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PubMed1993

[Diabetes mellitus in the elderly: a study on its clinical presentation, C-peptide reserve, and immunogenetic markers of insulin dependence].

In order to evaluate clinical presentation and to determinate classification criteria of type 1 diabetes in the elderly, we carried out a study in 258 diabetic patients more than 60 years old of which 100 used insulin by failure to oral hypoglycemic agents (OHA). The prevalence of ischemic cardiovascular disease was 36%, peripheral vascular disease 34% and stroke 30%. Non-proliferative retinopathy 47%, nephropathy 16% and peripheral neuropathy 37%. Cardiovascular risk factors as obesity (36%), hypertension (33%) and hypercholesterolemia (12%) were evaluated. The average duration of diabetes was 20 years. Post-glucagon C-Peptide, HLA-DR antigens and islet cell antibodies (ICA), were measured in 75 older diabetic patients on treatment of which 24 used insulin, 11 diet and 40 OHA. Older patients on treatment with insulin had longer duration of disease, less obesity, low level basal of C-Peptide and a low response to post glucagon C-Peptide (0.94 +/- 0.5 pmol/ml) compared with patients on diet (1.8 +/- 0.9 pmol/ml) and OHA (1.8 +/- 0.8 pmol/ml). Older diabetics on insulin therapy had a greater frequency of HLA-DR3 (42%) and HLA-DR4 (21%) than other older diabetics. The ICA was negative in most patients. This study shows the high prevalence of macrovascular and microvascular disease in elderly patients with diabetes mellitus and that the most reliable parameter in classifying type 1 (insulin-dependent) diabetes is the measurement of basal and post-glucagon C-Peptide. HLA-DR specific markers can be used with this parameter because their expression is partly shared. This approach appears useful in the older diabetic patients to help classify diabetes and its management.

Aged↗
PubMed1995

Cognitive design for sharing medical knowledge models.

By building a medical conceptual model inside the galen project, a methodology has been defined to deal with both operative goals and deep and unsolved problems about knowledge. This knowledge sharing oriented approach exploits existing medical coding systems such as knowledge sources and enables us to represent their concepts in a wider cognitive context referring to ontological theories. The tasks of cognitive ergonomy, quasi-naturalness of language, versatility, and flexibility seem to be supported through some functions, such as viewpoint, context, and sign, which act as spin-off points to knowledge or information which is not modeled.

Artificial Intelligence↗
PubMed1997

Paediatricians' views on renal services for children and adolescents in Scotland.

BACKGROUND: Paediatric nephrology is a small subspecialty whose patients are widely scattered geographically within Scotland making provision of uniform and optimal care difficult. AIM: We set out to determine what services are provided throughout Scotland as well as seeking paediatricians' views on improving services for children and adolescents with renal disease. METHOD: All 12 paediatric units in Scotland were visited and a senior consultant within each unit undertook to complete a questionnaire on behalf of his or her unit. RESULTS: Questionnaires were returned by 11/12 centres (92%). The scope of renal services offered varied widely. Most (10/11) favoured a 'shared care' approach using the comprehensive paediatric nephrology service in Glasgow as a focal point. Outreach services and a telephone advisory service were suggested by 7/10 and 6/10 units respectively. The development of a Scottish paediatric nephrology group was supported by 10/11 centres returning the questionnaire. CONCLUSION: There is both a need and an interest in developing a national strategy for paediatric nephrology in Scotland.

Adolescent↗
PubMed1998

Mental health services in the family physician's office: a Canadian experiment.

This paper describes a program in Hamilton-Wentworth, Ontario, Canada, that brings mental health counselors and psychiatrists into the offices of 87 local family physicians, working in 35 practices serving 170,000 people. It outlines the organization of the mental health teams in the family physician's office and the way in which these teams are coordinated and discusses how this "shared care" approach can overcome many of the problems that traditionally bedevil the relationship between psychiatric services and family practices. It summarizes the benefits of this approach for patients providers and the health care system and looks at its implications for learners and for new approaches to continuing education. This model can be adapted to most communities.

Canada↗
PubMed1994

Projections of health care expenditures as a share of the GDP: actuarial and macroeconomic approaches.

STUDY QUESTION. Can the steady increases in health care expenditures as a share of GDP projected by widely cited actuarial models be rationalized by a macroeconomic model with sensible parameters and specification? DATA SOURCES. National Income and Product Accounts, and Social Security and Health Care Financing Administration are the data sources used in parameters estimates. STUDY DESIGN. Health care expenditures as a share of gross domestic product (GDP) are projected using two methodological approaches--actuarial and macroeconomic--and under various assumptions. The general equilibrium macroeconomic approach has the advantage of allowing an investigation of the causes of growth in the health care sector and its consequences for the overall economy. DATA COLLECTION METHODS. Simulations are used. PRINCIPAL FINDINGS. Both models unanimously project a continued increase in the ratio of health care expenditures to GDP. Under the most conservative assumptions, that is, robust economic growth, improved demographic trends, or a significant moderation in the rate of health care price inflation, the health care sector will consume more than a quarter of national output by 2065. Under other (perhaps more realistic) assumptions, including a continuation of current trends, both approaches predict that health care expenditures will comprise between a third and a half of national output. In the macroeconomic model, the increasing use of capital goods in the health care sector explains the observed rise in relative prices. Moreover, this "capital deepening" implies that a relatively modest fraction of the labor force is employed in health care and that the rest of the economy is increasingly starved for capital, resulting in a declining standard of living.

Actuarial Analysis↗
PubMed2000

Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes.

OBJECTIVE: To determine patients' preferences for a shared or directed style of consultation in the decision making part of the general practice consultation. DESIGN: Structured interview, with video vignettes of acted consultations. SETTING: 5 practices in Lothian, Scotland. PARTICIPANTS: 410 patients (adults and adults accompanying children) attending surgery appointments. MAIN OUTCOME MEASURES: Preference for shared or directed form of video vignette for five different presenting conditions. RESULTS: Patients varied in their preference for involvement in decision making in the consultation. Under multiple regression analysis, patients' preference was found to be independently predicted by the problem viewed (patients presented with physical problems preferred a directed approach), patients' age (patients aged 61 or older were more likely to prefer the directed approach), social class (social classes I and II were more likely to prefer the shared approach), and smoking status (smokers more likely to prefer the shared approach). Those patients who were able to answer (or who thought their doctor's style similar to those in the vignettes) were more likely to describe their own doctor's style as similar to their preferred style. No major association in preference was found with sex, frequency of attendance, or perceived chronic ill health. CONCLUSION: Patients may vary in their desire for involvement in decision making in consultations. Although this variation seems to depend on the presenting problem, age, social class, and smoking status, these associations are not absolute, with large minorities in each group. Doctors need the skills, knowledge of their patients, and the time to determine on which occasions, with which illnesses, and at which level their patients wish to be involved in decision making.

Adult↗
PubMed2004

Self-reported use of shared decision-making among breast cancer specialists and perceived barriers and facilitators to implementing this approach.

BACKGROUND: Physicians are increasingly urged to practice shared decision-making with their patients. Using a cross-sectional survey, we explored the extent to which Ontario breast cancer specialists report practising shared decision-making with their patients, their comfort level with this approach, and perceived barriers and facilitators to implementation. PARTICIPANTS AND METHODS: All Ontario surgeons and oncologists (radiation and medical) treating women with early-stage breast cancer were eligible for this study. Likert scales were used to measure physicians' comfort level with and self-reported use of different treatment decision-making approaches as well as perceived barriers and facilitators to treatment decision-making with patients. RESULTS: The response rate was 79% for oncologists and 72% for surgeons. More physicians from each specialty (87% of oncologists and 89% of surgeons) expressed high levels of comfort with clinical example 4 (designed to illustrate a shared approach) than with any of the other examples presented (e.g. the informed and paternalistic approach). Similarly, more oncologists and surgeons reported that their usual approach to treatment decision-making was like example 4 than like any other approach presented (56% of oncologists and 69% of surgeons, respectively). Comfort levels with example 4 for oncologists and surgeons were 31% and 20% higher, respectively, than the reported use of this approach. Lack of time and patient anxiety, patient lack of information and/or misinformation, and patient unwillingness or inability to participate were perceived by a substantial minority of both oncologists and surgeons as barriers to patient involvement in treatment decision-making. Key facilitators identified included patients' emotional readiness, support, information and trust in the physician. More research is needed to identify contextual, physician, patient, and interaction factors that will facilitate shared decision-making in the medical encounter and help both parties create an environment conducive to implementing this approach to the extent desired.

Adult↗
PubMed2005

Silicon chelation in aqueous and nonaqueous media: the furanoidic diol approach.

Anhydroerythritol (AnEryt) shares some of its ligand properties with furanosides and furanoses. Its bonding to silicon centers of coordination number four, five, and six was studied by X-ray and NMR methods, and compared to silicon bonding of related compounds. Diphenyl(cycloalkylenedioxy)silanes show various degrees of oligomerization depending on the diol component involved. For example, Ph(2)Si(cis-ChxdH(-2)) (1) and Ph(2)Si[(R,R)-trans-ChxdH(-2))] (2; Chxd = cyclohexanediol) are dimeric, Ph(2)Si(AnErytH(-2)) (3) is monomeric, and Ph(2)Si(L-AnThreH(-2)) (4; AnThre = anhydrothreitol) is trimeric both in the solid state and in solution. Ph(2)Si(cis-CptdH(-2)) (5) (Cptd = cyclopentanediol) is monomeric in solution but dimerizes on crystallization. Si(AnErytH(-2))(2) (6) and Si(cis-CptdH(-2))(2) (7) are monomeric spiro compounds in solution but are pentacoordinate dimers in the crystalline state. Pentacoordinate silicate ions are found in A[Si(OH)(AnErytH(-2))(2)] (A = Na, 8 a; Rb, 8 b; Cs, 8 c). Related compounds are formed by substitution of the hydroxo by a phenyl ligand. K[SiPh(AnErytH(-2))(2)]1/2 MeOH (9) is a prototypical example as it shows the two most significant isomers in one crystal structure: the syn/anti and the anti/anti form (syn and anti define the oxolane ring orientation close to, or apart from, the monodentate ligand, respectively). syn/anti Isomerism generally rules the appearance of the NMR spectra of pentacoordinate silicates of furanos(id)e ligands. NMR spectroscopic data are presented for various pentacoordinate bis(diolato)silicates of adenosine, cytidine, methyl-beta-D-ribofuranoside, and ribose. In even more basic solutions, hexacoordinate silicates are enriched. Preliminary X-ray analyses are presented for Cs(2)[Si(CydH(-2))(3)] 21.5 H(2)O (10) and Cs(2)[Si(cis-InsH(-3))] cis-Ins8 H(2)O (11) (Cyd = cytidine, Ins = inositol).

Journal Article↗
PubMed1998

[Aortic valve prosthesis implantation from a mini approach].

The authors share their experiences with performing the first in Russia operation of making the aorta valve prosthetics from a mini-access--transverse sternotomy. It is concluded that operations through such accesses are safe for the patient and relatively easy for the surgeon. Its main advantage consists in quick surgical rehabilitation of the patient and good cosmetic effect.

Adult↗
PubMedDate not supplied

Shared ideology in Alcoholics Anonymous: a grounded theory approach.

This article uses grounded theory to explore the shared ideology espoused in Alcoholics Anonymous, specifically the nature and role of shared ideology in increasing the efficacy of the recovery process, and the features of the group's tenets and meetings that help facilitate members' indoctrination. Findings support Kassel and Wagner's (1993) contention of shared ideology's major role in the change process of the group, and Antze's (1976) categorizations of the AA ideology and alcoholics' characteristics. Antze's (1979) finding that AA ideology removes the concept of drinking from the voluntary sphere was also supported. The group was found to be a context in which members could change their assumptive worlds through reinterpreting life events, as Frank and Frank (1991) contended. Little support was found for Alexander and Rollins's (1984) comparison of AA to religious cults. The findings underscore the importance of human interaction as persuasion and reinforcement for AA ideology.

Adult↗
PubMed2004

A multimethod quality improvement intervention to improve preventive cardiovascular care: a cluster randomized trial.

BACKGROUND: Research is needed to validate effective and practical strategies for improving the provision of evidence-based medicine in primary care. OBJECTIVE: To determine whether a multimethod quality improvement intervention was more effective than a less intensive intervention for improving adherence to 21 quality indicators for primary and secondary prevention of cardiovascular disease and stroke. DESIGN: 2-year randomized, controlled clinical trial with the practice as the unit of randomization. SETTING: 20 community-based family or general internal medicine practices in 14 states. All used the same electronic medical record. PARTICIPANTS: 44 physicians, 17 midlevel providers, and approximately 200 staff members; data from the electronic medical records of 87,291 patients. INTERVENTIONS: All practices received copies of practice guidelines and quarterly performance reports. Intervention practices also hosted quarterly site visits to help them adopt quality improvement approaches and participated in 2 network meetings to share "best practice" approaches. MEASUREMENTS: The percentage of indicators at or above predefined targets and the percentage of patients who had achieved each clinical indicator. RESULTS: Intervention practices improved 22.4 percentage points (from 11.3% to 33.7%) in the percentage of indicators at or above the target; control practices improved 16.4 percentage points (from 6.3% to 22.7%). The 6.0-percentage point absolute difference between the intervention and control group was not statistically significant (P > 0.2). Patients in intervention practices had greater improvements than those in control practices for diagnoses of hypertension (improvement difference, 15.7 percentage points [95% CI, 5.2 to 26.3 percentage points]) and blood pressure control in patients with hypertension (improvement difference, 8.0 percentage points [CI, 0.0 to 16.0 percentage points]). LIMITATIONS: The study involved a small number of practices and lacked a pure control group. CONCLUSIONS: Primary care practices that use electronic medical records and receive regular performance reports can improve their adherence to clinical practice guidelines for cardiovascular disease and stroke prevention.

Adult↗
PubMedDate not supplied

Parents sharing information with their children about genetic conditions.

INTRODUCTION: Nurses are in an ideal situation to help families share information with their children about genetic conditions. While many factors contribute to this decision making, little is known about how parents decide when and how to convey this information to their children. The purpose of this qualitative analysis was to examine parents' beliefs and strategies related to sharing information about a genetic condition with their affected and unaffected children. METHOD: One hundred thirty-nine parents participated in this study. Narrative analysis and fundamental qualitative description were employed to identify approaches and strategies that parents used to share information with their children. RESULTS: Parents' information sharing approaches and strategies were grounded in the goal of promoting the child's adaptation to the genetic condition. Parents shared information based on their assessment of the child's developmental readiness and interest and described information sharing as an unfolding process that continued throughout childhood. DISCUSSION: The approaches and strategies contribute to understanding the processes associated with information sharing between parents and their children and between health care professionals and parents.

Adaptation, Psychological↗
PubMed2004

Shared decision making about screening and chemoprevention. a suggested approach from the U.S. Preventive Services Task Force.

Shared decision making is a process in which patients are involved as active partners with the clinician in clarifying acceptable medical options and in choosing a preferred course of clinical care. Shared decision making offers a way of individualizing recommendations, according to patients' special needs and preferences, when some patients may benefit from an intervention but others may not. This paper clarifies how the U.S. Preventive Services Task Force (USPSTF) envisions the application of shared decision making in the execution of screening and chemoprevention. Unlike conventional USPSTF reports, this paper is neither a systematic review nor a formal recommendation. Instead, it is a concept paper that includes a commentary on the current thinking and evidence regarding shared decision making. Although the USPSTF does not endorse a specific style of decision making, it does encourage informed and joint decisions. This means that patients should be informed about preventive services before they are performed, and that the patient-clinician partnership is central to decision making. The USPSTF suggests that clinicians inform patients about preventive services for which there is clear evidence of net benefit, and, if time permits, about other services with high visibility or special individual importance. Clinicians should make sure that balanced, evidence-based information about the service (including the potential benefits and harms, alternatives, and uncertainties) is available to the patient if needed. For preventive services for which the balance of potential benefits and harms is a close call, or for which the evidence is insufficient to guide a decision for or against screening, clinicians should additionally assist patients in determining whether individual characteristics and personal preferences favor performing or not performing the preventive service. The USPSTF believes that clinicians generally have no obligation to initiate discussion about services that have either no benefit or net harm. Nonetheless, clinicians should be prepared to explain why these services are discouraged and should consider a proactive discussion for services with high visibility or special individual importance or for services for which new evidence has prompted withdrawal of previous recommendations.

Chemoprevention↗
PubMed1996

What do physicians tell patients with end-stage COPD about intubation and mechanical ventilation?

BACKGROUND: At some point in time, many patients with end-stage COPD require intubation and mechanical ventilation (MV) to sustain life. MV decisions are most effective when the patient and physician have discussed the options in advance. The purpose of this study was to examine how the physician perceives the decision-making process. METHODS: Fifteen respirologists were interviewed to elicit information regarding intubation and MV, and the exchange of information between patients and physicians. Emergent themes were coded using a qualitative approach and were verified by a blinded researcher. RESULTS: Respondents included ten academic and five community-based respirologists from seven hospitals. Most physicians were men with between 4 and 37 years experience. Narratives were very similar in content and seemed well rehearsed. Approach and delivery, however, were unique to each physician. Fourteen respirologists emphasized the importance of knowing patients as individuals prior to initiating this discussion. This period of familiarization often dictated when the physician believed the ventilation discussion is appropriate. Individual physician comfort also appeared to affect the timing of the discussion. Physicians discussed the many elements that make the MV discussion difficult for physicians and patients. Intubation details included a tube being placed down the throat, the discomfort associated with the tube, the inability to speak, and the availability of pain reducing medication. All physicians discussed the possibility of death with their patients, although many preferred euphemisms in initial discussions. All physicians indicated that intubation is presented as the patient's choice. However, all but one physician commonly framed their discussions in order to influence patient choice. The positive or negative framing seemed contingent on the physician's expectations for that patient. CONCLUSIONS: Our interviews demonstrated considerable agreement between physicians about the content and timing of the intubation MV discussion. Physicians all agreed that knowing the patient and his or her situation was important in determining the timing of the intubation and MV discussion. Practice style and individual physician comfort with end-of-life decisions may influence the timing of the discussion and possibly the number of patients who are finally approached. All physicians advocated a shared decision-making approach, but they strongly influence the deliberation process. Thus, the decision-making model seemed to be physician driven in this study.

Attitude of Health Personnel↗
PubMed2000

Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series.

STUDY DESIGN: A retrospective review of all the surgically managed spinal fractures at the University of Missouri Medical Center during the 41/2-year period from January 1989 to July 1993 was performed. Of the 51 surgically managed patients, 46 were instrumented by short-segment technique (attachment of one level above the fracture to one level below the fracture). The other 5 patients in this consecutive series had multiple trauma. These patients were included in the review because this was a consecutive series. However, they were grouped separately because they were instrumented by long-segment technique because of their multiple organ system injuries. OBJECTIVES: The choice of the anterior or posterior approach for short-segment instrumentation was based on the Load-Sharing Classification published in a 1994 issue of Spine. The purpose of this review was to demonstrate that grading comminution by use of the Load-Sharing Classification for approach selection and the choice of patients with isolated fractures who are cooperative with spinal bracing for 4 months provide the keys to successful short-segment treatment of isolated spinal fractures. SUMMARY OF BACKGROUND DATA: The current literature implies that the use of pedicle screws for short-segment instrumentation of spinal fracture is dangerous and inappropriate because of the high screw fracture rate. METHODS: Charts, operative notes, preoperative and postoperative radiographs, computed tomography scans, and follow-up records of all patients were reviewed carefully from the time of surgery until final follow-up assessment. The Load-Sharing Classification had been used prospectively for all patients before their surgery to determine the approach for short-segment instrumentation. Denis' Pain Scale and Work Scales were obtained during follow-up evaluation for all patients. RESULTS: All patients were observed over 40 months except for 1 patient who died of unrelated causes after 35 months. The mean follow-up period was 66 months (51/2 years). No patient was lost to follow-up evaluation. Prospective application of the Load-Sharing Classification to the patients' injury and restriction of the short-segment approach to cooperative patients with isolated spinal fractures (excluding multisystem trauma patients) allowed 45 of 46 patients instrumented by the short-segment technique to proceed to successful healing in virtual anatomic alignment. CONCLUSIONS: The Load-Sharing Classification is a straightforward way to describe the amount of bony comminution in a spinal fracture. When applied to patients with isolated spine fractures who are cooperative with 3 to 4 months of spinal bracing, it can help the surgeon select short-segment pedicle-screw-based fixation using the posterior approach for less comminuted injuries and the anterior approach for those more comminuted. The choice of which fracture-dislocations should be strut grafted anteriorly and which need only posterior short-segment pedicle-screw-based instrumentation also can be made using the Load-Sharing Classification.

Adolescent↗
PubMed2000

Modeling repeated count data subject to informative dropout.

In certain diseases, outcome is the number of morbid events over the course of follow-up. In epilepsy, e.g., daily seizure counts are often used to reflect disease severity. Follow-up of patients in clinical trials of such diseases is often subject to censoring due to patients dying or dropping out. If the sicker patients tend to be censored in such trials, estimates of the treatment effect that do not incorporate the censoring process may be misleading. We extend the shared random effects approach of Wu and Carroll (1988, Biometrics 44, 175-188) to the setting of repeated counts of events. Three strategies are developed. The first is a likelihood-based approach for jointly modeling the count and censoring processes. A shared random effect is incorporated to introduce dependence between the two processes. The second is a likelihood-based approach that conditions on the dropout times in adjusting for informative dropout. The third is a generalized estimating equations (GEE) approach, which also conditions on the dropout times but makes fewer assumptions about the distribution of the count process. Estimation procedures for each of the approaches are discussed, and the approaches are applied to data from an epilepsy clinical trial. A simulation study is also conducted to compare the various approaches. Through analyses and simulations, we demonstrate the flexibility of the likelihood-based conditional model for analyzing data from the epilepsy trial.

Anticonvulsants↗
PubMed2001

Efficiency of database search for identification of mutated and modified proteins via mass spectrometry.

Although protein identification by matching tandem mass spectra (MS/MS) against protein databases is a widespread tool in mass spectrometry, the question about reliability of such searches remains open. Absence of rigorous significance scores in MS/MS database search makes it difficult to discard random database hits and may lead to erroneous protein identification, particularly in the case of mutated or post-translationally modified peptides. This problem is especially important for high-throughput MS/MS projects when the possibility of expert analysis is limited. Thus, algorithms that sort out reliable database hits from unreliable ones and identify mutated and modified peptides are sought. Most MS/MS database search algorithms rely on variations of the Shared Peaks Count approach that scores pairs of spectra by the peaks (masses) they have in common. Although this approach proved to be useful, it has a high error rate in identification of mutated and modified peptides. We describe new MS/MS database search tools, MS-CONVOLUTION and MS-ALIGNMENT, which implement the spectral convolution and spectral alignment approaches to peptide identification. We further analyze these approaches to identification of modified peptides and demonstrate their advantages over the Shared Peaks Count. We also use the spectral alignment approach as a filter in a new database search algorithm that reliably identifies peptides differing by up to two mutations/modifications from a peptide in a database.

Algorithms↗