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PubMed2004

Current Centers for Disease Control and Prevention guidelines for HIV counseling, testing, and referral: critical role of and a call to action for emergency physicians.

Although the rate of new cases of HIV infection has been relatively stable during the past decade, it remains unacceptably high, with 40,000 individuals newly infected each year. In 2001, the Centers for Disease Control and Prevention (CDC) issued revised guidelines for HIV counseling, testing, and referral directed toward promoting further reduction of HIV acquisition and transmission. The guidelines give explicit emphasis to the role of emergency physicians, according to recognition that the emergency department (ED) represents the only source of medical care for many patients and often serves as the primary site for routine health care to communities at risk for HIV. Despite the time and practical limitations inherent in ED practice, many studies suggest that routine HIV counseling, testing, and referral in the ED may be feasible and effective. This article reviews those studies in the context of the most up-to-date CDC HIV counseling, testing, and referral guidelines.

AIDS Serodiagnosis↗
PubMed1990

Client cognitive responses to counselor paradoxical and nonparadoxical directives.

Client cognitive responses to counselor paradoxical and nonparadoxical directives were examined. It was predicted (a) that clients who received paradoxical symptom prescriptions would display a greater negativity toward the counselor and counseling than those who received nonparadoxical directives; and (b) that clients who received no rationale for the paradoxical directives would display a greater negativity than those who received a rationale. Thirty clients who had reported performance anxiety received one 45-minute counseling interview. Ten clients received paradoxical directives with a rationale, 10 received paradoxical directives with no rationale, and 10 received nonparadoxical directives. Results showed no significant differences in either client in-session negativity or out-of-session implementation of directives between the paradoxical and nonparadoxical conditions and between the rationale and no rationale paradoxical conditions. Possible implications of the findings are discussed.

Adaptation, Psychological↗
PubMed2003

Emergency contraception: from accessibility to counseling.

Since emergency contraception (EC) users have a higher risk sexual profile, they may miss an opportunity for medical counseling if getting EC directly from a pharmacy. However, direct access to emergency contraception through pharmacies has been shown to increase EC use. Informational materials destined for EC users could alert women to the importance to check for sexually-transmitted infections considering health issues related to STDs.

Adolescent↗
PubMed2004

How do institutional review boards apply the federal risk and benefit standards for pediatric research?

CONTEXT: Federal regulations allow children in the United States to be enrolled in clinical research only when the institutional review board (IRB) determines that the risks are minimal or a minor increase over minimal, or that the research offers a prospect of direct benefit. Despite this reliance on IRBs, no data exist on how IRBs apply the risk and benefit categories for pediatric research. OBJECTIVE: To determine how IRB chairpersons apply the federal risk and benefit categories for pediatric research. DESIGN, SETTING, AND PARTICIPANTS: Telephone survey, conducted between May and August 2002 of 188 randomly selected chairpersons of IRBs in the Unites States. The survey consisted of 21 questions to assess the application of federal risk standards to research procedures, whether certain interventions offer a prospect of direct benefit to participating children, and the extent to which IRBs use the federal definition of minimal risk when categorizing the risks of research procedures in children. MAIN OUTCOME MEASURES: Responses regarding categorization of the risk level and direct benefits of pediatric research procedures. RESULTS: A single blood draw was the only procedure categorized as minimal risk by a majority (152 or 81%) of the 188 respondents. An electromyogram was categorized as minimal or a minor increase over minimal risk by 100 (53%) and as more than a minor increase over minimal risk by 77 (41%). Allergy skin testing was categorized as minimal risk by 43 IRB chairpersons (23%), a minor increase over minimal risk by 81 (43%), and more than a minor increase over minimal risk by 51 (27%). Regarding benefits, 113 chairpersons (60%) considered added psychological counseling to be a direct benefit, while participant payment was considered a direct benefit by 10% (n = 19). CONCLUSIONS: Application of the federal risk and benefit categories for pediatric research by IRB chairpersons is variable and sometimes contradicted by the available data on risks and the regulations themselves. To protect children from excessive risks while allowing appropriate research, IRB chairpersons need guidance on applying the federal risk and benefit categories and also need data on the risks children face in daily life and during routine physical or psychological tests.

Biomedical Research↗
PubMed1998

Patient-provider communication during the emergency department care of children with asthma. The National Cooperative Inner-City Asthma Study, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD.

OBJECTIVES: Poor children's reliance on emergency facilities is one factor implicated in the rise of morbidity attributed to asthma. Although studies have examined doctor-patient communication during routine pediatric visits, little data are available about communication during emergency care. This study sought to describe communication during emergency treatment of childhood asthma to learn if a "patient-centered" provider style was associated with increased parent satisfaction and increased parent and child participation. METHODS: This cross-sectional, observational study examined 104 children aged 4 to 9 years and their guardian(s) attending emergency departments in seven cities. Quantitative analysis of provider-family dialogue was performed. Questionnaires measured satisfaction with care, provider informativeness, and partnership. RESULTS: Providers' talk to children was largely supportive and directive; parents received most counseling and information. Children spoke little to providers (mean: 20 statements per visit versus 156 by parents). Providers made few statements about psychosocial aspects of asthma care (mean: three per visit). Providers' patient-centered style with parents was associated with more talk from parents and higher ratings for informativeness and partnership. Patient-centered style with children was associated with five times the amount of talk from children and with higher parent ratings for "good care," but not for informativeness or partnership. CONCLUSIONS: Communication during emergency asthma care was overwhelmingly biomedical. Children took little part in discussions. A patient-centered style correlated with increased parent and child participation, but required directing conversation toward both parents and children.

Asthma↗
PubMed2000

An evaluation of needs of female BRCA1 and BRCA2 carriers undergoing genetic counselling.

BACKGROUND: The discovery of the breast and ovarian cancer susceptibility genes BRCA1 and BRCA2 has improved our ability to counsel women at increased risk of developing breast and ovarian cancer. The objective of our study was to identify the needs of women who have undergone genetic counselling and testing for BRCA1/2 and to determine the impact of receiving a positive BRCA1/2 result. This is the first study to report on a large group of women who have received positive BRCA1/2 mutation results. METHODS: Questionnaires were distributed to 105 women who had received pre- and post-test genetic counselling for a positive BRCA1/2 result at the University of Toronto or at McGill University in Montreal, Canada between the years of 1994 and 1998. The questionnaire items included patient motivation for seeking genetic services, information needs, screening and prophylactic surgery practices, satisfaction with access to services and support, the desire for a support group, and overall client satisfaction. RESULTS: Seventy nine female carriers were surveyed. The majority of the respondents (77%) were satisfied with the information they received during the genetic counselling process. Women with a previous diagnosis of cancer indicated that they needed more information relating to cancer treatment compared to women without cancer (p=0.05). Nineteen percent of the women felt they needed more support than was received. Fifty eight percent of the women reported that their screening practices had changed since they received their result. Young women (below the age of 50) and women with no previous diagnosis of cancer were most likely to have changed their screening practices. Nearly two thirds of the respondents said they had considered prophylactic surgery of the breasts or ovaries. Twenty eight percent of the women had prophylactic mastectomy and 54% had undergone prophylactic oophorectomy. Women with an educational level of high school or more were more likely to have undergone prophylactic bilateral mastectomy than those with less education (p=0.07) but were less likely to undergo prophylactic oophorectomy (p=0.0007). CONCLUSION: These findings have a direct impact on the counselling and risk management of female BRCA mutation carriers. Age, education, and a previous diagnosis of cancer are important determinants in a woman's decision making after receiving positive genetic test results.

BRCA1 Protein↗
PubMedDate not supplied

The role and scope of practice of nurses working in Canadian heart failure clinics.

BACKGROUND: Nurses play an integral role in providing care in heart failure (HF) clinics and disease management programs that lead to improved outcomes for HF patients. OBJECTIVES: This pilot study explored how closely nurses in Canadian HF clinics follow consensus guideline recommendations and nursing interventions from published studies. METHODS: A total of 27 nurses from HF clinics across Canada completed a questionnaire about their role and scope of practice. RESULTS: The majority of nurses covered recommended topic areas for counseling and education with the exceptions of discussing advanced directives, teaching patients to titrate diuretics, and counseling on secondary prevention. Nurses with a postgraduate degree were more likely to independently titrate medications and order echocardiograms. Nurses affiliated with the Canadian Congestive HF Clinic Network were more likely to provide telephone management, titrate medications, and order echocardiograms and other diagnostic tests. CONCLUSION: Patients may not be experiencing the benefits that are reported in the literature for being followed up in a HF clinic because the role and scope of practice of nurses varies from one clinic to another. The role and scope of practice of nurses in HF clinics needs to be standardized.

Adult↗
PubMedDate not supplied

Lifestyle behavior counseling for women patients among a sample of California physicians.

BACKGROUND: Physical inactivity, poor diet, excessive alcohol consumption, and smoking are modifiable risk factors associated with development of chronic diseases. Although the prevalence of diseases associated with these detrimental lifestyle behaviors is high among women in the United States, they may not receive adequate counseling from physicians. METHODS: To predict physicians' lifestyle counseling practices, we assessed personal, professional, and health behavior characteristics from responses to a self-administered survey of breast cancer risk reduction practices. Subjects were California physicians identified through AMA Masterfile, in family practice, internal medicine, or obstetrics/gynecology, who were asked to report the percentages of women patients they counseled on physical activity, diet, alcohol, and smoking. RESULTS: Of 1647 eligible physicians, 822 (50.0%) responded. Fifty-six percent reported counseling at least 75% of patients about physical activity, 54.6% about diet, and 44.8% about alcohol. More than three quarters (78.7%) counseled at least 75% of patients about smoking. In logistic regression analyses, woman gender, family practice, and internal medicine specialties emerged as significant predictors of counseling for all lifestyle behaviors. Older age was associated with dietary and alcohol counseling. Race/ethnicity was associated only with smoking counseling, and country of medical school was associated with counseling for physical activity and smoking. Sources of new medical knowledge emerged as predictors for all types of counseling, whereas physicians' own level of physical activity only predicted counseling about physical activity. CONCLUSIONS: Physicians' personal, professional, practice, and health behavior characteristics were associated with reported lifestyle counseling of women patients. Results reveal important directions for future physician-based interventions to improve counseling.

Aged↗
PubMed1988

A multi-disciplinary approach to the prevention of coronary heart disease.

The South Birmingham Coronary Prevention Project is described, in which health checks by practice nurses in GPs' surgeries are combined with direct patient access to a secondary referral system. Where appropriate, health check attenders are offered the choice of either counselling by the practice nurse, direct referral to their GP, or direct referral to secondary intervention, including dietary advice for patients with high serum cholesterol, stress management training for mild hypertension, and smoking cessation groups run by specialist workers. Further developments of the project may be toward increasing areas of nurses intervention, for example running lipid clinics, and combining with Look After Your Heart! in the workplace. Progress in each of these areas is described and discussed.

Coronary Disease↗
PubMed1996

Beyond CAGE. A brief clinical approach after detection of substance abuse.

Generalist physicians should incorporate alcohol and drug abuse detection and brief intervention in the care of their patients. A suggestion of alcohol or drug abuse or a positive response to the CAGE questions deserves further assessment such as clarification about adverse consequences, inquiry about loss of control, determination of the patient's perception of the substance use, and an assessment of the patient's readiness to change behavior. Brief intervention with the patient in the clinical setting about alcohol or drug use can be effective. Motivational interviewing, a directive, patient-centered counseling style for enhancing motivation for change, can make brief interventions more effective by incorporating the patient's readiness to address alcohol or drug use. A useful clinical approach is presented that is tailored to the patient's stage of readiness to change alcohol or drug abuse behavior.

Attitude to Health↗
PubMed2004

Germline mutations in MLH1, MSH2 and MSH6 in Korean hereditary non-polyposis colorectal cancer families.

Hereditary non-polyposis colorectal cancer (HNPCC), the most common hereditary colon cancer syndrome, is a dominant disorder caused by germline defects in mismatch repair (MMR) genes. Identification of MMR gene mutations can have direct clinical implications in counseling and management of HNPCC families. We screened 44 HNPCC and 97 suspected HNPCC Korean families for germline mutations in three MMR genes: MLH1, MSH2 and MSH6. We identified twelve novel mutations: nine in MLH1(c.632_633insT, c.808_811delACTT, c.845C>G, c.1625A>C, c.1730+1delG, c.1907T>C, c.1918C>T, c.2104-2A>G and c.2170T>A), two in MSH2 (c.1886A>G, c.1316_1318delCCT) and one in MSH6 (c.3488A>T). In addition, two statically significant cSNPs in MLH1: c.1128T>C ( p=0.008 in HNPCC and p=0.037 in early-onset CRC) and c.2168C>A ( p<0.001 in HNPCC). Interestingly, the most frequent mutation, c.1757_1758insC in MLH1, was a founder mutation inherited from a common Korean ancestor.

Adaptor Proteins, Signal Transducing↗
PubMed2006

Use of prescription medications with a potential for fetal harm among pregnant women.

PURPOSE: To estimate the prevalence of use of prescription drugs with a potential for fetal harm among pregnant women in the United States. METHODS: A retrospective study was conducted using the automated databases of eight health maintenance organizations involved in the HMO Research Network Center for Education and Research on Therapeutics (CERT). Women who delivered an infant from January 1996 to December 2000 were identified. The frequency of use of prescription drugs with a potential for fetal harm was based upon the expert review of a clinical teratologist and the U.S. Food and Drug Administration (FDA) risk classification system, assuming a gestational duration of 270 days. RESULTS: Among the 114 165 women with no documentation of a diagnosis suggesting potential pre-term birth or dispensing of ovulation stimulants in the 270 days before delivery, 1305 (1.1%) received a teratogenic drug during the 270 days before delivery, based upon the expert review of a clinical teratologist. A larger proportion of women received U.S. FDA category D or X drugs (5.8%; N = 6600). However, the general patterns of use were similar, with higher use in early pregnancy compared to later trimesters. The proportion of women dispensed a teratogen during pregnancy was substantially higher among women who received a teratogen in the 90 days before pregnancy compared to women who did not (adjusted RR = 38.9, 95%CI, 33.5, 45.3). CONCLUSIONS: Our results suggest that further efforts directed at physicians to counsel women or at the women themselves about the potential risks of particular medications appear warranted.

Drug Prescriptions↗
PubMed1994

Towards an optimal teaching programme for supportive care.

The changes occurring in medical education have led to important principles being identified that are relevant to teaching in supportive care. Many of these principles are already an integral part of the Newcastle, NSW, Medical Faculty undergraduate course and are being applied to the teaching of oncology and supportive care. The same principles can be applied to curriculum development and implementation in other settings. A curriculum is proposed that builds on a general background of oncology knowledge. Factual knowledge is limited to the precarious clinical problems requiring optimal supportive care, the priority oncology syndromes, palliative care and principles of psychosocial and behavioural science interventions. The curriculum also includes critical reasoning, special skills including counselling, communication, self-directed learning, team management, health-service resources and structure, and relevant management skills. To implement the curriculum, consideration must be given to teaching methods (teaching in context and in small groups, problem-based learning and problem solving). The needs of students, quality of the teachers, when and where the teaching and learning will occur and methods of assessment should also be considered to ensure the curriculum can be used optimally.

Clinical Competence↗
PubMed1991

Prenatal deletion detection in a sporadic case of Duchenne muscular dystrophy without genotype information from the affected individual.

We describe the application of deletion screening by amplification of deletion-prone exons via polymerase chain reaction (PCR) in a family with a sporadic case of Duchenne muscular dystrophy (DMD). No DNA was available from the affected patient who died 12 years beforehand at the age of 18 years. Material obtained prenatally from two male fetuses exhibited an identical deletion. These findings effectively transformed a sporadic case into a familial case and a numerical carrier risk was substituted by obligate carrier status. Additionally an indirect genotype analysis was replaced by the possibility of direct DNA analysis. Genetic counselling, formerly based upon incomplete data, can now be aided by precise risk assessment.

Adult↗
PubMed1993

Family planning in Russia: experience and attitudes of gynecologists.

A survey was made of 375 Russian gynecologists. The questionnaire on family planning and contraceptives was distributed at the beginning of three local educational symposia. Almost all participants filled in the questionnaire on attitudes, knowledge and experience with family planning. The sample consisted of departmental specialists and heads of departments/clinics, working mainly at in- or out-patient women's health clinics. The mean age was 37 years; 83% were women, living in medium-sized or large cities (80%). Half of them had been working as a gynecologist for more than 10 years. Only 55% had been trained in family planning. The main reasons mentioned for the high abortion rate in Russia were the lack of education, non-involvement of male partner, and lack of modern contraceptives. Most of the gynecologists were in favor of special family planning clinics with special attention to services for the users. About half of the physicians knew how the pill works and estimated that 41% of women know that the pill contains estrogens. Sixty-two percent found that patients are badly informed about available contraception. Main sources of information on contraception were journals/books, colleagues and mass media. The majority reported having a directive style of patient counseling, and stated that parents should be informed of their teenagers' sexual experiences. The more experienced physicians with a training in family planning were better informed on contraception and showed a more patient-concerned attitude. It is concluded that health care providers should be the main target group of training and education in family planning, and need the support of Western European family planning organizations.

Abortion, Induced↗
PubMed2005

Differentiating imaging findings in primary and secondary tumors of the jugular foramen.

The preoperative diagnosis of a jugular foramen tumor may be challenging, since a large variety of unusual lesions may be located in this region. These tumors may be classified as primary lesions (which are located in the jugular foramen or extend from the jugular foramen into the surrounding structures) and as secondary lesions (that extend from the surrounding structures into the jugular foramen). Primary tumors include glomus jugulare tumors, schwannomas, meningiomas and peripheral primitive neuroectodermal tumors, while secondary tumors comprise chordomas, chondrosarcomas, chondroblastomas, giant-cell tumors, cholesterol granulomas, giant cholesterol cyst, endolymphatic sac tumors, reactive myofibroblastic tumors, temporal bone carcinomas and metastases. Accurate preoperative radiological suspicion is of great value for preoperative patient counseling and has a direct impact on the surgical planning in these cases. The present study describes and discusses the main differentiating imaging features of lesions involving the jugular foramen, whose accurate preoperative radiological evaluation is essential for proper surgical planning.

Brain Neoplasms↗
PubMedDate not supplied

Motivational interviewing: research, practice, and puzzles.

Motivational interviewing is a directive client-centered counseling approach for initiating behavior change by helping clients to resolve ambivalence. Background research that led to its development is reviewed, along with current evidence for its efficacy in reducing alcohol and other drug abuse. Elements of therapeutic style are briefly discussed. Although current evidence generally supports the effectiveness of motivational interviewing, the underlying reasons and mechanisms for change pose unsolved puzzles.

Alcoholism↗
PubMed2003

Comparison of alternative biochemical failure definitions based on clinical outcome in 4839 prostate cancer patients treated by external beam radiotherapy between 1986 and 1995.

PURPOSE: To assess the merit of the American Society for Therapeutic Radiology and Oncology (ASTRO) definition of biochemical failure after external beam radiotherapy for prostate cancer by testing alternative prostate-specific antigen (PSA) failure definitions against the "gold standard" of clinical failure and to study the effect of backdating the time of failure. METHODS AND MATERIALS: Nine participating institutions agreed to submit follow-up results for all patients with clinically localized prostatic cancer (Stage T1b, T1c, T2, N0M0) treated between 1986 and 1995 by external beam radiotherapy only, to doses of >or=60 Gy, with no androgen deprivation before treatment. A total of 4839 men met the study criteria, with a median follow-up time of 6.3 years. The prediction of clinical failure by 102 definitions of biochemical failure was assessed using various quantitative measures. RESULTS: Four definitions were superior as measured by the sensitivity, specificity, positive and negative predictive values, and hazard of clinical failure after biochemical failure: two rises of at least 0.5 ng/mL backdated, PSA level at or greater than the absolute nadir plus 2 ng/mL at the call date, and PSA level at or greater than the current nadir plus 2 or 3 ng/mL at the call date. The absolute nadir was the lowest measured PSA level during all of follow-up, and the current nadir was the lowest PSA measured previous to a particular PSA measurement during follow-up. With the possible exception of patients in the low-risk group, the likelihood of ultimate clinical failure decreased as the time of biochemical failure increased. Failure definitions based on PSA levels >0.2 or 0.5 ng/mL were inferior to other definitions. Backdating the failure time introduced bias into the estimate of freedom from biochemical failure, which was increasingly overestimated at shorter median follow-up times. This bias can be circumvented either by using a failure definition based on the call date or by backdating the censoring times of patients with one or two rises who could potentially have failure at a future (unobserved) time. A short follow-up time as such does not result in bias unless the failures are backdated; in the absence of backdating, it is the precision of failure-free survival that is increasingly compromised as the follow-up time is reduced. CONCLUSION: The ASTRO failure definition ended the confusion resulting from different failure definitions that had been in use, and it did so accurately enough that it is probably not necessary to recalculate previously published results. Nevertheless, for the current pooled analysis of outcome in 4839 men with a 6.3-year median follow-up, other definitions of biochemical failure were superior as assessed by various quantitative measures of concordance of biochemical and ultimate clinical failure. An additional disadvantage of the ASTRO definition is the bias introduced by backdating failures, as well as the necessarily retrospective nature of its application. Some "current" definitions, but not those based on the PSA level rising above a fixed threshold, have significantly higher sensitivity and specificity, do not lead to biased estimations of biochemical disease-free survival, and are directly applicable during patient counseling. These are all issues that would play a role in replacing the ASTRO consensus definition.

Adenocarcinoma↗