Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial.

Care for patients transitioning from chronic kidney disease to kidney failure often falls short of meeting patients' needs. The PREPARE NOW study is a cluster randomized controlled trial studying the effectiveness of a pragmatic health system intervention, 'Patient Centered Kidney Transition Care,' a multi-component health system intervention designed to improve patients' preparation for kidney failure treatment. Patient-Centered Kidney Transition Care provides a suite of new electronic health information tools (including a disease registry and risk prediction tools) to help providers recognize patients in need of Kidney Transitions Care and focus their attention on patients' values and treatment preferences. Patient-Centered Kidney Transition Care also adds a 'Kidney Transitions Specialist' to the nephrology health care team to facilitate patients' self-management empowerment, shared-decision making, psychosocial support, care navigation, and health care team communication. The PREPARE NOW study is conducted among eight [8] outpatient nephrology clinics at Geisinger, a large integrated health system in rural Pennsylvania. Four randomly selected nephrology clinics employ the Patient Centered Kidney Transitions Care intervention while four clinics employ usual nephrology care. To assess intervention effectiveness, patient reported, biomedical, and health system outcomes are collected annually over a period of 36 months via telephone questionnaires and electronic health records. The PREPARE NOW Study may provide needed evidence on the effectiveness of patient-centered health system interventions to improve nephrology patients' experiences, capabilities, and clinical outcomes, and it will guide the implementation of similar interventions elsewhere. TRIAL REGISTRATION: NCT02722382.

Religiosity and ethical ideology of physicians: a cross-cultural study.

In this study of ethical ideology and religiosity, 1,255 physicians from Canada, China, Ireland, India, Japan and Thailand participated. Forsyth's (1980) Ethical Position Questionnaire and Rohrbaugh and Jessor's (J Pers 43:136-155, 1975) Religiosity Measure were used as the survey instruments. The results demonstrated that physicians from India, Thailand and China reported significantly higher rates of idealism than physicians from Canada and Japan. India, Thailand and China also scored significantly higher than Ireland. Physicians from Japan and India reported significantly higher rates of relativism than physicians from Canada, Ireland, Thailand and China. Physicians from China also reported higher rates of relativism than physicians from Canada, Ireland and Thailand. Overall, religiosity was positively associated with idealism and negatively associated with relativism. This study is the first to explore the differences between ethical ideology and religiosity among physicians in an international setting as well as the relationship between these two constructs. Both religiosity and ethical ideology are extremely generalized, and the extent to which they may impact the actual professional behaviour of physicians is unknown. This paper sets up a point of departure for future research that could investigate the extent to which physicians actually employ their religious and/or ethical orientation to solve ambiguous medical decisions.

Perceptions of the effectiveness of ethical guidelines: an international study of physicians.

The intent of ethics is to establish a set of standards that will provide a framework to modify, regulate, and possibly enhance moral behaviour. Eleven focus groups were conducted with physicians from six culturally distinct countries to explore their perception of formalized, written ethical guidelines (i.e., codes of ethics, credos, value and mission statements) that attempt to direct their ethical practice. Six themes emerged from the data: lack of awareness, no impact, marginal impact, other codes or value statements supersede, personal codes or values dictate, and ethical guidelines are useful. Overall, codes were valued only when they were congruent with existing personal morality. The findings suggest the need to re-evaluate the purpose, content, and delivery of codes for them to improve their function in promoting ethical conduct.

Ethical decision-making about older adults and moral intensity: an international study of physicians.

Through discourse with international groups of physicians, we conducted a cross-cultural analysis of the types of ethical dilemmas physicians face. Qualitative analysis was used to categorise the dilemmas into seven themes, which we compared among the physicians by country of practice. These themes were a-theoretically-driven and grounded heavily within the text. We then subjected the dilemmas to an analysis of moral intensity, which represents an important (albeit novel within healthcare research) theoretical perspective of ethical decision making. These constructs (ie, culture and moral intensity) represent salient determinants of ethical behaviour and our cross-cultural sample afforded us the opportunity to consider both the pragmatic aspects of culture, as they are perceived by physicians, as well as the theory-driven concept of moral intensity. By examining both culture and moral intensity, we hope to better elucidate the complexities of ethical decision-making determinants among physicians in their daily practice. Doing so may potentially have practical implications for ethics training of medical students and foreign physicians.

Reliance on visible speech cues during multimodal language processing: individual and age differences.

The current study demonstrates that when a strong inhibition process is invoked during multimodal (auditory-visual) language understanding: older adults perform worse than younger adults, visible speech does not benefit language-processing performance, and individual differences in measures of working memory for language do not predict performance. In contrast, in a task that does not invoke inhibition: adult age differences in performance are not obtained, visible speech benefits language performance, and individual differences in working memory predict performance. The results offer support for a framework for investigating multimodal language processing that incorporates assumptions about general information processing, individual differences in working memory capacity, and adult cognitive aging.

Attention resources and visible speech encoding in older and younger adults.

Two experiments investigated adult age differences in the distribution of attention across a speaker's face during auditory-visual language processing. Dots were superimposed on the faces of speakers for 17-ms presentations, and participants reported the spatial locations of the dots. In Experiment 1, older adults showed relatively better detection performance at the mouth area than the eye area compared to younger adults. In Experiment 2, in the absence of audible language, both age groups did not differentially focus on the mouth area. The results are interpreted in light of Massaro's (1998, Perceiving talking faces: From speech perception to a behavioral principle. Cambridge, MA: MIT Press) theoretical framework for understanding auditory-visual speech perception. It is claimed that older adults' greater reliance on visible speech is due to a reallocation of resources away from the eyes and toward the mouth area of the face.

Making ethical choices: a comprehensive decision-making model for Canadian psychologists.

This paper proposes a theoretical augmentation of the seven-step decision-making model outlined in the Canadian Code of Ethics for Psychologists. We propose that teleological, deontological, and existential ethical perspectives should be taken into account in the decision-making process. We also consider the influence of individual, issue-specific, significant-other, situational, and external factors on ethical decision-making. This theoretical analysis demonstrates the richness and complexity of ethical decision-making.

Discovery of the hemifumarate and (alpha-L-alanyloxy)methyl ether as prodrugs of an antirheumatic oxindole: prodrugs for the enolic OH group.

Ether, ester, and carbonate derivatives of the antirheumatic oxindole 1 were prepared and screened as potential prodrugs of 1. This effort led to the discovery of the (alpha-L-alanyloxy)-methyl ether and hemifumarate derivatives of 1 which deliver the drug efficiently into the circulation of test animals, are stable in the solid state, and possess good stability in solution at low pH as required to ensure gastric stability. Success in achieving acceptable bioavailabilities of 1 across species (rats, dogs, and monkeys) followed the inclusion of ionizable functionality within the promoiety to compensate for masking the polar enolic OH group of the free drug. However, the introduction of ionizable functionality was often associated with decreased stability, as demonstrated by the hemisuccinate, hemiadipate, hemisuberate, and alpha-amino ester derivatives of 1 which could not be isolated. A clear exception was the hemifumarate derivative of 1 which was not only isolable but actually more stable at neutral pH than the nonionizable ester analogues. The solution and solid state stability of the hemifumarate, together with its activity as a prodrug of 1, suggests that hemifumarate be considered as an alternative to hemisuccinate as a prodrug derivative for alcohols, particularly in situations where solution state stability is an issue.

Evaluation of a Treponema pallidum enzyme immunoassay as a screening test for syphilis.

The CAPTIA Syphilis-G enzyme immunoassay for the detection of antibodies to Treponema pallidum was evaluated as a screening test for syphilis in comparison with the standard rapid plasma reagin (RPR) test. One thousand samples were tested, and the standard fluorescent treponemal antibody absorption test and the standard microhemmaglutination test were used to confirm the presence of treponemal antibodies. Diagnosis of syphilis was based on traditional standard serology results. Clinical data used in the diagnosis of patients whose samples yielded conflicting results were provided by physicians. Initially, 7 patients whose samples were reactive in the RPR test and 14 patients whose samples yielded positive or equivocal results in the CAPTIA Syphilis-G test were diagnosed as not being infected. After discrepancies due to technical problems were reconciled, samples from six patients remained reactive in the RPR test and that from one patient remained positive in the CAPTIA Syphilis-G test. In addition, seven patients whose samples were nonreactive in the RPR test and two patients whose samples were negative in the CAPTIA Syphilis-G test were diagnosed as having untreated syphilis. After discrepancies were reconciled, samples from five patients remained nonreactive in the RPR test and none remained negative in the CAPTIA Syphilis-G test. Final results indicate that the specificities are 99.4 and 99.9%, respectively. In addition to the improved sensitivity and specificity of the CAPTIA Syphilis-G screen, other potential benefits of this assay lead us to believe that this method could serve as a better screening tool than the RPR test.

Giardiasis: a case report and discussion of outbreaks in the United States.

Outbreaks of giardiasis occur every year in the United States, and waterborne infections appear to be increasing. Accurate identification of cases, proper hygiene in day-care and institutional settings, and adequate treatment of water sources will allow better control of this disease.

Detection of Borrelia burgdorferi using the polymerase chain reaction.

Segments of the ospA gene of Borrelia burgdorferi were amplified by the polymerase chain reaction (PCR). Oligonucleotide primers used in the reaction flank a 309-base-pair segment within the ospA gene. After 35 cycles of amplification, the product could be detected by agarose gel electrophoresis or dot hybridization with a 32P-labeled probe. This segment was amplified in all strains of B. burgdorferi tested, but it was not detected in other bacterial species. An additional primer pair which has a broad specificity for conserved 16S rRNA sequences that are present in eubacteria amplified a 215-base-pair fragment in all organisms tested. The sensitivity of PCR for the detection of B. burgdorferi in clinical samples was evaluated by seeding blood and urine specimens with B. burgdorferi and subjecting them to amplification. We were able to detect 10 organisms per ml of blood or urine, using PCR with dot hybridization detection. DNA extraction is not required for sample preparation. Blood and urine specimens were obtained from canines with clinical and serologic evidence of Lyme disease and subjected to PCR analysis. Of 17 clinical specimens from 15 animals, one blood specimen showed reactivity in the PCR.

Detection of murine typhus infection in fleas by using the polymerase chain reaction.

Polymerase chain reaction (PCR) amplification of DNA was used to detect the etiologic agent of murine typhus, Rickettsia typhi, in experimentally infected adult fleas. A primer pair derived from the 17-kilodalton antigen sequence of typhus and spotted fever group rickettsiae was used to amplify a 434-base-pair (bp) fragment of the genome of the murine typhus rickettsiae. The amplified 17-kilodalton protein antigen-specific sequence was detected in ethidium bromide-stained agarose gels in individual fleas as early as 2 days after exposure to rickettsemic rats (two of six tested). The 434-bp sequence was not detected in uninfected control fleas. A dot hybridization assay used to detect the 434-bp fragment was also specific and about 100-fold more sensitive than the agarose gel PCR assay. Since the PCR assay employed a boiled extract of triturated fleas, both PCR and an antigen capture enzyme-linked immunosorbent assay (ELISA) could be performed on the same individual flea homogenate. The ELISA identified 12 infected fleas out of 29 randomly selected fleas, compared with 14 specimens which were positive by PCR. The PCR assay detected rickettsiae in samples in which no viable rickettsiae were detected by plaque assay. Like the ELISA, the PCR assay sensitivity was due in part to its suitability for detecting small numbers of both live and dead R. typhi in fleas.

Genetic structure of the bacteriophage P22 PL operon.

The sequence of 1416 base-pairs of the P22 PL operon was determined, linking a continuous sequence from PL through abc2. P22 mutants bearing deletions in the sequenced region were constructed and tested for their phenotypes. Plasmids were constructed to express PL operon genes singly and in combination from Plac UV5. Two previously known genes, 17 and c3, are located within this sequence. In addition, three new genes have been identified: ral, kil and arf. Genes ral and c3 are homologous, as well as functionally analogous, to lambda ral and cIII, respectively. P22 kil, like lambda kil, kills the host cell when it is expressed. The two kil genes, although analogous in cell killing and map location, have no apparent sequence homology. The functions of the P22 and lambda kil genes are unknown; however, P22 kil is essential for lytic growth in the absence of abc. Gene arf (accessory recombination function) is located just upstream from erf; it is essential for P22 growth in the absence of kil or other genes upstream in PL. The growth defect of P22 bearing a deletion that removes arf is complemented by expression of either arf or the lambda red genes from plasmids. Sequences that include the stop codon for gene 17 may form a small stem-loop structure and are nearly identical to lambda sequences that contain the stop codon for ssb, which is near lambda tL 2b. Plasmids that include the P22 structure negatively regulate kil gene expression in cis.

Cerebral infarction secondary to unsuspected intracranial fibromuscular dysplasia following bypass of aortic coarctation.

Fibromuscular dysplasia (FMD) is an uncommon finding in the cerebral circulation. We present a case of unsuspected intracranial FMD in a patient dying from a large cerebral infarct following a bypass operation for coarctation of the aorta. The need for recognizing the possible co-existence of these two lesions is emphasized.

Management of acute subdural hematomas from aneurysmal rupture.

Subdural hematomas (SDH) from ruptured aneurysm (RA) are much less common than intracerebral (ICH) hematomas or subarachnoid (SAH) or intraventricular hemorrhage (IVH). With computerized tomography, preoperative diagnosis is now made more often. The authors have collected 18 such cases from a review of 897 cases of RA admitted to eleven medical centers in 1980 and 1981. Nine (50%) of these patients died prior to discharge from hospital. Four (22%) had surgery and died postoperatively and 9 (50%) were operated upon and survived. Thirteen (72%) of the patients showed anisocoria, decreased consciousness and unilateral weakness prior to surgery. Eight (89%) of the fatalities had shown preoperative herniation as opposed to only 5 (56%) of the survivors. The overall incidence of delayed ischemia due to vasospasm was 11% (2 cases). Those who died had greater midline shift and larger SDH on the admission CT scan. Sixteen (89%) of these patients were female. Thirteen (72%) had ruptured aneurysms on the internal carotid artery. All of these hematomas were unilateral and uniformly hyperdense, and the convexity hematomas were crescentic in shape. Seventeen (94%) had evidence of blood in locations other than the subdural space. If the patient is potentially salvageable and has a midline shift, the SDH should probably be evacuated immediately and the aneurysm clipped at the same operation since the development of a tentorial herniation has such an adverse effect on outcome.

Intraventricular hemorrhage from ruptured aneurysm. Retrospective analysis of 91 cases.

Intraventricular hemorrhage (IVH) from aneurysm rupture is generally considered to be of grave prognostic significance. Ninety-one cases have been studied retrospectively from seven medical centers. The overall mortality rate was 64%. The dramatically poor condition of these patients leads to their rapid admission to the hospital. Eighty-seven percent were admitted on Day 0 or 1, and more than half were classified neurologically as Grade 4 or 5. A multiple regression analysis explained 56% of the variance in survival, using the variables of ventriculocranial ratio (VCR), day of admission, diastolic blood pressure, location of aneurysm, associated intracerebral hematoma, age, grade on admission, sex, and systolic blood pressure. No patient with a VCR of more than 0.25, as calculated from the initial computerized tomography (CT) scan, survived. No patient whose smallest VCR was 0.23 or more survived. This ratio can be simply measured with a millimeter ruler from the CT scan. Patients with IVH usually had enlarged ventricles, even initially. The overall results suggest that early management of intracranial hypertension should be more generally considered, although even when this was done the prognosis was still guarded. The timing of surgery was not an important determinant of outcome, although a significant number of patients died awaiting surgery.