients admitted to the ICU, the average ICU length of stay deceased to 4.3 days. CONCLUSIONS: The use of the CPAP in the prehospital setting is beneficial for patients in acute respiratory distress.

Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study.

OBJECTIVE: To assess the natural course and the important predictors of severe symptoms in urinary tract infection and the effect of antibiotics and antibiotic resistance. DESIGN: Observational study. SETTING: Primary care. PARTICIPANTS: 839 non-pregnant adult women aged 18-70 presenting with suspected urinary tract infection. MAIN OUTCOME MEASURE: Duration and severity of symptoms. RESULTS: 684 women provided some information on symptoms; 511 had both laboratory results and complete symptom diaries. For women with infections sensitive to antibiotics, severe symptoms, rated as a moderately bad problem or worse, lasted 3.32 days on average. After adjustment for other predictors, moderately bad symptoms lasted 56% longer (incidence rate ratio 1.56, 95% confidence interval 1.22 to 1.99, P<0.001) in women with resistant infections; 62% longer (1.62, 1.13 to 2.31, P=0.008) when no antibiotics prescribed; and 33% longer (1.33, 1.14 to 1.56, P<0.001) in women with urethral syndrome. The duration of symptoms was shorter if the doctor was perceived to be positive about diagnosis and prognosis (continuous 7 point scale: 0.91, 0.84 to 0.99; P=0.021) and longer when the woman had frequent somatic symptoms (1.03, 1.01 to 1.05, P=0.002; for each symptom), a history of cystitis, urinary frequency, and more severe symptoms at baseline. CONCLUSION: Antibiotic resistance and not prescribing antibiotics are associated with a greater than 50% increase in the duration of more severe symptoms in women with uncomplicated urinary tract infection. Women with a history of cystitis, frequent somatic symptoms (high somatisation), and severe symptoms at baseline can be given realistic advice that they are likely to have severe symptoms lasting longer than three days.

Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial.

OBJECTIVE: To assess the impact of different management strategies in urinary tract infections. DESIGN: Randomised controlled trial. SETTING: Primary care. PARTICIPANTS: 309 non-pregnant women aged 18-70 presenting with suspected urinary tract infection. INTERVENTION: Patients were randomised to five management approaches: empirical antibiotics; empirical delayed (by 48 hours) antibiotics; or targeted antibiotics based on a symptom score (two or more of urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result (nitrite or both leucocytes and blood), or a positive result on midstream urine analysis. Self help advice was controlled in each group. MAIN OUTCOME MEASURES: Symptom severity (days 2 to 4) and duration, and use of antibiotics. RESULTS: Patients had 3.5 days of moderately bad symptoms if they took antibiotics immediately. There were no significant differences in duration or severity of symptoms (mean frequency of symptoms on a 0 to 6 scale: immediate antibiotics 2.15, midstream urine 2.08, dipstick 1.74, symptom score 1.77, delayed antibiotics 2.11; likelihood ratio test for the five groups P=0.177). There were differences in antibiotic use (immediate antibiotics 97%, midstream urine 81%, dipstick 80%, symptom score 90%, delayed antibiotics 77%; P=0.011) and in sending midstream urine samples (immediate antibiotics 23%, midstream urine 89%, dipstick 36%, symptom score 33%, delayed antibiotics 15%; P<0.001). Patients who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio 0.57 (95% confidence interval 0.36 to 0.89), P=0.014) but on average had symptoms for 37% longer than those taking immediate antibiotics (incident rate ratio 1.37 (1.11 to 1.68), P=0.003), particularly the midstream urine group (73% longer, 22% to 140%; none of the other groups had more than 22% longer duration). CONCLUSION: All management strategies achieve similar symptom control. There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use. STUDY REGISTRATION: National Research Register N0484094184 ISRCTN: 03525333.

Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study.

OBJECTIVES: To estimate clinical and dipstick predictors of infection and develop and test clinical scores; to compare management using clinical and dipstick scores with commonly used alternative strategies; to estimate the cost-effectiveness of each strategy; and to understand the natural history of urinary tract infection (UTI) and women's concerns about its presentation and management. DESIGN: There were six studies: (1) validation development for diagnostic clinical and dipstick scores; (2) validation of the scores developed; (3) observation of the natural history of UTI; (4) randomised controlled trial (RCT) of scores developed in study 1; (5) economic analysis of the RCT; (6) qualitative study of patients in the RCT. SETTING: Primary care. PARTICIPANTS: Women aged 17-70 with suspected UTI. INTERVENTIONS: Patients were randomised to five management approaches: empirical antibiotics; empirical delayed antibiotics; target antibiotics based on a higher symptom score; target antibiotics based on dipstick results; or target antibiotics based on a positive mid-stream specimen of urine (MSU). MAIN OUTCOME MEASURES: Antibiotic use, use of MSUs, rates of reconsultation and duration, and severity of symptoms. RESULTS: (1) 62.5% of women had confirmed UTI. Only nitrite, leucocyte esterase and blood independently predicted diagnosis of UTI. A dipstick rule--based on having nitrite or both leucocytes and blood--was moderately sensitive (77%) and specific (70%) [positive predictive value (PPV) 81%, negative predictive value (NPV) 65%]. A clinical rule--based on having two of urine cloudiness, offensive smell, reported moderately severe dysuria, moderately severe nocturia--was less sensitive (65%) (specificity 69%, PPV 77%, NPV 54%). (2) 66% of women had confirmed UTI. The predictive values of nitrite, leucocyte esterase and blood were confirmed. The dipstick rule was moderately sensitive (75%) but less specific (66%) (PPV 81%, NPV 57%). (3) Symptoms rated as moderately bad or worse lasted 3.25 days on average for infections sensitive to antibiotics; resistant infections lasted 56% longer, infections not treated with antibiotics 62% longer and symptoms associated with urethral syndrome 33% longer. Symptom duration was shorter if the doctor was perceived to be positive about prognosis, and longer with frequent somatic symptoms, previous history of cystitis, urinary frequency and more severe symptoms at baseline. (4) 66% of the MSU group had laboratory-confirmed UTI. Women suffered 3.5 days of moderately bad symptoms if they took antibiotics immediately but 4.8 days if they delayed taking antibiotics for 48 hours. Taking bicarbonate or cranberry juice had no effect. (5) The MSU group was more costly over 1 month but not over 1 year. Cost-effectiveness acceptability curves showed that for a value per day of moderately bad symptoms of over 10 pounds, the dipstick strategy is most likely to be cost-effective. (6) Fear of spread to the kidneys, blood in the urine, and the impact of symptoms on vocational and leisure activities were important triggers for seeking help. When patients are asked to delay taking antibiotics the uncomfortable and worrying journey from 'person to patient' needs to be acknowledged and the rationale behind delaying the antibiotics made clear. CONCLUSIONS: To achieve good symptom control and reduce antibiotic use clinicians should either offer a 48-hour delayed antibiotic prescription to be used at the patient's discretion or target antibiotic treatment by dipsticks (positive nitrite or positive leucocytes and blood) with the offer of a delayed prescription if dipstick results are negative.

The occurrence of black corals in Jamaican reef environments, with special reference to Stichopathes lutkeni (Antipatharia: Antipathidae)

The purpose of this study was to record the species of Antipatharia on Jamaican reefs and to carry out limited studies on densities and sizes of the common species.In addition,a cliff face created by dredging in 2002 provided the opportunity to study growth of newly settled colonies.Observations since 1998 and measurements since 2001 were made using SCUBA at depths down to 35 m.Seven species of Antipatharia were observed on steep coral reef escarpments below 25 m depth.The commonest species was the unbranched "wire coral " Stichopathes lutkeni .Other common species included the fan-shaped black corals Antipathes atlantica and A. gracilis .Frequently encountered species included commercially important A.caribbeana and a species with an unusual,scrambling growth form, A. rubusiformis.The other major commercial species in the Caribbean, Plumapathes pennacea ,and a cave-dwelling species,A.umbratica ,were rarely observed.Greatest black coral abundance occurred on steep slopes of hard substrata in low light intensity but exposed to the long-shore current. Combined densities of the commoner Antipatharia at 30 m deep at Rio Bueno on the north coast,ranged from 0.1 to 2.5 m-2 (eleven 10 m x 1 m belt transects,1-25 colonies per transect,68 colonies in total).Forty-six of the 68 colonies were S.lutkeni ,while nearby at Discovery Bay at 30-35 m,55 out of 59 colonies were S.lutkeni. There was a significant difference between the mean length of colonies in these two populations of S.lutkeni (100 cm and 80 cm,respectively),probably relating to habitat.A third population of S.lutkeni growing at 15-20 m deep on the recently dredged cliff had a much smaller mean length of 36.6 cm (n=27).The largest individual measured 83 cm long,indicating a minimum growth rate of the unbranched corallum of 2.1 mm per day

The occurrence of black corals in Jamaican reef environments, with special reference to Stichopathes lutkeni (Antipatharia: Antipathidae).

The purpose of this study was to record the species of Antipatharia on Jamaican reefs and to carry out limited studies on densities and sizes of the common species. In addition, a cliff face created by dredging in 2002 provided the opportunity to study growth of newly settled colonies. Observations since 1998 and measurements since 2001 were made using SCUBA at depths down to 35 m. Seven species of Antipatharia were observed on steep coral reef escarpments below 25 m depth. The commonest species was the unbranched "wire coral" Stichopathes lutkeni. Other common species included the fan-shaped black corals Antipathes atlantica and A. gracilis. Frequently encountered species included commercially important A. caribbeana and a species with an unusual, scrambling growth form, A. rubusiformis. The other major commercial species in the Caribbean, Plumapathes pennacea, and a cave-dwelling species, A. umbratica, were rarely observed. Greatest black coral abundance occurred on steep slopes of hard substrata in low light intensity but exposed to the long-shore current. Combined densities of the commoner Antipatharia at 30 m deep at Rio Bueno on the north coast, ranged from 0.1 to 2.5 m(-2) (eleven 10 m x 1 m belt transects, 1-25 colonies per transect, 68 colonies in total). Forty-six of the 68 colonies were S. lutkeni, while nearby at Discovery Bay at 30-35 m, 55 out of 59 colonies were S. lutkeni. There was a significant difference between the mean length of colonies in these two populations of S. lutkeni (100 cm and 80 cm, respectively), probably relating to habitat. A third population of S. lukeni growing at 15-20 m deep on the recently dredged cliff had a much smaller mean length of 36.6 cm (n= 27). The largest individual measured 83 cm long, indicating a minimum growth rate of the unbranched corallum of 2.1 mm per day.

Coronary artery fistula in a patient with pulmonary atresia and tricuspid atresia clinical and MRI findings.

The MRI findings of a case of coronary artery fistula occurring in a patient with pulmonary atresia and tricuspid atresia is presented.

Acute myocardial injury caused by Sydney funnel-web spider (Atrax robustus) envenoming.

A 67-year-old female suffered envenoming by a Sydney funnel-web spider (Atrax robustus), complicated by ST elevation and elevated troponin levels consistent with an acute myocardial injury. She was treated primarily with funnel-web spider antivenom, admission to intensive care and initial respiratory support for acute pulmonary oedema. The mechanism by which funnel-web spider envenomation caused myocardial injury is unclear but follow-up nuclear studies in the patient demonstrated that she had minimal atherosclerotic disease.

Validation study of a diary for use in acute lower respiratory tract infection.

BACKGROUND: Despite lower respiratory tract infection (LRTi) being the most common illness treated by doctors, no validated outcome measure to assess symptom duration and severity has been developed for patient self-completion. METHODS: As part of a randomized control trial researching management of acute LRTi, an easy self-completion diary was formulated and validated against the 'measure yourself medical outcome profile 2' (MYMOP2), an instrument previously validated in general practice. RESULTS: Spearman rank correlations of the diary profile versus MYMOP2 profile at baseline (r = 0.62), day 11 (r = 0.81) and change in score over time (r = 0.51) indicate that our diary correlates significantly with MYMOP2. The standardized response mean of the diary profile (mean change/SD change) = 1.48, indicating sensitivity to change. CONCLUSION: This study shows that a simple symptom diary is internally reliable, valid and sensitive to change for acute LRTi. This instrument could be used as a routine measure of LRTi in further research in both primary and secondary care.

Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations.

OBJECTIVE: To measure patients' perceptions of patient centredness and the relation of these perceptions to outcomes. DESIGN: Observational study using questionnaires. SETTING: Three general practices. PARTICIPANTS: 865 consecutive patients attending the practices. MAIN OUTCOME MEASURES: Patients' enablement, satisfaction, and burden of symptoms. RESULTS: Factor analysis identified five components. These were communication and partnership (a sympathetic doctor interested in patients' worries and expectations and who discusses and agrees the problem and treatment, Cronbach's alpha=0.96); personal relationship (a doctor who knows the patient and their emotional needs, alpha=0.89); health promotion (alpha=0.87); positive approach (being definite about the problem and when it would settle, alpha=0.84); and interest in effect on patient's life (alpha=0.89). Satisfaction was related to communication and partnership (adjusted beta=19.1; 95% confidence interval 17.7 to 20.7) and a positive approach (4.28; 2.96 to 5.60). Enablement was greater with interest in the effect on life (0.55; 0.25 to 0.86), health promotion (0.57; 0.30 to 0.85), and a positive approach (0.82; 0.52 to 1.11). A positive approach was also associated with reduced symptom burden at one month (beta=-0.25; -0.41 to -0.10). Referrals were fewer if patients felt they had a personal relationship with their doctor (odds ratio 0.70; 0.54 to 0.90). CONCLUSIONS: Components of patients' perceptions can be measured reliably and predict different outcomes. If doctors don't provide a positive, patient centred approach patients will be less satisfied, less enabled, and may have greater symptom burden and higher rates of referral.