Assessing Shared Decision-Making Clinical Behaviors Among Genetic Counsellors.

Shared decision-making (SDM) is a collaborative approach in which clinicians educate, support, and guide patients as they make informed, value-congruent decisions. SDM improves patients' health-related outcomes through increasing knowledge, reducing decisional conflict, and enhancing experience of care. We measured SDM in genetic counselling appointments with 27 pregnant women who were at increased risk to have a baby with a genetic abnormality. The eight experienced genetic counsellors who participated had no specific SDM training and were unaware that SDM was being assessed. Audio transcripts of appointments were scored using 'Observing Patient Involvement in Decision Making' (OPTION12). Patients' anxiety and decisional conflict were also assessed. The genetic counsellors' mean OPTION12 score was 42.4% (SD 9.0%; possible range 0-100%). Specific SDM behaviours that scored highest included introducing the concept of equipoise and listing all options with their pros and cons. Behaviours that scored lowest included eliciting patients' preferred approach to receiving information and desired degree of involvement in decision-making. Patients' levels of anxiety and decisional conflict were unassociated with genetic counsellors' OPTION12 scores. Some SDM behaviours were better demonstrated in this prenatal genetic counselling study than others. Formal training of genetic counsellors in SDM may enhance use of this approach in their professional practice.

DECIDE: a Decision Support Tool to Facilitate Parents' Choices Regarding Genome-Wide Sequencing.

We describe the rationale, development, and usability testing for an integrated e-learning tool and decision aid for parents facing decisions about genome-wide sequencing (GWS) for their children with a suspected genetic condition. The online tool, DECIDE, is designed to provide decision-support and to promote high quality decisions about undergoing GWS with or without return of optional incidental finding results. DECIDE works by integrating educational material with decision aids. Users may tailor their learning by controlling both the amount of information and its format - text and diagrams and/or short videos. The decision aid guides users to weigh the importance of various relevant factors in their own lives and circumstances. After considering the pros and cons of GWS and return of incidental findings, DECIDE summarizes the user's responses and apparent preferred choices. In a usability study of 16 parents who had already chosen GWS after conventional genetic counselling, all participants found DECIDE to be helpful. Many would have been satisfied to use it alone to guide their GWS decisions, but most would prefer to have the option of consulting a health care professional as well to aid their decision. Further testing is necessary to establish the effectiveness of using DECIDE as an adjunct to or instead of conventional pre-test genetic counselling for clinical genome-wide sequencing.

Comparison of flank and midline approaches to the ovariohysterectomy of cats.

In a survey of uk veterinary practitioners, 96 per cent indicated that they performed ovariohysterectomy on cats via flank laparatomy rather than a midline coeliotomy. At a veterinary teaching hospital 32 cats were spayed by the midline approach and 34 by the flank approach, by undergraduate students under the continuous supervision of a veterinary surgeon. The duration of each part of the procedures was recorded and information was obtained from the students, the supervisors and the owners of the cats by means of questionnaires. The total duration of the surgery and the students' assessment of the difficulty of the surgery were not significantly different between the two groups. The time taken from the skin incision to entering the peritoneum was significantly longer with the flank approach, but finding the uterus took significantly longer with the midline approach. There was a high incidence of wound complications, in the form of swelling, redness or discharges, but the only statistically significant difference between the groups was a greater incidence of discharges in the cats spayed via the flank (five cases) than in the cats spayed via the midline (one case).

Prostatopexy as a treatment for urethral sphincter mechanism incompetence in male dogs.

OBJECTIVES: The incidence of urinary incontinence due to urethral sphincter mechanism incompetence (USMI) in male dogs is relatively rare compared with the incidence in bitches, but the medical management of USMI in male dogs is less rewarding than in bitches. Attempts have been made to manage this condition surgically using either urethral bulking agents such as Teflon or by relocating the intrapelvic bladder neck to an intra-abdominal position by vas deferentopexy. This paper reports the response to prostatopexy in male dogs with USMI. METHODS: The response to prostatopexy was determined in nine severely incontinent male dogs with USMI that were followed up for periods ranging from 10 months to five years (mean 2.3 years). RESULTS: One dog was cured, four were improved, and no improvement in the frequency or degree of urinary incontinence occurred in the remaining four animals. No complications were seen in any of the dogs. CLINICAL SIGNIFICANCE: Prostatopexy may provide a further method of treating male dogs with USMI that do not respond to medical therapy.

Age differences in neophilia, exploration, and innovation in family groups of callitrichid monkeys.

The prevailing assumption in the primate literature is that young or juvenile primates are more innovative than adult individuals. This innovative tendency among the young is frequently thought to be a consequence, or side effect, of their increased rates of exploration and play. Conversely, Reader and Laland's [International Journal of Primatology 22:787-806, 2001] review of the primate innovation literature noted a greater reported incidence of innovation in adults than nonadults, which they interpreted as (in part) a reflection of the greater experience and competence of older individuals. Within callitrichids there is contradictory evidence for age differences in response to novel objects, foods, and foraging tasks. By presenting novel extractive foraging tasks to family groups of callitrichid monkeys in zoos, we examined, in a large sample, whether there are positive or negative relationships of age with neophilia, exploration, and innovation, and whether play or experience most facilitates innovation. The results indicate that exploration and innovation (but not neophilia) are positively correlated with age, perhaps reflecting adults' greater manipulative competence. To the extent that there was evidence for play in younger individuals, it did not appear to contribute to innovation. The implications of these findings for the fields of innovation and conservation through reintroduction are considered.

Selection of assessment methods for evaluating banana weevil Cosmopolites sordidus (Coleoptera: Curculionidae) damage on highland cooking banana (Musa spp., genome group AAA-EA).

Cosmopolites sordidus (Germar) is an important pest on bananas and plantains. Population build-up is slow and damage becomes increasingly important in successive crop cycles (ratoons). Yield loss results from plant loss, mat disappearance and reduced bunch size. Damage assessment requires destructive sampling and is most often done on corms of recently harvested plants. A wide range of damage assessment methods exist and there are no agreed protocols. It is critical to know what types of damage best reflect C. sordidus pest status through their relationships with yield loss. Multiple damage assessment parameters (i.e. for the corm periphery, cortex and central cylinder) were employed in two yield loss trials and a cultivar-screening trial in Uganda. Damage to the central cylinder had a greater effect on plant size and yield loss than damage to the cortex or corm periphery. In some cases, a combined assessment of damage to the central cylinder and cortex showed a better relationship with yield loss than an assessment of the central cylinder alone. Correlation, logistic and linear regression analyses showed weak to modest correlations between damage to the corm periphery and damage to the central cylinder. Thus, damage to the corm periphery is not a strong predictor of the more important damage to the central cylinder. Therefore, C. sordidus damage assessment should target the central cylinder and cortex.

Slipped capital femoral epiphysis in dogs.

In a retrospective review of 43 femoral fractures, three dogs had separation of the femoral capital epiphysis from the metaphysis in the absence of trauma. Two of these dogs also had evidence of pathology in the contralateral femoral neck including, in one dog, displacement of the capital epiphysis in relation to the metaphysis without actual separation. The case histories, radiographic features and histopathological findings of these cases were reviewed and compared with previous cases of slipped capital femoral epiphysis (SCFE) reported in dogs and also with SCFE in children. Pre-slip, acute, chronic and acute-on-chronic slips were Identified. Based on the cases reviewed, the authors advise internal fixation of stable slipped epiphyses in dogs. This may also be appropriate for unstable separations, although resorption of the femoral neck may preclude stable fixation and necessitate femoral head and neck excision.

Management of MRSA septic arthritis in a dog using a gentamicin-impregnated collagen sponge.

Methicillin-resistant Staphylococcus aureus septic arthritis occurred in a dog following elective joint surgery for cranial cruciate ligament rupture. Resolution of the infection was assisted by using a surgically implanted absorbable gentamicin-impregnated sponge.

Reproductive isolation caused by colour pattern mimicry.

Speciation is facilitated if ecological adaptation directly causes assortative mating, but few natural examples are known. Here we show that a shift in colour pattern mimicry was crucial in the origin of two butterfly species. The sister species Heliconius melpomene and Heliconius cydno recently diverged to mimic different model taxa, and our experiments show that their mimetic coloration is also important in choosing mates. Assortative mating between the sister species means that hybridization is rare in nature, and the few hybrids that are produced are non-mimetic, poorly adapted intermediates. Thus, the mimetic shift has caused both pre-mating and post-mating isolation. In addition, individuals from a population of H. melpomene allopatric to H. cydno court and mate with H. cydno more readily than those from a sympatric population. This suggests that assortative mating has been enhanced in sympatry.

Development and validation of a sensitive method for hydromorphone in human plasma by normal phase liquid chromatography-tandem mass spectrometry.

Liquid chromatography coupled with tandem mass spectrometry (LC-MS-MS) was developed for the quantitation of hydromorphone (HYD), an opiate analgesic, in human plasma. A simple liquid-liquid extraction was used to extract the analyte and its deuterated internal standard (d3-HYD). Chromatographic separation of hydromorphone from its metabolite hydromorphone-3-glucuronide (H3G) was necessary because of the significant H3G fragmentation to HYD before Ql of the mass spectrometer, which could result in false detection as HYD in the multiple reaction mode (MRM). This separation was achieved using a 50 x 2 mm, I.D. silica column (5 microm) and a mobile phase of acetonitrile-water formic acid (80:20:1, v/v/v). The method was validated in the concentration range 0.05-10 ng ml(-1) in plasma and met the acceptance criteria of industry guidelines for accuracy, precision, and stability.

Physician participation in TQM in geriatric medicine.

BACKGROUND: Quality improvement (QI) approaches such as total quality management (TQM) and continuous quality improvement (CQI) have great potential for improving the care provided to older people. Geriatricians have the necessary experience and skills to initiate and lead these QI efforts. A national sample of practicing geriatricians was surveyed in 1998 regarding involvement in, satisfaction with, and insights regarding TQM processes in four care settings. RESULTS: Of 537 questionnaires returned in time for analysis, 497 were included for analysis after omitting questionnaires that were undeliverable or unusable (n = 25) and those from respondents who worked fewer than 20 hours per week (n = 15). More than one-third of the respondents (37.1%) reported no TQM activity at all. For the remainder, the primary site for TQM activity was the nursing home (33.0%), the hospital (22.5%), the office (11.4%), and the patient's home (3.7%). A majority of the respondents spent two hours per week or less on TQM projects. Planning an intervention and acting to maintain it in practice after its evaluation were the two stages of the improvement cycle these respondents engaged in most frequently. DISCUSSION: More geriatricians should be encouraged to participate in TQM training and in specific projects to improve systems of care for older people. Incentives to increase participation should be made available. Rapid-cycle improvement may fit better with physicians' culture of working for outcomes that have relatively short turnaround times.

Communication between the hospitalized older patient and physician.

Much research has shown that how physicians communicate with patients can have profound influence on behavioral, psychosocial, and clinical outcomes of the encounter. Communication with older patients, however, is often compromised by some attributes of the aging process. Communication can also be affected by the setting in which it takes place, and the hospital presents some barriers not found in ambulatory sites. These concerns are often compounded in end-of-life decisions for older patients when discussed in hospital settings.

Quantitation of efletirizine in human plasma and urine using automated solid-phase extraction and column-switching high-performance liquid chromatography.

A heart-cut column-switching, ion-pair, reversed-phase HPLC system was used for the quantitation of efletirizine (EFZ) in biological fluids. The analyte and an internal standard (I.S.) were extracted from human EDTA plasma by C18 solid-phase extraction (SPE) using a RapidTrace workstation. The eluent from the SPE was evaporated, reconstituted and injected onto the HPLC column. Urine samples were diluted and injected directly without the need of extraction. The compounds of interest were separated from most of the extraneous matrix materials by the first C18 column, and switched onto a second C18 column for further separation using a mobile phase of stronger eluting capability. Linearity range was 10-2000 ng ml(-1) for plasma and 0.05-10 microg ml(-1) for urine. The lower limit of quantitation (LOQ) was 10 ng from 1 ml of plasma, with a signal-to-noise ratio of 15:1. Inter-day precision and bias of quality control samples (QCs) were <5% for plasma and <7% for urine. Selectivity was established against six other antihistamines, three analogs of efletirizine, and on 12 control plasma lots and nine control urine lots. Recovery was 90.0% for EFZ and 89.5% for I.S. from plasma. One hundred samples can be processed in every 2.75 h on a 10-module RapidTrace workstation with minimal human attention. Method ruggedness were tested on three brands of SPE and six different lots of one SPE brand. Performance ruggedness was demonstrated by different analysts on multiple HPLC systems. Analyte stability through sample storage, extraction process (benchtop, freeze-thaw, refrigeration after extraction) and chromatography (on-system, reinjection) was established.

Effect of hoof characteristics on the propensity of cattle to slip.

Bovine hooves were assessed for their linear and volumetric characteristics and ranked in sets of four for hoof volume. An artificial cow was constructed with the hooves set into metal cylinders underneath a platform containing a known weight. The device was connected via a strain gauge to a pulling handle operated by two people, and the horizontal force required to move each set of hooves was determined three times. The coefficient of friction, calculated as the horizontal force divided by the fixed vertical force, was positively correlated with hoof volume. The same exercise was repeated with the hooves ranked for toe angle, and the hooves with steep toe angles had a lower coefficient of friction than the hooves with shallow toe angles. However, since both hoof volume and toe angle were related to toe length, the relationship between friction and toe angle was believed to derive from the larger size of claws with shallow toe angles. The results indicate that young cattle that have small claws with smooth surfaces and steep toe angles are more likely to slip.

Do physicians discuss HIV and AIDS with patients? A survey of physician practices.

HIV and AIDS continue to be major concerns to the health care community and the world around them. Preventive efforts and education have been the focus of the fight against AIDS thus far. By the year 2000, 75% of physicians are expected to conduct risk-reduction counseling for patients regularly. Previous studies show that a smaller percentage "routinely" follow this recommendation. The purpose of our study was to assess with what percentage of patients physicians discuss several HIV/ AIDS-related topics, what percentage of their patients are considered at risk for infection, and how comfortable the physicians are with their knowledge level and discussing the subject matter. We sent surveys to the last five graduating classes from St. Louis University School of Medicine and to 169 physician preceptors in the community. The survey asked about patients considered at risk, physician comfort level with HIV/ AIDS, the percentage of patients they discuss various HIV/AIDS topics with, and his or her preparedness for these discussions. Total responses were 464 (53.7%) representing all areas of medicine. Most of the physicians (72.9%) consider 0-25% of their patients at risk for HIV/AIDS. Eighty-one percent claim they are moderately or very comfortable discussing the material with patients and more than 90% feel they have at least adequate knowledge. Most of the respondents discuss the HIV/ AIDS topics with 0-25% of patients. Recent medical school graduates and primary care physicians are more comfortable with HIV/AIDS and discuss the surveyed topics with a higher percentage of patients.

The magic of science and the science of magic: an essay on the process of healing.

The field of medical sociology has developed rapidly in recent years in sophistication of conceptualization and research techniques. Nonetheless, there remains a considerable amount of "unexplained variance" in knowledge about health and illness behaviors. This paper asserts that to grow further, medical sociology should become more interdisciplinary in conceptualization and design of research projects. The application of research findings from the field of psychoneuroimmunology to explain the effects of placebos as a form of magic is used as an illustration.

Inner-city older blacks have high levels of functional disability.

OBJECTIVES: To describe the frequency and severity of functional problems in two groups of noninstitutionalized inner-city blacks aged 70 years and older contrasted with results from appropriate groups of white and black older adults and with the goals of the Healthy People 2000 program. DESIGN: Cross-sectional descriptive study. SETTING: Community-based samples. PARTICIPANTS: A population-based sample of 416 older adults living in a 3.5-square mile catchment area in north St. Louis (NSL), Missouri, and a sample of 197 older residents living in public housing in East St. Louis (ESL), Illinois. MEASUREMENTS: Health status, preventive health activities, health services utilization, and risks for progressive frailty were assessed by self report and observation using well validated, standardized instruments. Whenever possible, comparison data were derived from national datasets, original samples used to validate the measures, and other useful comparison groups. RESULTS: The NSL sample had somewhat better health status and risk for progressive disability than the ESL sample. However, compared with national or regional reference groups using age-gender adjustments, both study groups demonstrated increased levels of dependence in intermediate activities of daily living, restricted activity days, inability to walk one-half mile without assistance, reported poor vision, living alone, and limited income compared with both older whites and blacks, and increased levels of worsening health, inability to perform heavy work around the house, never walking a mile or more, and currently unmarried versus whites with variable decrements versus blacks. Contrasted with other comparison groups, the two samples had increased body fat; consistent decrements in gait speed, timed chair stands, timed one-leg balance, and frequency of preventive exercise; and lower levels of dental care; results relative to physician visits and hospital days were mixed. They also had high levels of measured visual and hearing impairments, unmet needs for home delivered meals, and problems with false teeth. Deficiencies compared with the goals of Healthy People 2000 were large. CONCLUSIONS: The special attributes of inner-city blacks, including poverty and access to and acceptance of remedial programs, will have to be considered if the goals of Healthy People 2000 are to be met in this important and growing segment of older Americans. 44:0000-0000, 1996.

Determination of 5-fluorouracil in human plasma by a simple and sensitive reversed-phase HPLC method.

A simple and sensitive reversed-phase HPLC method with UV detection was developed and validated for the quantitation of 5-fluorouracil (5-FC) in human plasma. After acidification and salting out, 5-FU was extracted into ethyl acetate and back-extracted into a basic buffer. The extract was adjusted to neutral pH before being injected onto the HPLC column. 5-FU was separated from the matrix components on a YMC ODS-AQ column at 40 degrees C using an aqueous mobile phase of 10 mM potassium phosphate at pH 5.5. A linear gradient of 0-25% methanol wash eluted late peaks, maintained column performance, and increased column stability. The run time was 20 min. The linear range was 25-300 ng ml-1 (r2 > 0.999). The limit of quantitation was 25 ng ml-1, with a signal-to-noise ratio of 23:1. Interday precision and accuracy of quality control samples were 6.2-8.4% relative standard deviation and -0.1(-)+1.9% relative error.

Nutritional risk in inner-city-dwelling older black Americans.

OBJECTIVE: To define the degree of nutritional risk in older inner-city black Americans and to identify important underlying factors associated with high nutritional risk. DESIGN: Cross-sectional descriptive study. SETTING AND PARTICIPANTS: A population-based sample of 400 noninstitutionalized persons older than 69 years of age in north St. Louis (NSL), Missouri, and a community-based sample of 115 residents aged 50 years and older living in public housing in East St. Louis (ESL), Illinois. Both study areas have high levels of poverty. MEASUREMENTS: Nutritional risk was measured using the Nutrition Screening Initiative Checklist. Demographic information, economic status, self-rated health, Geriatric Depression Scale score, and body mass index were assessed using established standardized instruments. MAIN RESULTS: Forty-eight percent of NSL and 66% of ESL subjects scored high on the Checklist. Compared with a mostly white (96%) comparison group from New England, both samples demonstrated particularly high prevalence for limited intake of fruits, vegetables, and milk; tooth and mouth problems; lack of money for food; eating alone; polypharmacy; and inability to shop, cook or feed on their own. High levels of depressive symptoms, fair or poor self-rated health, perceived inadequacy of income, and low income levels were associated with high risk, but even those subjects with no or few such predisposing factors were still high on the Checklist score compared with the New England sample. CONCLUSIONS: If confirmed, these results indicate that inner-city-dwelling older black Americans are at high nutritional risk. Attempts to reduce their nutritional risk should focus on improving nutritional content of their diet, oral health, polypharmacy, depressive symptoms, and poor general health; offering group meals; and providing assistance with shopping and cooking.