Determination of the absolute intensity of the 1205 keV γ-ray emission from 91Y.

A radiochemically pure solution of 91Y was produced by the thermal neutron fission of 235U followed by successive chemical separations to remove fission product impurities. The gamma emission rate of the 91Y 1205 keV gamma was measured using multiple high purity germanium gamma spectrometers previously calibrated for counting efficiency using a certificated mixed nuclide gamma standard. The activity concentration of the 91Y was subsequently standardised by liquid scintillation counting. From the combination the activity concentration and gamma emission intensity, the absolute intensity of the 1205 keV gamma emission was derived as 0.2297(39)%. This data agrees within the quoted uncertainties with the absolute intensity of 0.26(4)% published in nuclear data sheets A=91 (Baglin, 2013), but reduces the uncertainty by an order of magnitude.

A plastic scintillator and HPGe ß-γ coincidence detection system.

A network of specialist laboratories support the International Monitoring System (IMS) of the Comprehensive Nuclear-Test-Ban Treaty (CTBT) with re-measurements of radionuclide samples, including xenon gas. The measurement of four xenon fission product radionuclides (133Xe, 135Xe, 131mXe and 133mXe) can be used to detect an underground nuclear explosion. Laboratories use a range of techniques to measure the radionuclides, including beta-gamma (ß-γ) coincidence spectrometry. These highly-sensitive measurements are capable of detecting concentrations of down to 500 atoms of 133Xe in a few cm3 of xenon. In some detector systems, detection of the metastable isomers (131mXe and 133mXe) can be more challenging due to interferences between the signatures of different radionuclides. Recent work has shown that using high-purity Germanium (HPGe) high-resolution gamma detectors, these interferences can be reduced, lowering the dependence of the detection limits on radionuclide sample isotopic composition. One downside of these detectors is the reduction in detection efficiency, which impacts the overall detection sensitivity; so assessing different detector systems is a priority for radionuclide laboratories. This work presents a coincidence detector system comprising of a plastic scintillator gas cell and a large-crystal high-purity germanium detector. The energy resolution, coincidence detection efficiency, MDA and interference factors are determined from measurements of synthetic radioxenon gas samples.

Time use in clinical encounters: are African-American patients treated differently?

Racial disparities in the process and outcome of health care may be partially explained by differences in time use during outpatient visits by African-American and white patients. This study was undertaken to determine whether physicians use their time in clinical encounters with African-American patients differently than with white patients. This study was a multimethod, cross-sectional study conducted between October 1994 and August 1995 in 84 family practices in northeast Ohio. Participants were 4,352 white and African-American outpatients visiting 138 physicians. Time use during the patient visit was measured by the Davis Observation Code, which categorizes every 20-second interval into 20 different behavioral categories. Among 3,743 white and 509 African-American patients, after adjustment for potential confounders, visits by African-American patients were slightly longer than visits with white patients (10.7 vs. 10.1 minutes, p = 0.027). After further adjustment for multiple comparisons, physicians spent a lower proportion of time intervals with African-American patients as compared to white patients planning treatment (29.0% vs. 32.1%, p < 0.001), providing health education (16.4% vs. 19.7%, p < 0.001), chatting (5.2% vs. 7.6%, p < 0.001), assessing patients' health knowledge (0.8% vs. 1.2%, p < 0.001), and answering questions (5.8% vs. 6.9%, p = 0.002). Physicians spent relatively more time intervals with African-American patients discussing what is to be accomplished (9.3% vs. 7.6%, p < 0.001) and providing substance use assessment and advice (0.8% vs. 0.4%, p = 0.001). In conclusion, physicians spend time differently with African-American as compared with white patients. These differences may represent appropriate tailoring of services to meet unique needs, but could also represent racial bias.

Does health habit counseling affect patient satisfaction?

BACKGROUND: Health behavior advice can potentially prevent a large burden of illness, but the acceptability of this advice to patients is not well understood. This study assessed whether physician discussion of behavioral risk factors decreases patient satisfaction with the outpatient visit. METHODS: In a cross-sectional study of 2,459 consecutive adult outpatient visits to 138 community family physicians in Northeast Ohio, the association of health habit counseling, measured by direct observation, with patient satisfaction, assessed by a modified subscale of the MOS 9-item visit rating scale, was calculated by logistic regression. RESULTS: In analyses controlling for patient mix, discussion of diet, exercise, alcohol and other substance use, sexually transmitted disease, and HIV prevention was not associated with patient satisfaction. Patients who were asked about their tobacco use or counseled about quitting were more likely to be very satisfied with the physician. CONCLUSIONS: Discussion of health behavior change, as practiced by community family physicians, is not associated with diminished patient satisfaction. In fact, tobacco use assessment and cessation counseling are associated with greater satisfaction.

The delivery of preventive services for patient symptoms.

BACKGROUND: Although data are available on rates of delivery of preventive services by primary care physicians, the proportion of services delivered because of related symptoms or signs, rather than for primary or secondary prevention of disease is not known. METHODS: Research nurses directly observed 4454 consecutive visits to 138 practicing family physicians. Direct observation was used to identify delivery of 36 different services recommended by the U.S. Preventive Services Task Force and to assess whether delivery of these services was associated with related signs or symptoms. RESULTS: One or more preventive services were delivered in 33% of visits, with rates ranging from 0.2% (HIV prevention) to 19.9% (tobacco counseling). In contrast to pure prevention, services were frequently performed for assessment or care of symptoms or signs, with the ratio ranging from 0% (eye examination; car seat, poison control, and HIV prevention counseling) to 66.7% (hearing test). Physicians varied considerably in the frequency at which their delivery of recommended preventive services was associated with patient symptoms, from 0% to 100% for screening services and from 0% to 100% for counseling services. CONCLUSIONS: Because of the illness focus of most primary care visits, preventive service delivery is often associated with related signs or symptoms. Care of illnesses appears to present an important impetus and perhaps teachable moments for providing preventive care. Clinician variability in preventive service delivery for patient symptoms shows an opportunity to improve the primary and secondary prevention focus of practice to meet public health prevention goals.

Is diabetes treated as an acute or chronic illness in community family practice?

OBJECTIVE: Poor quality of diabetes care has been ascribed to the acute care focus of primary care practice. A better understanding of how time is spent during outpatient visits for diabetes compared with visits for acute conditions and other chronic diseases may facilitate the design of programs to enhance diabetes care. RESEARCH DESIGN AND METHODS: Research nurses directly observed consecutive outpatient visits during two separate days in 138 community family physician offices. Time use was categorized into 20 different behaviors using the Davis Observation Code (DOC). Time use was compared for visits for diabetes, other chronic conditions, and acute illnesses during 1,867 visits by patients > or =40 years of age. RESULTS: Of 20 DOC behavioral categories, 10 exhibited differences among the three groups. Discriminant analysis identified two distinct factors that distinguished visits for chronic disease from visits for acute illness and visits for diabetes from those for other chronic diseases. Compared with visits for other chronic diseases, visits for diabetes devoted a greater proportion of time to nutrition counseling, health education, and feedback on results and less time to chatting. Compared with visits for acute illness, visits for diabetes were longer and involved a higher proportion of dietary advice, negotiation, and assessment of compliance. CONCLUSIONS: Visits for diabetes are distinct from visits for other chronic diseases and acute illnesses in ways that may facilitate patient self-management. Novel quality-improvement interventions could support and expand existing differences between family physicians' current approaches to care of diabetes and other chronic and acute illnesses.

A clinical trial of tailored office systems for preventive service delivery. The Study to Enhance Prevention by Understanding Practice (STEP-UP).

BACKGROUND: The potential of primary care practice settings to prevent disease and morbidity through health habit counseling, screening for asymptomatic disease, and immunizations has been incompletely met. This study was designed to test a practice-tailored approach to increasing preventive service delivery with particular emphasis on health habit counseling. DESIGN: Group randomized clinical trial and multimethod process assessment. SETTING/PARTICIPANTS: Seventy-seven community family practices in northeast Ohio. INTERVENTION: After a 1-day practice assessment, a nurse facilitator met with practice clinicians and staff and assisted them with choosing and implementing individualized tools and approaches aimed at increasing preventive service delivery. MAIN OUTCOME MEASURE: Summary scores of the health habit counseling, screening and immunization services recommended by the U.S. Preventive Services Task Force up to date for consecutive patients during randomly selected chart review days. RESULTS: A significant increase (p=0.015) in global preventive service delivery rates at the 1-year follow-up was found in the intervention group (31% to 42%) compared to the control group (35% to 37%). Rates specifically for health habit counseling (p=0.007) and screening services (p=0.048) were increased, but not for immunizations. CONCLUSIONS: An approach to increasing preventive service delivery that is individualized to meet particular practice needs can increase global preventive service delivery rates.

Direct observation of rates of preventive service delivery in community family practice.

BACKGROUND: Data on preventive service delivery in primary care practice have been limited by indirect methods of measurement. This study describes directly observed rates of preventive service delivery during outpatient visits to community family physicians. METHODS: In a multimethod cross-sectional study, research nurses directly observed consecutive patient visits in the offices of 138 family physicians in Northeast Ohio. Patient eligibility for services recommended by the U.S. Preventive Services Task Force was determined from medical record review. Service delivery was assessed by direct observation of outpatient visits. Rates of delivery of specific preventive services were computed. Global summary measures were calculated for health habit counseling, screening, and immunization services. RESULTS: Among 4,049 visits by established patients with available medical records, wide variation was observed among rates of different preventive services delivered during well-care visits. During illness visits, rates were uniformly low for all preventive services. Counseling services were delivered at only slightly lower rates during illness visits compared to well visits. Patients were up to date on 55% of screening, 24% of immunization, and 9% of health habit counseling services. CONCLUSION: Rates of preventive service delivery are low. Illness visits are important opportunities to deliver preventive services, particularly health habit counseling, to patients. Preventive service delivery summary scores are useful in providing a patient population perspective on the delivery of preventive services and in focusing attention on delivery of a comprehensive portfolio of services.

Two physician styles of focusing on the family.

BACKGROUND: Previous research has identified 2 styles of family physicians' focus on the patient's family: (1) using the family history as the context of care of the patient; and (2) maintaining a family orientation with the family as the unit of care. The purpose of our study was to determine whether these styles affect patient outcomes and time use during outpatient visits. METHODS: In a cross-sectional study, data on 4454 outpatient visits to 138 community family physicians were collected using direct observation, patient and physician questionnaires, and medical record review. We computed partial correlations between the physician's family practice style score and patient outcomes for delivery of preventive services, patient visit satisfaction, and patient-reported delivery of specific components of primary care. We controlled for relevant patient characteristics. RESULTS: The patients of the physicians using either practice style had similar levels of satisfaction with coordination of care and interpersonal communication, and their value of continuity of care was comparable. Patients of physicians with a family-history style, however, rated their physicians lower on a measure of in-depth knowledge of the patient and family but higher on preventive services delivery. Differences in time use during the visit reflected how these styles were manifested during the outpatient visit. CONCLUSIONS: The different styles physicians use to focus on the family affect the process and outcomes of patient care. This difference may be explained by the developmental life cycle of family physicians, as younger physicians may be more focused on family history and older physicians may have a more family-oriented focus. Physicians may need to find alternate ways of meeting those patient needs not well met by their predominant practice style.

Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice.

OBJECTIVE: To compare the concordance of family physicians' billing for evaluation and management services with medical record documentation. DESIGN: Multi-method, cross-sectional observation study. SETTING: Eighty-four family practices in northeast Ohio. PARTICIPANTS: Four thousand fifty-four outpatients visiting 138 family physicians. MAIN OUTCOME MEASURE: The degree of concordance between evaluation and management Current Procedural Terminology codes billed by physicians, with those codes assigned by trained research nurses using American Medical Association criteria to code medical records for the same visits. RESULTS: Discrepancies between the multifactorial nature of family practice outpatient visits and the Current Procedural Terminology coding criteria, which dictate overcoding for depth rather than breadth, made coding difficult (multiple-rater kappa statistic between research nurses = 0.36). Among 4137 outpatient visits with complete billing information, 57% of the Current Procedural Terminology codes generated by medical record review were concordant with the actual billing code assigned by physicians. Undercoding and overcoding occurred at a similar frequency (21% and 19%, respectively) and differed by more than 1 code in fewer than 4% of visits. Visits by new patients were more likely to be inaccurately coded than visits by established patients. CONCLUSIONS: Record documentation by community family physicians largely reflects the level of services billed using evaluation and management codes. Undercoding is as common as overcoding. Efforts from regulatory agencies should be redirected from penalizing physicians for overcoding to focusing on the development of coding criteria that reflect the multifactorial nature of outpatient primary care practice.

Facilitating participatory decision-making: what happens in real-world community practice?

BACKGROUND: Participatory decision-making (PDM), a widely held ideal, depends on physician facilitation of patient participation. However, little is known about how PDM facilitation is actualized in outpatient primary care. OBJECTIVES: The objective of this study was to describe the prevalence of physician facilitation of PDM in community family practices and associated physician, patient, and visit characteristics. RESEARCH DESIGN: This was a cross-sectional observational study. SUBJECTS: The study included 3,453 patients seen by 138 family physicians in 84 community practices. MAIN OUTCOME MEASURES: Research nurses directly observed PDM facilitation in consecutive adult outpatient visits. The association between PDM facilitation and patient, physician, and visit characteristics was assessed with multilevel multivariable regression. RESULTS: PDM facilitation occurred during 25% of observed patient visits. Rates varied considerably among physicians, from 0% to 79% of visits. Patient satisfaction was not associated with PDM facilitation. In multivariable analyses, employed physicians, chronic illness visits, longer visit duration, and visits involving referral were independently associated with PDM facilitation. Visits in which greater time was spent planning treatment and conducting health education were also more likely to involve facilitation of PDM. CONCLUSIONS: Community family physicians facilitate PDM at highly variable rates but focus it on patients with the greatest medical needs and most complex levels of decision making. This selective approach appears to meet patient expectations, because PDM facilitation and patient satisfaction are not associated. If patient participation is to be more widely incorporated into outpatient primary care, it must be addressed within the complexity and multiple demands of community practice.

Family history-taking in community family practice: implications for genetic screening.

PURPOSE: To identify characteristics of physicians, patients, and visits associated with obtaining family history information in community family practice. METHODS: Research nurses directly observed 4,454 patient visits to 138 family physicians and reviewed office medical records. RESULTS: Family history was discussed during 51% of visits by new patients and 22% of visits by established patients. Physicians' rates of family history-taking varied from 0% to 81% of visits. Family history was more often discussed at well care rather than illness visits. The average duration of family history discussions was <2.5 minutes. CONCLUSIONS: These data can form the basis for realistic interventions to increase the use of family history in primary care.

Direct observation of health-habit counseling of adolescents.

OBJECTIVES: To determine the rate of health-habit counseling of adolescents seeing community family physicians and to identify the factors associated with the delivery of recommended preventive counseling services. DESIGN: Cross-sectional multimethod study emphasizing direct observation of patient visits. SETTING: Community family practices in northeast Ohio. PATIENTS OR OTHER PARTICIPANTS: Adolescents (n = 445) aged 11 to 21 years who were being seen for outpatient visits to community family physicians (n = 119) during 2 days of observation by trained research nurses. MAIN OUTCOME MEASURE: Direct observation of the delivery of clinical preventive counseling services recommended by the Guidelines for Adolescent Preventive Services. RESULTS: During the 445 visits made by adolescents, the most frequently delivered counseling service was exercise advice (13%). At least 1 health-habit counseling service was delivered during 38% of visits. In multivariable analyses, older patient age was strongly associated with increased service delivery. Visits for well care, longer visits, and new patient visits were also associated with the provision of counseling. Visits including preventive counseling services were on average 2.5 minutes longer than visits without preventive counseling. CONCLUSIONS: The rates of delivery of preventive counseling services in clinical practice were low, raising concern about the feasibility of current recommendations. The practical implementation of prevention guidelines may require a greater use of well-care visits and longer patient visits than are currently used in community family practice.

Direct observation of exercise counseling in community family practice.

BACKGROUND: Although physical activity is important for the prevention and management of a variety of common chronic diseases, the prevalence and patient and visit characteristics associated with provision of physical activity advice by community family physicians is not well understood. METHODS: In a cross-sectional multi-method study of 138 family physicians in northeast Ohio, exercise advice was measured by direct observation and patient report of consecutive patient visits to 138 practicing family physicians. The association of exercise advice with patient and visit characteristics, assessed by direct observation, medical record review, patient exit questionnaire, and billing data, was determined by logistic regression analysis. RESULTS: In 4,215 visits by patients older than 2 years of age, exercise counseling was observed during 927 visits (22.3%), but reported by only 13% of patients returning questionnaires. The mean time spent counseling about exercise was 0.78 minutes, with a range of 0.33 to 6.00 minutes (SD = 0.67). Exercise advice was more common during longer visits, visits for well care, and visits by patients who were older, male, and had chronic illnesses for which lack of physical activity is a risk factor. CONCLUSIONS: Exercise counseling is relatively common during outpatient visits to family physicians, and is more commonly given to patients with risk factors. Multiple patient visits over time present opportunities to integrate exercise counseling among the competing demands of primary care practice.

Multi-centric histiocytosis: Experimental induction in broiler and specific pathogen-free leghorn chickens.

Seventy-five 3-day-old broiler chicks and twenty specific pathogen-free leghorn chicks were injected with 0.5 ml of a homogenate, prepared from organs from broilers diagnosed with naturally-occurring multicentric histiocytosis (MH). Equal numbers of uninjected broiler and leghorn chicks (controls) were maintained in adjacent pens. Ten weeks later, nine broilers had well-developed gross and microscopic MH lesions. The distribution and histological appearance of lesions in these experimental chicks was similar to lesions described in naturally occurring field cases. Six leghorns had gross lesions similar to those found in their broiler counterparts; however, in the leghorns, the cellular masses contained more lymphocytes and, additionally, masses were found in the gizzard musculature. One gizzard contained a sarcoma. Broiler chickens with MH weighed less than their control counterparts and were more likely to be anaemic. Sequences specific for reticuloendotheliosis viruses (REV) were found in the MH homogenate, in organs from most affected experimental leghorns and broilers, and in organs from a control broiler. However, REV were not isolated from these tissues, nor were specific antibodies for REV or avian leukosis/sarcoma viruses (ALV) found in chick serum. Leukosis/sarcoma viruses were isolated from some MH-affected experimental leghorns and broilers. Sequences specific for Marek's disease herpesvirus were not identified by polymerase chain reaction. The aetiology of MH remains unknown.

Clinical application of a light microscopic scoring method to make decisions regarding the pharmacotherapy of an Eimeria maxima abatement programme.

The purpose of the present study was to use an Eimeria maxima light microscopic lesion scoring (MLS) system to measure magnitudes of E. maxima infection in sections of broiler chick intestine, and to help make decisions regarding the efficacy of an E. maxima abatement programme. Chicks with whole-body pallor, elevated feed conversion ratios (10 points higher than normal) and reduced body sizes (0.1 kg smaller than normal) had light microscopic lesions caused by E. maxima infections. These intestine segments had high Eimeria maxima MLSs. High scores, coupled with the fact that there was no microscopic evidence for the presence of gastrointestinal pathogens other than E. maxima, allowed us to conclude that E. maxima was the cause of the signs observed. When changes in the pharmacotherapy of the coccidiosis abatement programme were made (substitution of one ionophore coccidiostat for another ionophore coccidiostat), the MLSs were significantly (P < 0.01) reduced, and chicks returned to their normal colour (yellow) and normal target body size (2.091 kg) on a normal feed conversion ratio (2.06). It was decided that the MLS is suitable for use in health programmes that depend upon detection of E. maxima in broilers.

Use of Aviguard and other intestinal bioproducts in experimental Clostridium perfringens-associated necrotizing enteritis in broiler chickens.

Clostridium perfringens-associated necrotic enteritis (CPANE) is a common problem among rapidly growing broiler strains of chickens that are raised intensively in modern microenvironments. The purpose of this study was to compare the use of Aviguard and three other intestinal bioproducts (two normal gut flora [NGF] products and one probiotic product) in experimental CPANE in broiler chickens. Male broiler chicks were housed in the same environmentally controlled facility and given one of six treatments. The necrotic enteritis infection model (NEIM) used in the present study was effective in inducing CPANE intestinal gross lesions in broiler chickens. Equally important, Aviguard was found to be significantly more effective than either the other two NGF products or the probiotic for reducing gross lesions induced by the NEIM. In addition, Aviguard/NEIM-treated chicks ate more feed and had better feed efficiency than their NGF- or probiotic/NEIM-treated counterparts. Other significant differences among these four reconstituted microbial preparations were not found. Results from this study have additional importance because they further support the use of reconstituted microbial preparations as novel and effective alternatives to antibiotics that can reduce the severity of C. perfringens-associated necrotic enteritis challenge in broilers.

Patient and visit characteristics associated with opportunistic preventive services delivery.

BACKGROUND: This study's purpose was to identify patient and visit characteristics associated with the use of illness visits as opportunities for the delivery of preventive services and to determine if time is allocated differently during illness visits that make use of these opportunities. METHODS: Research nurses directly observed the delivery of preventive services during consecutive patient visits on 2 separate days in the offices of 138 family physicians. Data on patient eligibility for preventive services were collected by medical record review. Time use during patient visits was categorized using the Davis Observation Code (DOC). Patient characteristics, visit characteristics, and time use were compared during illness visits in which at least one service recommended by the US Preventive Services Task Force was delivered to eligible patients, compared with illness visits during which no recommended preventive services were delivered. RESULTS: Preventive services were delivered during 32% of 3547 illness visits. Adults, overweight patients, those who smoke or drink alcohol, new patients, and patients with fewer visits in the past year were more likely to receive preventive services. Patient request was also associated with increased delivery of preventive services. The presence of another family member, visits for an acute illness, and the prescription of a drug were associated with a decreased likelihood of a patient's receiving preventive services. When preventive services were delivered during illness visits, less time was spent on chatting, procedures, and physical examination, and more time was spent on history-taking. CONCLUSIONS: Family physicians take greater advantage of opportunities for the delivery of preventive services during the illness visits of high-risk patients. The results of our study suggest strategies that could be used to expand the opportunistic delivery of preventive services to other patients and types of visits.

Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation.

BACKGROUND: Little is known about the accuracy of family physicians' use of the Current procedural Terminology (CPT) coding scheme for office visits, despite increased administrative oversight of Medicare billing practices. In addition, the patient and visit characteristics that are associated with over- and undercoding are not well understood. METHODS: This study compared coding for evaluation and management (E&M) services billed for 3791 visits to 138 family physicians with the codes assigned by trained research nurses using direct observation. We calculated the degree to which the codes for E&M were concordant with the observer-assigned codes. Analysis of variance and logistic regression were used to examine the association of visit and patient characteristics with discordance between billed and observer-assigned CPT codes. RESULTS: Billing codes were concordant for 55% of encounters. Discordance was evenly distributed between under- and overcoding. Concordance of billed and observed codes was greatest for patients with indemnity insurance. Undercoding increased with longer visit length and a smaller percentage of the visit spent planning treatment. Overcoding was more common during visits with a greater percentage of time spent chatting, planning treatment, and delivering preventive services. CONCLUSIONS: Family physicians are generally accurate in their billing procedures. The findings on patient and visit characteristics associated with over- or undercoding may be used by practicing clinicians to enhance the accuracy of their coding and billing procedures.

Effect of Poultry Litter Treatment (PLT) on death due to ascites in broilers.

The purposes of this study were to determine the effect of Poultry Litter Treatment (PLT) on levels of litter moisture, litter nitrogen, atmospheric ammonia, and death due to ascites. Data were collected from chicks raised in containment conditions that resembled commercial settings. The ascites death rate (5.9%) in broiler chicks on PLT-treated litter was significantly (chi 2 = 15.5, df = 1, P = 0.0001) lower than that (31.5%) in broiler chicks raised on untreated litter. Likewise, atmospheric ammonia levels in pens that had been treated with PLT were significantly (P < 0.05) lower than those in pens that received no treatment. Under the conditions of the present study, litter moisture and litter nitrogen levels were not different (P > 0.05) among treatments at any sample interval.