Parents' voices: "Our process of advocating for our child with autism." A meta-synthesis of parents' perspectives.

BACKGROUND: Advocacy has been described by parents of children with autism as an important coping strategy, enabling them to move forward by redirecting emotions into actions. A key factor in the development of collaborative and constructive partnerships between service providers and parents is having an understanding of how parents engage in advocacy and the support needed to do so. This meta-synthesis was undertaken to consolidate in-depth qualitative data from parents' perspectives of the process that they use to advocate for their children with autism. METHODS: A qualitative meta-synthesis was conducted, whereby 15 databases were systematically searched. Thirty-one studies were identified and appraised using an adapted version of the Critical Appraisal Skills Programme tool. Data were synthesized into themes through the steps of review, meta-aggregation, integration, and interpretation. RESULTS: The voices of 1,662 parents are presented describing the process of advocacy in the stages of seeking a diagnosis, seeking self-education, and taking action. Taking action includes 2 subthemes: seeking, access, and use of support services and community engagement and educating others. CONCLUSIONS: Results highlight the significant impact that positive experiences with first-line professionals have during the diagnosis process and how these experiences lay the foundation for all future relationships with other service providers. Important implications arise from this meta-synthesis for service providers in supporting parents' advocacy and hence building constructive relationships with families with a child with autism.

Parents' voices: 'why and how we advocate'. A meta-synthesis of parents' experiences of advocating for their child with autism spectrum disorder.

Parenting a child with autism spectrum disorder (ASD) can be stressful, and accessing services can add to this stress. Self-efficacy, agency and advocacy are important for parents when accessing and using services. To develop insight into parental advocacy, a meta-synthesis was undertaken to consolidate the literature focussing on parents' experiences of advocating for their child with ASD. A qualitative meta-synthesis was conducted. Fifteen databases were systematically searched by using key terms related to ASD, children, parents/carers, advocacy and qualitative studies. Twenty-four studies were identified and appraised using an adapted version of the Critical Appraisal Skills Programme tool. Data were synthesized into themes through the steps of review, meta-aggregation, integration and interpretation. Two overarching concepts emerged, illustrating both the challenging nature of advocacy and the associated personal and societal benefits. These two concepts are supported by eight themes: a life-long, all-encompassing challenge; advocacy as a parental coping strategy; advocacy involving working to create a future; balancing roles and needs; isolation versus support; personal impacts of advocacy; benefits of advocacy; and the barriers to advocacy. The experience of advocacy for parents with a child with ASD is complex and intensive, presenting both personal and societal benefits, as well as challenges for parents. In supporting individuals with ASD and family well-being, service providers need to have an understanding of the advocating role of parents and ensure that opportunities exist for their voices to be heard during service delivery.

Gamete formation via meiotic nuclear restitution generates fertile amphiploid F1 (oat×maize) plants.

Hybrid (oat×maize) zygotes developed into euhaploid plants with complete oat chromosome complements without maize chromosomes and into aneuhaploid plants with complete oat chromosome complements and different numbers of retained individual maize chromosomes. The elimination of maize chromosomes in the hybrid embryo is caused by uniparental genome loss during early steps of embryogenesis. Some of these haploid plants set seed in up to 50% of their self-pollinated spikelets. The high fertility was found to be mainly caused by formation of numerically unreduced female and male gametes (nunreduced=3x+0…3=21…24 chromosomes). Gamete formation involves meiotic nuclear restitution. The restitution process is caused by an alternative type of meiosis. It follows the model of levigatum-type semi-heterotypic divisions, but with a formation of the nuclear membrane at the transition from telophase I to interkinesis, which resembles the model of pygaera-type pseudo-homotypic divisions. We propose the name haploid meiotic restitution for this particular process combination. We discuss the use and implications of the specific process of gamete formation in F1 (oat×maize) plants.

Effect of reduced ferulate-mediated lignin/arabinoxylan cross-linking in corn silage on feed intake, digestibility, and milk production.

Cross-linking of lignin to arabinoxylan by ferulates limits in vitro rumen digestibility of grass cell walls. The effect of ferulate cross-linking on dry matter intake (DMI), milk production, and in vivo digestibility was investigated in ad libitum and restricted-intake digestion trials with lambs, and in a dairy cow performance trial using the low-ferulate sfe corn mutant. Silages of 5 inbred corn lines were fed: W23, 2 W23sfe lines (M04-4 and M04-21), B73, and B73bm3. As expected, the W23sfe silages contained fewer ferulate ether cross-links and B73bm3 silage had a lower lignin concentration than the respective genetic controls. Silages were fed as the sole ingredient to 4 lambs per silage treatment. Lambs were confined to metabolism crates and fed ad libitum for a 12-d adaptation period followed by a 5-d collection period of feed refusals and feces. Immediately following the ad libitum feeding trial, silage offered was limited to 2% of body weight. After a 2-d adaptation to restricted feeding, feed refusals and feces were collected for 5 d. Seventy Holstein cows were blocked by lactation, days in milk, body weight, and milk production and assigned to total mixed ration diets based on the 5 corn silages. Diets were fed for 28 d and data were collected on weekly DMI and milk production and composition. Fecal grab samples were collected during the last week of the lactation trial for estimation of feed digestibility using acid-insoluble ash as a marker. Silage, total mixed ration, feed refusals, and fecal samples were analyzed for crude protein, starch, neutral detergent fiber (NDF), cell wall polysaccharides, and lignin. The W23sfe silages resulted in lower DMI in the ad libitum trial than the W23 silage, but DMI did not differ in the restricted trial. No differences were observed for NDF or cell wall polysaccharide digestibility by lambs with restricted feeding, but the amount of NDF digested daily increased for lambs fed the M04-21 W23sfe silage ad libitum. Lambs were less selective against NDF and lignin when offered W23sfe silages. The B73bm3 silage did not affect DMI or digestibility of cell walls at the restricted feeding level, but total daily NDF digested was greater at ad libitum intake. Intake, milk production, and cell wall digestibility were greater for cows fed diets containing W23sfe silages than for those fed W23 silage. Although milk production was greater for the B73bm3 diet, DMI and cell wall digestibility were not altered. Cows were less selective against cell wall material when fed both W23sfe and B73bm3 silages. Reduced ferulate cross-linking in sfe corn silage is a new genetic mechanism for improving milk production.

Grazing management contributions to net global warming potential: a long-term evaluation in the Northern Great Plains.

The role of grassland ecosystems as net sinks or sources of greenhouse gases (GHGs) is limited by a paucity of information regarding management impacts on the flux of nitrous oxide (N(2)O) and methane (CH(4)). Furthermore, no long-term evaluation of net global warming potential (GWP) for grassland ecosystems in the northern Great Plains (NGP) of North America has been reported. Given this need, we sought to determine net GWP for three grazing management systems located within the NGP. Grazing management systems included two native vegetation pastures (moderately grazed pasture [MGP], heavily grazed pasture [HGP]) and a heavily grazed crested wheatgrass [Agropyron desertorum (Fisch. ex. Link) Schult.] pasture (CWP) near Mandan, ND. Factors evaluated for their contribution to GWP included (i) CO(2) emissions associated with N fertilizer production and application, (ii) literature-derived estimates of CH(4) production for enteric fermentation, (iii) change in soil organic carbon (SOC) over 44 yr using archived soil samples, and (iv) soil-atmosphere N(2)O and CH(4) fluxes over 3 yr using static chamber methodology. Analysis of SOC indicated all pastures to be significant sinks for SOC, with sequestration rates ranging from 0.39 to 0.46 Mg C ha(-1) yr(-1). All pastures were minor sinks for CH(4) (<2.0 kg CH(4)-C ha(-1) yr(-1)). Greater N inputs within CWP contributed to annual N(2)O emission nearly threefold greater than HGP and MGP. Due to differences in stocking rate, CH(4) production from enteric fermentation was nearly threefold less in MGP than CWP and HGP. When factors contributing to net GWP were summed, HGP and MGP were found to serve as net CO(2equiv.) sinks, while CWP was a net CO(2equiv.) source. Values for GWP and GHG intensity, however, indicated net reductions in GHG emissions can be most effectively achieved through moderate stocking rates on native vegetation in the NGP.

Identification of a maize neocentromere in an oat-maize addition line.

We report a neocentromere event on maize chromosome 3 that occurred due to chromosome breakage. The neocentromere lies on a fragment of the short arm that lacks the primary centromere DNA elements, CentC and CRM. It is transmitted in the genomic background of oat via a new centromere (and kinetochore), as shown by immunolocalization of the oat CENH3 protein. Despite normal transmission of the maize fragment in most progeny, neocentromeres appear to vary in size within the same tissue, as shown by fluorescent measurements. A secondary truncation in one line lowered mitotic transmission to 3% and precipitously reduced the size of the chromosome. The results support the view that neocentromere formation is generally associated with major genomic disturbances such as wide species crosses or deletion of an existing centromere. The data further suggest that new centromeres may undergo a period of instability that is corrected over a period of several generations.

Medication errors reported by US family physicians and their office staff.

BACKGROUND: Most medication error studies come from inpatient settings. There is limited information about medication errors in primary care settings. OBJECTIVE: To describe medication errors reported by family physicians and their office staff and to estimate their preventability using currently available electronic prescribing and monitoring tools. Design, setting, participants and study instrument: In two error reporting studies conducted by the American Academy of Family Physicians (AAFP) National Research Network (NRN), 1265 medical errors were voluntarily reported by >440 primary care clinicians and staff from 52 physician offices. The 194 error reports related to medications were abstracted and analysed using a medication error coding tool-Medication Error Types, Reasons, and Informatics Preventability (METRIP). MAIN OUTCOME MEASURES: Type, severity and preventability of medication errors and associated adverse drug events (ADEs). RESULTS: 126 (70%) of the medication errors were prescribing errors, 17 (10%) were medication administration errors, 17 (10%) documentation errors, 13 (7%) dispensing errors and 5 (3%) were monitoring errors. ADEs resulted from 16% of reported medication errors. The severity of harm from reported errors were: prevented and did not reach patients, (72, 41%), reached patients but did not require monitoring (63, 35%), reached patients and required monitoring (15, 8%), reached patients and required intervention (23, 13%) and reached patients and resulted in hospitalisation (5, 3%). No deaths were reported. Of the errors that were prevented from reaching patients, 29 (40%) were prevented by pharmacists, 14 (19%) by physicians, 12 (17%) by patients and 5 (7%) by nurses. 102 (57%) of the reported errors might have been prevented with enhanced electronic prescribing and monitoring tools. CONCLUSIONS: Most medication errors reported from US family physician offices were related to prescribing errors and more than half of the errors reached patients. The errors were prevented by pharmacists, patients and physicians. More than half of the errors could be prevented by electronic tools.

Who filled first-year family medicine residency positions from 1991 to 2004?

Graduates of U.S. allopathic schools have filled less than one half of the family medicine positions offered in the National Resident Matching Program (NRMP) Match since 2001. Overall fill rates in July have been relatively stable at approximately 94 percent. Family medicine has become reliant on international medical graduates (IMGs), who in 2004 made up 38 percent of first-year residents.

Quantitative trait loci for partial resistance to crown rust, Puccinia coronata, in cultivated oat, Avena sativa L.

To facilitate the detection of quantitative trait loci (QTLs) for partial resistance to oat crown rust, Puccinia coronata f. sp. avenae Eriks., a genetic map was generated in a population of 158 F(6)-derived oat recombinant inbred lines from a cross of a partial resistance line MN841801-1 by a susceptible cultivar selection 'Noble-2'. The map, developed using 230 marker loci, mostly restriction fragment length polymorphism and amplified fragment length polymorphism markers, spanned 1,509 cM (Haldane) arranged into 30 linkage groups of 2-18 markers each. Four consistently detected major QTLs for partial rust resistance, Prq1a, Prq1b, Prq2, and Prq7, and three minor QTLs, Prq3, Prq5, and Prq6, were found in tests involving three field and two greenhouse environments. In addition, two major QTLs for flowering time, Ftq1 and Ftq7, and five weaker QTLs, Ftq2, Ftq3, Ftq4, Ftq5, and Ftq6, were revealed. Overlapping of the map segments of Ftq1 and Prq1 and of Ftq7 and Prq7 suggested either linkage between the flowering time QTLs and resistance QTLs or a pleiotropic effect of the Ftq QTLs on rust resistance. Relatively low heritability estimates (0.30) obtained for partial resistance to crown rust in the field indicate a potential value for marker-assisted selection.

Molecular mousetraps and the serpinopathies.

Members of the serine proteinase inhibitor or serpin superfamily inhibit their target proteinases by a remarkable conformational transition that involves the enzyme being translocated more than 70 A (1 A = 10(-10) m) from the upper to the lower pole of the inhibitor. This elegant mechanism is subverted by point mutations to form ordered polymers that are retained within the endoplasmic reticulum of secretory cells. The accumulation of polymers underlies the retention of mutants of alpha(1)-antitrypsin and neuroserpin within hepatocytes and neurons to cause cirrhosis and dementia respectively. The formation of polymers results in the failure to secrete mutants of other members of the serpin superfamily: antithrombin, C1 inhibitor and alpha1-antichymotrypsin, to cause a plasma deficiency that results in the clinical syndromes of thrombosis, angio-oedema and emphysema respectively. Understanding the common mechanism underlying the retention and deficiency of mutants of the serpins has allowed us to group these conditions as the serpinopathies. We review in this paper the molecular and structural basis of the serpinopathies and show how this has allowed the development of specific agents to block the polymerization that underlies disease.

Novel inter-series hybrids in Solanum, section Petota.

Sexual hybrids between distantly related Solanum species can undergo endosperm failure, a post-zygotic barrier in inter-species hybridizations. This barrier is explained by the endosperm balance number (EBN) hypothesis, which states that parents must have corresponding EBNs for viable seed formation. Tests for inter-crossability were made involving the Mexican species Solanum pinnatisectum Dunal. (series Pinnatisecta, ApiApi, 1EBN), autotetraploids of this species, Solanum verrucosum Schlechtd. (series Tuberosa, AA, 2EBN), haploids (2x, 2EBN) of the South American S. tuberosum L. (series Tuberosa, A1A1A2A2, 4EBN), and F2 haploid-species hybrids with South American species (AA, 2EBN) S. berthaultii Hawkes, S. sparsipilum (Bitter.) Juz. and Bukasov and S. chacoense Bitter. The development of hybrid endosperms was investigated for these combinations by confocal microscopy with regard to cell-division timing and tissue collapse. Novel sexual diploid (AApi) and triploid (AApiApi) inter-series hybrids were generated from S. verrucosum x S. pinnatisectum crosses by using post-pollination applications of auxin. F1 embryos were rescued in vitro. The hybrid status of recovered plants was verified by microsatellite marker analysis, and the ploidy was determined by chromosome counting. The application of phytohormones in inter-ploidy S. pinnatisectum x S. tuberosum crosses, however, did not delay endosperm collapse, and embryos were not formed. Other diploid, 1EBN species tested in remote hybridizations with Group Tuberosum were S. cardiophyllum Lindl., S. trifidum Correll, and S. tarnii Hawkes and Hjert., series Pinnatisecta, and S. bulbocastanum Dunal., series Bulbocastana. Based on the analysis of post-zygotic reproductive barriers among isolated species of section Petota, we propose strategies to overcome such incompatibilities.

What people want from their family physician.

The public wants and is satisfied by care provided within a patient-physician relationship based on understanding, honesty, and trust. If the U.S. health care system is ever to become patient-centered, it must be designed to support these values and sustain, rather than fracture, the relationships people have with their primary physician.

Few people in the United States can identify primary care physicians.

Almost one decade after the Institute of Medicine (IOM) defined primary care, only one third of the American public is able to identify any of the medical specialties that provide it, and only 17 percent were able to accurately distinguish primary care physicians from medical or surgical specialists and non-physicians. This lack of discrimination compromises the goal of achieving primary care for all and merits immediate attention.

Chiropractors are not a usual source of primary health care.

Chiropractors are the largest source of office-based care in the United States that does not involve a physician, but people do not view chiropractors as primary providers of health care or advice. Unlike the care given by primary care providers, the majority of care provided by chiropractors is limited to musculoskeletal problems.

Learning from malpractice claims about negligent, adverse events in primary care in the United States.

BACKGROUND: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. METHODS: Physician Insurers Association of America malpractice claims data (1985-2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. RESULTS: Of 49345 primary care claims, 26126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). CONCLUSIONS: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.

The U.S. primary care physician workforce: minimal growth 1980-1999.

Growth in the primary care physician workforce (physicians per capita) in the United States has trailed the growth of the specialist physician population in recent years. This has occurred despite calls during the same period for increased production of primary care physicians and educational reforms focusing on primary care.

The U.S. primary care physician workforce: undervalued service.

Primary care physicians work hard, but their compensation is not correlated to their work effort when compared with physicians in other specialties. This disparity contributes to student disinterest in primary care specialties.

The U.S. primary care physician workforce: persistently declining interest in primary care medical specialties.

A persistent, six-year trend in the choice of specialty training by U.S. medical students threatens the adequacy of the physician workforce of the United States. This pattern should be reversed and requires the attention of policy makers and medical educators.