Screening for Fetal Chromosomal Abnormalities: ACOG Practice Bulletin Summary, Number 226.

Prenatal testing for chromosomal abnormalities is designed to provide an accurate assessment of a patient's risk of carrying a fetus with a chromosomal disorder. A wide variety of prenatal screening and diagnostic tests are available; each offers varying levels of information and performance, and each has relative advantages and limitations. When considering screening test characteristics, no one test is superior in all circumstances, which results in the need for nuanced, patient-centered counseling from the obstetric care professional and complex decision making by the patient. Each patient should be counseled in each pregnancy about options for testing for fetal chromosomal abnormalities. It is important that obstetric care professionals be prepared to discuss not only the risk of fetal chromosomal abnormalities but also the relative benefits and limitations of the available screening and diagnostic tests. Testing for chromosomal abnormalities should be an informed patient choice based on provision of adequate and accurate information, the patient's clinical context, accessible health care resources, values, interests, and goals. All patients should be offered both screening and diagnostic tests, and all patients have the right to accept or decline testing after counseling.The purpose of this Practice Bulletin is to provide current information regarding the available screening test options available for fetal chromosomal abnormalities and to review their benefits, performance characteristics, and limitations. For information regarding prenatal diagnostic testing for genetic disorders, refer to Practice Bulletin No. 162, Prenatal Diagnostic Testing for Genetic Disorders. For additional information regarding counseling about genetic testing and communicating test results, refer to Committee Opinion No. 693, Counseling About Genetic Testing and Communication of Genetic Test Results. For information regarding carrier screening for genetic conditions, refer to Committee Opinion No. 690, Carrier Screening in the Age of Genomic Medicine, and Committee Opinion No. 691, Carrier Screening for Genetic Conditions. This Practice Bulletin has been revised to further clarify methods of screening for fetal chromosomal abnormalities, including expanded information regarding the use of cell-free DNA in all patients regardless of maternal age or baseline risk, and to add guidance related to patient counseling.

Screening for Fetal Chromosomal Abnormalities: ACOG Practice Bulletin, Number 226.

Prenatal testing for chromosomal abnormalities is designed to provide an accurate assessment of a patient's risk of carrying a fetus with a chromosomal disorder. A wide variety of prenatal screening and diagnostic tests are available; each offers varying levels of information and performance, and each has relative advantages and limitations. When considering screening test characteristics, no one test is superior in all circumstances, which results in the need for nuanced, patient-centered counseling from the obstetric care professional and complex decision making by the patient. Each patient should be counseled in each pregnancy about options for testing for fetal chromosomal abnormalities. It is important that obstetric care professionals be prepared to discuss not only the risk of fetal chromosomal abnormalities but also the relative benefits and limitations of the available screening and diagnostic tests. Testing for chromosomal abnormalities should be an informed patient choice based on provision of adequate and accurate information, the patient's clinical context, accessible health care resources, values, interests, and goals. All patients should be offered both screening and diagnostic tests, and all patients have the right to accept or decline testing after counseling.The purpose of this Practice Bulletin is to provide current information regarding the available screening test options available for fetal chromosomal abnormalities and to review their benefits, performance characteristics, and limitations. For information regarding prenatal diagnostic testing for genetic disorders, refer to Practice Bulletin No. 162, Prenatal Diagnostic Testing for Genetic Disorders. For additional information regarding counseling about genetic testing and communicating test results, refer to Committee Opinion No. 693, Counseling About Genetic Testing and Communication of Genetic Test Results. For information regarding carrier screening for genetic conditions, refer to Committee Opinion No. 690, Carrier Screening in the Age of Genomic Medicine and Committee Opinion No. 691, Carrier Screening for Genetic Conditions. This Practice Bulletin has been revised to further clarify methods of screening for fetal chromosomal abnormalities, including expanded information regarding the use of cell-free DNA in all patients regardless of maternal age or baseline risk, and to add guidance related to patient counseling.

Are we in crisis? National mental health and treatment trends in college counseling centers.

The current state of college student mental health is frequently labeled a "crisis," as the demand for services and severity of symptomatology have appeared to increase in recent decades. Nationally representative findings are presented from the Center for Collegiate Mental Health, a practice research network based in the United States, composed of more than 340 university and college counseling centers, in an effort to illuminate trends in symptom severity and patterns in treatment utilization for the campus treatment seeking population. Clinical data collected over 5 academic years (2010-2015) showed small but significantly increasing trends for self-reported distress in generalized anxiety, depression, social anxiety, family distress, and academic distress, with the largest effect sizes observed for generalized anxiety, depression, and social anxiety. On the other hand, a significantly decreasing trend was observed for substance use. No significant changes were observed for eating concerns and hostility. Utilization data over 6 years indicated a gradual yet steady increase in the number of students seeking services (beyond the rate expected with increasing institutional enrollment), as well as increases in the number of appointments scheduled and attended, with great variation between centers. Within the context of changing national trends, we conclude that it is advisable to consider the specific needs of local centers to best accommodate distinct student bodies. (PsycINFO Database Record

eCONSULTS TO ENDOCRINOLOGISTS IMPROVE ACCESS AND CHANGE PRIMARY CARE PROVIDER BEHAVIOR.

OBJECTIVE: To describe the impact of an eConsult service on access to endocrinologists along with its influence on changing primary care provider (PCP) course of action and referral behaviors. METHODS: Established in 2011, the Champlain BASE (Building Access to Specialist Care via eConsult) service allows PCPs to access specialist care in lieu of traditional face-to-face referrals. We conducted a cross-sectional study of eConsult cases submitted to endocrinologists by PCPs between April 15, 2011 and January 31, 2015. Usage data and PCP responses to a mandatory closeout survey were analyzed to determine eConsult response times, PCP practice behavior, referral outcomes, and provider satisfaction. Each eConsult was coded according to clinical topic and question type based on established taxonomies. RESULTS: A total of 180 PCPs submitted 464 eConsults to endocrinology during the study period. Specialist median response time was 7 hours, with 90% of responses occurring within 3 days. PCPs received a new or additional course of action in 62% of submitted cases. An unnecessary face-to-face referral was avoided in 44% of all eConsults and in 67% of cases where the PCP initially contemplated requesting a referral. Over 95% of cases were rated at least 4 out of 5 in value for PCPs and their patients. CONCLUSION: The use of eConsult improves access to endocrinologists by providing timely, highly rated practice-changing clinical advice while reducing the need for patients to attend face-to-face office visits. ABBREVIATIONS: BASE = Building Access to Specialist Advice through eConsult PCP = primary care physician UCSF = University of California San Francisco.

Stakeholders' expectations and perceived effects of the pharmacy ownership liberalization reform in Sweden: a qualitative interview study.

BACKGROUND: Reforms in the health-care sector, including the pharmacy sector, can have different rationales. The Swedish pharmacies were prior to 2009 organized in a state-owned monopoly. In 2009, a liberalization of the ownership took place, in which a majority of the pharmacies were sold to private owners. The rationales for this liberalization changed profoundly during the preparatory work, making it probable that other rationales than the ones first expressed existed. The aim of this study was to explore the underlying rationales (not stated in official documents) for the liberalization in the Swedish pharmacy sector, and also to compare the expectations with the perceived outcomes. METHODS: Semi-structured interviews were conducted with representatives from key stakeholder organizations; i.e., political, patient, and professional organizations. The analysis was performed in steps, and themes were developed in an inductive manner. RESULTS: One expectation among the political organization participants was that the ownership liberalization would create opportunities for ideas. The competition introduced in the market was supposed to lead to a more diversified pharmacy sector. After the liberalization, the participants in favor of the liberalization were surprised that the pharmacies were so similar. Among the professional organization participants, one important rationale for the liberalization was to get better use of the pharmacists' knowledge. However, all the professional, and some of the patient organization participants, thought that the counseling in the pharmacies had deteriorated after the liberalization. As expected in the interviews, the post-liberalization pharmacy sector consists of more pharmacies. However, an unexpected perceived effect of the liberalization was, among participants from all the stakeholder groups, less access to prescription medicines in the pharmacies. CONCLUSIONS: This study showed that the political organization participants had an ideological basis for their opinion. The political stakeholders did not have a clear view about what the liberalization should lead to, apart from abolishing the monopoly. The perceived effects are quite similar in the different stakeholder groups, and not as positive as were expected.

Unmet education, psychological and peer support needs of people with multiple sclerosis.

OBJECTIVE: Multiple sclerosis is a complex neurological disease which can cause impairment in a range of aspects of an individual's life. It often requires a degree of adjustment and peer support. The aim of the present study was to examine satisfaction with educational, psychological and peer support services of people with MS across gender, age and symptom severity. METHOD: Participants completed a needs analysis questionnaire using Likert scales to determine the level of satisfaction with the support services. The questionnaire was sent to participants (n=3502) throughout Australia as paper copy with reply paid envelope, or made available to them online via email links. A total of 2805 responded and completed the questionnaire (80% response rate). Of those, 79% were female and 21% were male. The participants ranged in age from 19 to 92 years, (M=52.10; SD=11.82). RESULTS: In terms of psychological services, females were less satisfied with their access to relationship and family counseling. There was also a clear need for more varieties in peer support groups, times, as well as modes of communication, especially among young people and mildly affected groups. Symptom severity was associated with a greater need for almost all education and psychological support services. CONCLUSION: The findings of this study highlight current areas of unmet needs and may be used to inform the design and development of future education, psychological and social support services to ensure they are relevant and useful, as well as providing direction for future research.

'Country women are resilient but. ': Family planning access in rural Victoria.

OBJECTIVE: This study examined barriers to accessing three types of family planning service (emergency contraception, termination of pregnancy and options counselling) within the Grampians region of Victoria. In addressing the challenges faced by geographically marginalised women, the intention was to contribute to feminist psychological research in the field of women's health. DESIGN: The qualitative study drew on community and health psychology frameworks. Community psychology's ecological perspective takes into account the different contexts of people's lives, while the focus on psychosocial aspects of women's reproductive health behaviour places the study in a health psychology domain. SETTING: Grampians region of Victoria, Australia. PARTICIPANTS: Eleven professionals whose employment was connected to family planning services in Victoria. INTERVENTIONS: Semi-structured interviews. MAIN OUTCOME MEASURES: The study documented professionals' perceptions of facilitators and barriers to accessing family planning services in rural areas and the implications for women's psychosocial health and their ability to make timely decisions about a pregnancy. RESULTS: A thematic analysis confirmed that women in the Grampians region face many barriers including lack of local services, privacy, misinformation and judgmental service providers. While these issues could arise anywhere, the problem is compounded in rural areas by limited options and rural cultural pressures. CONCLUSIONS: This study highlights the complexity of many rural women's reproductive 'choices', and recommends plausible strategies to tackle barriers and facilitate access to family planning services. Reproductive health research can benefit from community and health psychology perspectives that consider psychosocial and cultural contexts as well as biomedical factors.

The case for creating a model insurance policy: payer coverage of breastfeeding counseling services, pumps, and supplies.

With the implementation of the Health Resources and Services Administration Women's Preventive Services Guidelines, which went into effective August 1, 2012, under the Affordable Care Act, healthcare insurance companies across the country have interpreted the breastfeeding support provision in a variety of ways. In order to improve benefit design and promote transparency and accountability, the National Breastfeeding Center and the United States Breastfeeding Committee co-authored a model insurance policy that seeks to educate insurance executives about appropriately supporting breastfeeding medicine for purposes of improving population health.

Demand and predictors for post-discharge medical counseling in home care patients: a prospective cohort study.

RATIONALE: Post-discharge care is challenging due to the high rate of adverse events after discharge. However, details regarding post-discharge care requirements remain unclear. Post-discharge medical counseling (PDMC) by telephone service was set-up to investigate its demand and predictors. METHODS: This prospective study was conducted from April 2011 to March 2012 in a tertiary referral center in northern Taiwan. Patients discharged for home care were recruited and educated via telephone hotline counseling when needed. The patient's characteristics and call-in details were recorded, and predictors of PDMC use and worsening by red-flag sign were analyzed. RESULTS: During the study period, 224 patients were enrolled. The PDMC was used 121 times by 65 patients in an average of 8.6 days after discharge. The red-flag sign was noted in 17 PDMC from 16 patients. Of the PDMC used, 50% (n = 60) were for symptom change and the rest were for post-discharge care problems and issues regarding other administrative services. Predictors of PDMC were underlying malignancy and lower Barthel index (BI). On the other hand, lower BI, higher adjusted Charlson co-morbidity index (CCI), and longer length of hospital stay were associated with PDMC and red-flag sign. CONCLUSIONS: Demand for PDMC may be as high as 29% in home care patients within 30 days after discharge. PDMC is needed more by patients with malignancy and lower BI. More focus should also be given to those with lower BI, higher CCI, and longer length of hospital stay, as they more frequently have red flag signs.

Tailoring clinical services to address the unique needs of adolescents from the pregnancy test to parenthood.

Clinicians across disciplines and practice settings are likely to encounter adolescents who are at risk for a pregnancy. In 2010, 34.2/1000 15-19-year-old teens had a live birth in the United States, many more will seek care for a pregnancy scare or options counseling. Teen mothers are also at risk for a second or higher-order pregnancy during adolescence. This paper provides clinicians with adolescent-friendly clinical and counseling strategies for pregnancy prevention, pre- and post-pregnancy test counseling, pregnancy-related care, and a review of the developmental challenges encountered by teens in the transition to parenthood. Clinicians are in a better position to approach the developmental, health and mental health needs of adolescents related to pregnancy if they understand and appreciate the obstacles adolescents may face negotiating the healthcare system. In addition, when clinical services are specially tailored to the needs of the adolescent, fewer opportunities will be lost to prevent unintended pregnancies, assist teens into timely prenatal services, and improve outcomes for their pregnancies and the transition to parenthood.

Missed opportunities for providing low-fat dietary advice to people with diabetes.

INTRODUCTION: Because cardiovascular disease is closely linked to diabetes, national guidelines recommend low-fat dietary advice for patients who have cardiovascular disease or are at risk for diabetes. The prevalence of receiving such advice is not known. We assessed the lifetime prevalence rates of receiving low-fat dietary advice from a health professional and the relationship between having diabetes or risk factors for diabetes and receiving low-fat dietary advice. METHODS: From 2002 through 2009, 188,006 adults answered the following question in the Medical Expenditure Panel Survey: "Has a doctor or other health professional ever advised you to eat fewer high-fat or high-cholesterol foods?" We assessed the association between receiving advice and the following predictors: a diabetes diagnosis, 7 single risk factors for type 2 diabetes, and total number of risk factors. RESULTS: Among respondents without diabetes or risk factors for diabetes, 7.4% received low-fat dietary advice; 70.6% of respondents with diabetes received advice. Respondents with diabetes were almost twice as likely to receive advice as respondents without diabetes or its risk factors. As the number of risk factors increased, the likelihood of receiving low-fat dietary advice increased. Although unadjusted advice rates increased during the study period, the likelihood of receiving advice decreased. CONCLUSION: Although most participants with diabetes received low-fat dietary advice, almost one-third did not. Low-fat dietary advice was more closely associated with the total number of diabetes risk factors than the presence of diabetes. Increasing rates of diabetes and diabetes risk factors are outpacing increases in provision of low-fat dietary advice.

The Do-Well study: protocol for a randomised controlled trial, economic and qualitative process evaluations of domiciliary welfare rights advice for socio-economically disadvantaged older people recruited via primary health care.

BACKGROUND: Older people in poor health are more likely to need extra money, aids and adaptations to allow them to remain independent and cope with ill health, yet in the UK many do not claim the welfare benefits to which they are entitled. Welfare rights advice interventions lead to greater welfare income, but have not been rigorously evaluated for health benefits. This study will evaluate the effects on health and well-being of a domiciliary welfare rights advice service provided by local government or voluntary organisations in North East England for independent living, socio-economically disadvantaged older people (aged ≥60 yrs), recruited from general (primary care) practices. METHODS/DESIGN: The study is a pragmatic, individually randomised, single blinded, wait-list controlled trial of welfare rights advice versus usual care, with embedded economic and qualitative process evaluations. The qualitative study will examine whether the intervention is delivered as intended; explore responses to the intervention and examine reasons for the trial findings; and explore the potential for translation of the intervention into routine policy and practice. The primary outcome is the effect on health-related quality of life, measured using the CASP 19 questionnaire. Volunteer men and women aged ≥60 years (1/household) will be identified from general practice patient registers. Patients in nursing homes or hospitals at the time of recruitment will be excluded. General practice populations will be recruited from disadvantaged areas of North East England, including urban, rural and semi-rural areas, with no previous access to targeted welfare rights advice services delivered to primary care patients. A minimum of 750 participants will be randomised to intervention and control arms in a 1:1 ratio. DISCUSSION: Achieving a trial design that is both ethical and acceptable to potential participants, required methodological compromises. The choice of follow-up length required a trade-off between sufficient time to demonstrate health impact and the need to allow the control group access to the intervention as early as possible. The study will have implications for fundamental understanding of social inequalities and how to tackle them, and provides a model for similar evaluations of health-orientated social interventions. If the health benefits of this intervention are proven, targeted welfare rights advice services should be extended to ensure widespread provision for older people and other vulnerable groups. CURRENT CONTROLLED TRIALS ISRCTN NUMBER: ISRCTN37380518.

How do psychosocial challenges associated with living with congenital heart disease translate into treatment interests and preferences? A qualitative approach.

OBJECTIVES: There is an increasing amount of research being conducted regarding the psychosocial challenges associated with living with congenital heart disease (CHD), however little is known about how these challenges influence the type of psychosocial services patients want. This study investigated (1) the type of services patients want; (2) how they want to access these services; and (3) why they want these services. METHODS: Three focus groups with adults with CHD (total of 14 participants aged 19-67) were conducted and thematic analysis was used to identify emerging themes. RESULTS: Participants described wanting to access specific psychosocial services in three broad categories (counselling, connecting with other adults with CHD and psycho-education) and in three main formats (individual/group therapy, mentorship programmes and patient conferences). Reasons for wanting these services were grouped under two overarching themes, namely intrapersonal factors and interpersonal challenges. CONCLUSIONS: Psychosocial challenges are part of the everyday lives of adults with CHD, yet they are rarely addressed as part of routine medical care. Patients themselves have clear opinions regarding the psychological services most appropriate to target their experiences of living with CHD.

Nurse practitioner and physician assistant physical activity counseling knowledge, confidence and practices.

OBJECTIVE: This exploratory cross-sectional study examined nurse practitioners' (NPs) and physician assistants' (PAs) perceptions about their physical activity counseling practices. METHOD: Participants were currently practicing NPs (n=240) and PAs (n=78) primarily in Arizona, USA during 2010. Participants completed a modified version of the Promotion of Physical Activity by Nurse Practitioners Questionnaire either online or in person during a practitioner specific conference. Mann-Whitney U tests and Chi-Square analyses examined differences between NPs and PAs. RESULTS: NP respondents were older (48 vs. 40 yrs, p<0.001) and more likely to be female (94% vs. 76%; p<0.001) compared to PAs. The majority of respondents (NPs:75%; PAs:64%; p<0.07) reported routinely counseling patients about physical activity. There were no differences in perceived knowledge (p=0.10) or confidence (p=0.75) to provide physical activity counseling between NPs and PAs. Approximately half of all respondents reported receiving training to provide physical activity counseling as part of their educational preparation to become a health practitioner (p=0.18). CONCLUSION: Study results indicate that NPs and PAs are knowledgeable, confident and currently providing some level of physical activity counseling to patients. However, the majority of respondents are interested in receiving additional training to aid in providing physical activity counseling.

Potential barriers to veterinary student access to counselling and other support systems: perceptions of staff and students at a UK veterinary school.

Considerable evidence suggests that veterinary surgeons' mental health is often poorer than comparable populations and that the incidence of suicide is higher among veterinary surgeons than the general public. Veterinary students also appear to suffer from high levels of anxiety and stress, and may possess inadequate coping strategies when faced with adversity. Veterinary students may find it difficult to access central university support systems due to their heavy workload and geographical isolation on some veterinary campuses. A previous study of University of Edinburgh fourth-year veterinary students found that support services located several miles from the main veterinary campus was a barrier to students accessing counselling services. Consequently, a pilot project was initiated, which provided a counselling service at the University of Edinburgh's rural Easter Bush veterinary campus one afternoon a week during 2010. As part of the evaluation of this service, web-based questionnaires were delivered via e-mail to all veterinary staff and students towards the end of the 12-month pilot period to evaluate perceptions of barriers to student counselling and to investigate student-valued support services. Questionnaire responses were received from 35 per cent of veterinary students and 52 per cent of staff. Stigmatisation of being unable to cope was a potent inhibitor of seeking support within the veterinary environment, but counselling was perceived as valuable by the majority of staff and students. Provision of an on-site counselling service was considered important for increasing ease of access; however, students viewed friends and family as their most important support mechanism. Workload was cited as the main cause of veterinary student stress. The majority of staff and student respondents perceived veterinary students as having an increased need for counselling support compared with other students.

Implementation of patient education at first and second dispensing of statins in Dutch community pharmacies: the sequel of a cluster randomized trial.

BACKGROUND: As a result of the previous part of this trial, many patients with cardiovascular disease were expected to receive a statin for the first time. In order to provide these patients with comprehensive information on statins, as recommended by professional guidance, education at first and second dispensing of statins had to be implemented. This study was designed to assess the effectiveness of an intensive implementation program targeted at pharmacy project assistants on the frequency of providing education at first dispensing (EAFD) and education at second dispensing (EASD) of statins in community pharmacies. METHODS: The participating community pharmacies were clustered on the basis of local collaboration, were numbered by a research assistant and subsequently an independent statistician performed a block randomization, in which the cluster size (number of pharmacies in each cluster) was balanced. The pharmacies in the control group received a written manual on the implementation of EAFD and EASD; the pharmacies in the intervention group received intensive support for the implementation. The impact of the intensive implementation program on the implementation process and on the primary outcomes was examined in a random coefficient logistic regression model, which took into account that patients were grouped within pharmacy clusters. RESULTS: Of the 37 pharmacies in the intervention group, 17 pharmacies (50%) provided EAFD and 12 pharmacies (35.3%) provided EASD compared to 14 pharmacies (45.2%, P = 0.715) and 12 pharmacies (38.7%, P = 0.899), respectively, of the 34 pharmacies in the control group. In the intervention group a total of 72 of 469 new statin users (15.4%) received education and 49 of 393 patients with a second statin prescription (12.5%) compared to 78 of 402 new users (19.4%, P = 0.944) and 35 of 342 patients with a second prescription (10.2%, P = 0.579) in the control group. CONCLUSION: The intensive implementation program did not increase the frequency of providing EAFD and EASD of statins in community pharmacies. TRIAL REGISTRATION: clinicaltrials.gov NCT00509717.

Devising work schedules for a collective: favouring intergenerational collaboration among counsellors in a shelter for female victims of conjugal violence.

OBJECTIVE: The work activity of counsellors in shelters for female victims of conjugal violence is explored. The consortium of shelters requested the study because of complaints of worker stress, difficulties in management and high employee turnover. METHODS: This qualitative and participatory community study involved a team of specialists in ergonomics and social work from the Centre de recherche interdisciplinaire sur la biologie, la santé, la sociélté et l'environnement (CINBIOSE), brought together by the Community Outreach Service of Université du Québec à Montréal (UQAM). Presented here are the study findings pertaining to training. Twenty-two semi-structured interviews and 80 hours of observation of work and training were conducted with counsellors from two contrasting shelters. RESULTS: Observations revealed an intense collaborative activity involving communication by many means. Nonetheless, young counsellors interviewed complained of having few opportunities to develop their counselling skills because they were isolated on evening, night and weekend shifts. In collaboration with the ergonomists, one shelter experimented with new ways of devising the work schedule to favour learning and training. CONCLUSION: By transforming the training mechanism, job status and work schedules, the shelter made the conditions more conducive to the development of counsellors' skills and health, while eliminating turnover for at least the two following years.