Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments.

OBJECTIVE: Improving care transitions for older adults can reduce emergency department (ED) visits, adverse events, and empower community autonomy. We conducted an inductive qualitative content analysis to identify themes emerging from comments to better understand ED care transitions. METHODS: The LEARNING WISDOM prospective longitudinal observational cohort includes older adults (≥ 65 years) who experienced a care transition after an ED visit from both before and during COVID-19. Their comments on this transition were collected via phone interview and transcribed. We conducted an inductive qualitative content analysis with randomly selected comments until saturation. Themes that arose from comments were coded and organized into frequencies and proportions. We followed the Standards for Reporting Qualitative Research (SRQR). RESULTS: Comments from 690 patients (339 pre-COVID, 351 during COVID) composed of 351 women (50.9%) and 339 men (49.1%) were analyzed. Patients were satisfied with acute emergency care, and the proportion of patients with positive acute care experiences increased with the COVID-19 pandemic. Negative patient comments were most often related to communication between health providers across the care continuum and the professionalism of personnel in the ED. Comments concerning home care became more neutral with the COVID-19 pandemic. CONCLUSION: Patients were satisfied overall with acute care but reported gaps in professionalism and follow-up communication between providers. Comments may have changed in tone from positive to neutral regarding home care over the COVID-19 pandemic due to service slowdowns. Addressing these concerns may improve the quality of care transitions and provide future pandemic mitigation strategies.

Cognitive-Behavioral Therapy for Panic Disorder in Patients with Stable Coronary Artery Disease: A Feasibility Study.

Implementing cognitive-behavioral therapy (CBT), the first-line psychological treatment for panic disorder (PD), may be challenging in patients with comorbid coronary artery disease (CAD).This study aimed at assessing the feasibility and acceptability of a CBT for PD protocol that was adapted to patients suffering from comorbid CAD. It also aimed at evaluating the efficacy of the intervention to reduce PD symptomatology and psychological distress and improve quality of life. This was a single-case experimental design with pre-treatment, post-treatment and 6-month follow-up measures. Patients with PD and stable CAD received 14 to 17 individual, 1-h sessions of an adapted CBT for PD protocol. They completed interviews and questionnaires at pre-treatment, post-treatment and at a 6-month follow-up assessing intervention acceptability, PD symptomatology, psychological distress and quality of life. A total of 6 patients out of 7 completed the intervention and 6-month follow-up, indicating satisfactory feasibility. Acceptability was high (medians of ≥ 8.5 out of 9 and ≥ 80%) both at pre and post treatment. Remission rate was of 83% at post-treatment and 6-month follow-up. The intervention appeared to have positive effects on comorbid anxiety and depression symptoms and quality of life. The intervention appeared feasible and acceptable in patients with comorbid CAD. The effects of the adapted CBT protocol on PD symptoms, psychological distress and quality of life are promising and were maintained at the 6-month follow-up. Further studies should aim at replicating the present results in randomized-controlled trials.

Validation d'un questionnaire mesurant la consommation de boissons sucrées, jus et eau auprès d'adolescents francophones.

Purpose: To examine the temporal stability and relative validity of the adapted French version of an English self-reported questionnaire measuring the beverage intake (BEVQ) of adolescents.Methods: The French adaptation of the BEVQ (AF-BEVQ) included conversion from the imperial to the metric system and the adjustment of some formats to those available in Canada. Next, 60 adolescents from two regions in Quebec completed the AF-BEVQ and two web-based 24-hour dietary recalls (R24W) (one for a weekday and one for a weekend day) on two occasions, two weeks apart.Results: The AF-BEVQ had moderate intraclass correlation coefficients (ICC) for amounts of sugar-sweetened beverages (ICC: 0.68; 95% confidence interval [CI]: 0.46-0.81), fruit juice (ICC: 0.54; 95% CI: 0.23-0.72) and water (ICC: 0.66; 95% CI: 0.38-0.81) consumed. The amounts of sugar-sweetened beverages (rs = 0.49; p < 0.0001), fruit juice (rs = 0.38; p = 0.0024) and water (rs = 0.65; p < 0.0001) reported in the AF-BEVQ were significantly correlated with those of both R24Ws.Conclusions: For the most part, the AF-BEVQ had adequate metrological properties. It is an interesting tool to quickly measure the sugar-sweetened beverage, fruit juice and water intake of French-speaking adolescents.

Objectif : Vérifier la stabilité temporelle et validité relative de la version française adaptée d'un questionnaire auto-déclaré en anglais mesurant la consommation de diverses boissons (BEVQ) chez les adolescents.Méthodes : L'adaptation française du BEVQ (AF-BEVQ) comprenait notamment la conversion des unités impériales en unités métriques et l'ajustement de certains formats selon ceux disponibles au Canada. Ensuite, 60 adolescents provenant de deux régions du Québec ont complété l'AF-BEVQ et deux rappels de 24 heures Web (R24W) (un jour de semaine et un de fin de semaine) à deux reprises à deux semaines d'intervalle.Résultats : L'AF-BEVQ avait des coefficients intra-classe (ICC) modérés pour les quantités de boissons sucrées (ICC : 0,68; intervalle de confiance [IC] 95 % : 0,46­0,81), de jus de fruits (ICC : 0,54; IC 95 % : 0,23­0,72) et d'eau (ICC : 0,66; IC 95 % : 0,38­0,81) consommées. Les quantités de boissons sucrées (rs = 0,49; p < 0,0001), de jus de fruits (rs = 0,38; p = 0,0024) et d'eau (rs = 0,65; p < 0,0001) rapportées dans l'AF-BEVQ étaient significativement corrélées à celles des deux R24W.Conclusions : L'AF-BEVQ présentait majoritairement des propriétés métrologiques adéquates. Il est un outil d'intérêt pour mesurer rapidement la consommation de boissons sucrées, de jus de fruits et d'eau d'adolescents francophones.

Anxiety disorders in patients with noncardiac chest pain: association with health-related quality of life and chest pain severity.

BACKGROUND: Patients with noncardiac chest pain (NCCP) report more severe symptoms and lowered health-related quality of life when they present with comorbid panic disorder (PD). Although generalized anxiety disorder (GAD) is the second most common psychiatric disorder in these patients, its impact on NCCP and health-related quality of life remains understudied. This study describes and prospectively compares patients with NCCP with or without PD or GAD in terms of (1) NCCP severity; and (2) the physical and mental components of health-related quality of life. METHODS: A total of 915 patients with NCCP were consecutively recruited in two emergency departments. The presence of comorbid PD or GAD was assessed at baseline with the Anxiety Disorder Schedule for DSM-IV. NCCP severity at baseline and at the six-month follow-up was assessed with a structured telephone interview, and the patients completed the 12-item Short-Form Health Survey Version 2 (SF-12v2) to assess health-related quality of life at both time points. RESULTS: Average NCCP severity decreased between baseline and the six-month follow-up (p < .001) and was higher in the patients with comorbid PD or GAD (p < .001) at both time points compared to those with NCCP only. However, average NCCP severity did not differ between patients with PD and those with GAD (p = 0.901). The physical component of quality of life improved over time (p = 0.016) and was significantly lower in the subset of patients with PD with or without comorbid GAD compared to the other groups (p < .001). A significant time x group interaction was found for the mental component of quality of life (p = 0.0499). GAD with or without comorbid PD was associated with a lower mental quality of life, and this effect increased at the six-month follow-up. CONCLUSIONS: Comorbid PD or GAD are prospectively associated with increased chest pain severity and lowered health-related quality of life in patients with NCCP. PD appears to be mainly associated with the physical component of quality of life, while GAD has a greater association with the mental component. Knowledge of these differences could help in the management of patients with NCCP and these comorbidities.

Epidemiology and prognostic implications of panic disorder and generalized anxiety disorder in patients with coronary artery disease: rationale and design for a longitudinal cohort study.

BACKGROUND: Anxiety is associated with poorer prognosis in patients with coronary artery disease (CAD). Due to their severity and chronic course, anxiety disorders, particularly generalized anxiety disorder (GAD) and panic disorder (PD), are of considerable interest and clinical importance in this population. This study has two main objectives: (1) to estimate the prevalence and incidence of GAD and PD in patients with CAD over a 2-year period and (2) to prospectively assess the association between PD or GAD and adverse cardiac events, treatment adherence, CAD-related health behaviors, quality of life and psychological distress. DESIGN/METHOD: This is a longitudinal cohort study in which 3610 participants will be recruited following a CAD-related revascularization procedure. They will complete an interview and questionnaires at 5 time points over a 2-year period (baseline and follow-ups after 3, 6, 12 and 24 months). The presence of PD or GAD, adherence to recommended treatments, health behaviors, quality of life and psychological distress will be assessed at each time point. Data regarding mortality and adverse cardiac events will be collected with a combination of interviews and review of medical files. DISCUSSION: This study will provide essential information on the prevalence and incidence of anxiety disorders in patients with CAD and on the consequences of these comorbidities. Such data is necessary in order to develop clear clinical recommendations for the management of PD and GAD in patients with CAD. This will help improve the prognosis of patients suffering from both conditions.

Correlates of sugar-sweetened beverages consumption among adolescents.

OBJECTIVE: To identify correlates and underlying beliefs regarding the adolescents' intention to abstain from consuming sugar-sweetened beverages (SSB) and the consumption of ≤1 daily portion of SSB. DESIGN: Correlational study. SETTING: Region of Chaudière-Appalaches in the province of Quebec, Canada. PARTICIPANTS: 311 adolescents aged 13-18 years completed a self-administrated online questionnaire based on the Reasoned Action Approach. Frequency and quantity of different types of SSB within the past month were measured. RESULTS: Total mean SSB intake was 882·6 ml/d (654·0 kJ/d ). Only 11·3 % abstained from SSB within the last month. Intention to abstain from SSB was explained by identification as SSB abstainers (ß = 0·47), perceived norm (ß = 0·32), attitude (ß = 0·30), age 13-14 years (ß = -0·27) and perception of the school environment (ß = 0·14), which explained 66 % of the variance. Consumption of ≤1 daily portion of SSB was explained by the intention to abstain (OR = 1·55; 95 % CI 1·14, 2·11), perceived behavioural control to abstain (OR = 1·80; 95 % CI 1·29, 2·52), sex (girls v. boys: OR = 2·34; 95 % CI 1·37, 3·98) and socio-economic status (advantaged v. disadvantaged school: OR = 2·08; 95 % CI 1·21, 3·56). Underlying beliefs (i.e. more energy, decreased risk of addiction and friends' approval) associated with intention as well as perceived barriers (e.g. access to SSB, after an activity that makes you thirsty), and facilitating factors (e.g. access to water) linked to SSB consumption were identified. CONCLUSIONS: The results can inform public health interventions to decrease SSB consumption and their associated health problems among adolescents.

Prospective Clinical Trial Comparing Curettage and Cryosurgery to Curettage and Electrodesiccation in the Management of Minimally Invasive Basal and Squamous Cell Carcinomas [Formula: see text].

BACKGROUND: Basal and squamous cell carcinomas represent the most common cancers in North America. Their management is an important issue. OBJECTIVES: The evaluation of cure rates of minimally invasive cutaneous carcinomas with curettage-cryosurgery compared to curettage-electrodesiccation, as well as the assessment of the aesthetic appearance of scars. METHODS: This prospective trial randomized 117 patients 1:1 to treatments of curettage-cryosurgery or curettage-electrodesiccation. They were then followed at 6, 12, 18, and 24 months. RESULTS: At 12-month follow-up, only one (1/49) patient had a recurrence of cutaneous carcinoma in the curettage-cryosurgery group and none (0/43) in the curettage-electrodesiccation group. Farrington-Manning analysis with a 5% margin of error showed the non-inferiority of the first method (P = .04). For the aesthetic appearance of scars after 12 months, better results with curettage-cryosurgery procedure has been observed, but this was not statistically significant (P = .80 and P = .27 for evaluations of patients and clinicians respectively). LIMITATIONS: This study was mainly limited by its small sample size. CONCLUSION: We have demonstrated that curettage-cryosurgery compared to curettage-electrodesiccation for the treatment of minimally invasive carcinomas is noninferior (comparable) with regards to cure rates at 12-month follow-up. No significant difference has been demonstrated for the appearance of scars.

Interventions for increasing the use of shared decision making by healthcare professionals.

BACKGROUND: Shared decision making (SDM) is a process by which a healthcare choice is made by the patient, significant others, or both with one or more healthcare professionals. However, it has not yet been widely adopted in practice. This is the second update of this Cochrane review. OBJECTIVES: To determine the effectiveness of interventions for increasing the use of SDM by healthcare professionals. We considered interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and five other databases on 15 June 2017. We also searched two clinical trials registries and proceedings of relevant conferences. We checked reference lists and contacted study authors to identify additional studies. SELECTION CRITERIA: Randomized and non-randomized trials, controlled before-after studies and interrupted time series studies evaluating interventions for increasing the use of SDM in which the primary outcomes were evaluated using observer-based or patient-reported measures. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane.We used GRADE to assess the certainty of the evidence. MAIN RESULTS: We included 87 studies (45,641 patients and 3113 healthcare professionals) conducted mainly in the USA, Germany, Canada and the Netherlands. Risk of bias was high or unclear for protection against contamination, low for differences in the baseline characteristics of patients, and unclear for other domains.Forty-four studies evaluated interventions targeting patients. They included decision aids, patient activation, question prompt lists and training for patients among others and were administered alone (single intervention) or in combination (multifaceted intervention). The certainty of the evidence was very low. It is uncertain if interventions targeting patients when compared with usual care increase SDM whether measured by observation (standardized mean difference (SMD) 0.54, 95% confidence interval (CI) -0.13 to 1.22; 4 studies; N = 424) or reported by patients (SMD 0.32, 95% CI 0.16 to 0.48; 9 studies; N = 1386; risk difference (RD) -0.09, 95% CI -0.19 to 0.01; 6 studies; N = 754), reduce decision regret (SMD -0.10, 95% CI -0.39 to 0.19; 1 study; N = 212), improve physical (SMD 0.00, 95% CI -0.36 to 0.36; 1 study; N = 116) or mental health-related quality of life (QOL) (SMD 0.10, 95% CI -0.26 to 0.46; 1 study; N = 116), affect consultation length (SMD 0.10, 95% CI -0.39 to 0.58; 2 studies; N = 224) or cost (SMD 0.82, 95% CI 0.42 to 1.22; 1 study; N = 105).It is uncertain if interventions targeting patients when compared with interventions of the same type increase SDM whether measured by observation (SMD 0.88, 95% CI 0.39 to 1.37; 3 studies; N = 271) or reported by patients (SMD 0.03, 95% CI -0.18 to 0.24; 11 studies; N = 1906); (RD 0.03, 95% CI -0.02 to 0.08; 10 studies; N = 2272); affect consultation length (SMD -0.65, 95% CI -1.29 to -0.00; 1 study; N = 39) or costs. No data were reported for decision regret, physical or mental health-related QOL.Fifteen studies evaluated interventions targeting healthcare professionals. They included educational meetings, educational material, educational outreach visits and reminders among others. The certainty of evidence is very low. It is uncertain if these interventions when compared with usual care increase SDM whether measured by observation (SMD 0.70, 95% CI 0.21 to 1.19; 6 studies; N = 479) or reported by patients (SMD 0.03, 95% CI -0.15 to 0.20; 5 studies; N = 5772); (RD 0.01, 95%C: -0.03 to 0.06; 2 studies; N = 6303); reduce decision regret (SMD 0.29, 95% CI 0.07 to 0.51; 1 study; N = 326), affect consultation length (SMD 0.51, 95% CI 0.21 to 0.81; 1 study, N = 175), cost (no data available) or physical health-related QOL (SMD 0.16, 95% CI -0.05 to 0.36; 1 study; N = 359). Mental health-related QOL may slightly improve (SMD 0.28, 95% CI 0.07 to 0.49; 1 study, N = 359; low-certainty evidence).It is uncertain if interventions targeting healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.30, 95% CI -1.19 to 0.59; 1 study; N = 20) or reported by patients (SMD 0.24, 95% CI -0.10 to 0.58; 2 studies; N = 1459) as the certainty of the evidence is very low. There was insufficient information to determine the effect on decision regret, physical or mental health-related QOL, consultation length or costs.Twenty-eight studies targeted both patients and healthcare professionals. The interventions used a combination of patient-mediated and healthcare professional directed interventions. Based on low certainty evidence, it is uncertain whether these interventions, when compared with usual care, increase SDM whether measured by observation (SMD 1.10, 95% CI 0.42 to 1.79; 6 studies; N = 1270) or reported by patients (SMD 0.13, 95% CI -0.02 to 0.28; 7 studies; N = 1479); (RD -0.01, 95% CI -0.20 to 0.19; 2 studies; N = 266); improve physical (SMD 0.08, -0.37 to 0.54; 1 study; N = 75) or mental health-related QOL (SMD 0.01, -0.44 to 0.46; 1 study; N = 75), affect consultation length (SMD 3.72, 95% CI 3.44 to 4.01; 1 study; N = 36) or costs (no data available) and may make little or no difference to decision regret (SMD 0.13, 95% CI -0.08 to 0.33; 1 study; low-certainty evidence).It is uncertain whether interventions targeting both patients and healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.29, 95% CI -1.17 to 0.60; 1 study; N = 20); (RD -0.04, 95% CI -0.13 to 0.04; 1 study; N = 134) or reported by patients (SMD 0.00, 95% CI -0.32 to 0.32; 1 study; N = 150 ) as the certainty of the evidence was very low. There was insuffient information to determine the effects on decision regret, physical or mental health-related quality of life, or consultation length or costs. AUTHORS' CONCLUSIONS: It is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low.

Factors associated with shared decision making among primary care physicians: Findings from a multicentre cross-sectional study.

BACKGROUND: Despite growing recognition that shared decision making (SDM) is central for patient-centred primary care, adoption by physicians remains limited in routine practice. OBJECTIVE: To examine the characteristics of physicians, patients and consultations associated with primary care physicians' SDM behaviours during routine care. METHODS: A multicentre cross-sectional survey study was conducted with 114 unique patient-physician dyads recruited from 17 primary care clinics in Quebec and Ontario, Canada. Physicians' SDM behaviours were assessed with the 12-item OPTION scale scored by third observers using audio-recordings of consultations. Independent variables included 21 physician, patient and consultation characteristics. We assessed factors associated with OPTION scores using multivariate linear regression models. RESULTS: On the OPTION scale, where higher scores indicated greater SDM behaviours, physicians earned an overall mean score of 25.7±9.8 of 100. In the final adjusted regression model, higher OPTION scores were associated with physicians' social participation (involvement in one committee ß=5.75, P=.04; involvement in two or more committees ß=7.74, P=.01), patients' status as employed (ß=6.48, P=.02), clinically significant decisional conflict in patients (ß=7.15, P=.002) and a longer duration of consultations (ß=0.23, P=.002). CONCLUSION: Physicians' social participation, patients' employment status and decisional conflict and the duration of consultations were associated with primary care physicians' SDM behaviours in routine care. These factors should be considered when designing strategies to implement SDM and promote more patient-centred care in primary care.

Impacts of online and group perinatal education: a mixed methods study protocol for the optimization of perinatal health services.

BACKGROUND: Prenatal education is a core component of perinatal care and services provided by health institutions. Whereas group prenatal education is the most common educational model, some health institutions have opted to implement online prenatal education to address accessibility issues as well as the evolving needs of future parents. Various studies have shown that prenatal education can be effective in acquisition of knowledge on labour and delivery, reducing psychological distress and maximising father's involvement. However, these results may depend on educational material, organization, format and content. Furthermore, the effectiveness of online prenatal education compared to group prenatal education remains unclear in the literature. This project aims to evaluate the impacts of group prenatal education and online prenatal education on health determinants and users' health status, as well as on networks of perinatal educational services maintained with community-based partners. METHODS: This multipronged mixed methods study uses a collaborative research approach to integrate and mobilize knowledge throughout the process. It consists of: 1) a prospective cohort study with quantitative data collection and qualitative interviews with future and new parents; and 2) a multiple case study integrating documentary sources and interviews with stakeholders involved in the implementation of perinatal information service networks and collaborations with community partners. Perinatal health indicators and determinants will be compared between prenatal education groups (group prenatal education and online prenatal education) and standard care without these prenatal education services (control group). DISCUSSION: This study will provide knowledge about the impact of online prenatal education as a new technological service delivery model compared to traditional group prenatal education. Indicators related to the complementarity of these interventions and those available in community settings will refine our understanding of regional perinatal services networks. Results will assist decision-making regarding service organization and delivery models of prenatal education services. PROTOCOL VERSION: Version 1 (February 9 2018).

Improving flow in the OR.

Purpose The purpose of this paper is to increase efficiency in ORs without affecting quality of care by improving the workflow processes. Administrative processes independent of the surgical act can be challenging and may lead to clinical impacts such as increasing delays. The authors hypothesized that a Lean project could improve efficiency of surgical processes by reducing the length of stays in the recovery ward. Design/methodology/approach Two similar Lean projects were performed in the surgery departments of two hospitals of the Centre Hospitalier Universitaire de Québec: Hôtel Dieu de Quebec (HDQ) and Hôpital de l'Enfant Jesus (HEJ). The HDQ project designed around a Define, Measure, Analyse, Improve and Control process revision and a Kaizen workshop focused on patients who were hospitalized in a specific care unit after surgery and the HEJ project targeted patients in a post-operative ambulatory context. The recovery ward output delay was measured retrospectively before and after project. Findings For the HDQ Lean project, wasted time in the recovery ward was reduced by 62 minutes (68 percent reduction) between the two groups. The authors also observed an increase of about 25 percent of all admissions made in the daytime after the project compared to the time period before the project. For the HEJ Lean project, time passed in the recovery ward was reduced by 6 min (29 percent reduction). Originality/value These projects produced an improvement in the flow of the OR without targeting clinical practices in the OR itself. They demonstrated that change in administrative processes can have a great impact on the flow of clinical pathways and highlight the need for comprehensive and precise monitoring of every step of the elective surgery patient trajectory.

More primary care patients regret health decisions if they experienced decisional conflict in the consultation: a secondary analysis of a multicenter descriptive study.

BACKGROUND: We sought to estimate the extent of decision regret among primary care patients and identify risk factors associated with regret. METHODS: Secondary analysis of an observational descriptive study conducted in two Canadian provinces. Unique patient-physician dyads were recruited from 17 primary care clinics and data on patient, physician and consultation characteristics were collected before, during and immediately after consultations, as well as two weeks post-consultation, when patients completed the Decision Regret Scale (DRS). We examined the DRS score distribution and performed ordinal logistic regression analysis to identify predictors of regret. RESULTS: Among 258 unique patient-physicians dyads, mean ± standard deviation of decision regret scores was 11.7 ± 15.1 out of 100. Overall, 43 % of patients reported no regret, 45 % reported mild regret and 12 % reported moderate to strong regret. In multivariate analyses, higher decision regret was strongly associated with increased decisional conflict and less significantly associated with patient age and education, as well with male (vs. female) physicians and residents (vs. teachers). CONCLUSION: After consulting family physicians, most primary care patients experience little decision regret, but some experience more regret if there is decisional conflict. Strategies for reducing decisional conflict in primary care, such as shared decision-making with decision aids, seem warranted.

Role of Psychosocial Factors and Health Literacy in Pregnant Women's Intention to Use a Decision Aid for Down Syndrome Screening: A Theory-Based Web Survey.

BACKGROUND: Deciding about undergoing prenatal screening is difficult, as it entails risks, potential loss and regrets, and challenges to personal values. Shared decision making and decision aids (DAs) can help pregnant women give informed and values-based consent or refusal to prenatal screening, but little is known about factors influencing the use of DAs. OBJECTIVE: The objective of this study was to identify the influence of psychosocial factors on pregnant women's intention to use a DA for prenatal screening for Down syndrome (DS). We also added health literacy variables to explore their influence on pregnant women's intention. METHODS: We conducted a survey of pregnant women in the province of Quebec (Canada) using a Web panel. Eligibility criteria included age >18 years, >16 weeks pregnant, low-risk pregnancy, and having decided about prenatal screening for the current pregnancy. We collected data based on an extended version of the Theory of Planned Behavior assessing 7 psychosocial constructs (intention, attitude, anticipated regret, subjective norm, descriptive norm, moral norm, and perceived control), 3 related sets of beliefs (behavioral, normative, and control beliefs), 4 health literacy variables, and sociodemographics. Eligible women watched a video depicting the behavior of interest before completing a Web-based questionnaire. We performed descriptive, bivariate, and ordinal logistic regression analyses. RESULTS: Of the 383 eligible pregnant women who agreed to participate, 350 pregnant women completed the Web-based questionnaire and 346 were retained for analysis (completion rate 350/383, 91.4%; mean age 30.1, SD 4.3, years). In order of importance, factors influencing intention to use a DA for prenatal screening for DS were attitude (odds ratio, OR, 9.16, 95% CI 4.02-20.85), moral norm (OR 7.97, 95% CI 4.49-14.14), descriptive norm (OR 2.83, 95% CI 1.63-4.92), and anticipated regret (OR 2.43, 95% CI 1.71-3.46). Specific attitudinal beliefs significantly related to intention were that using a DA would reassure them (OR 2.55, 95% CI 1.73-4.01), facilitate their reflections with their spouse (OR 1.55, 95% CI 1.05-2.29), and let them know about the advantages of doing or not doing the test (OR 1.53, 95% CI 1.05-2.24). Health literacy did not add to the predictive power of our model (P values range .43-.92). CONCLUSIONS: Implementation interventions targeting the use of a DA for prenatal screening for DS by pregnant women should address a number of modifiable factors, especially by introducing the advantages of using the DA (attitude), informing pregnant women that they might regret not using it (anticipated regret), and presenting the use of DAs as a common practice (descriptive norm). However, interventions on moral norms related to the use of DA should be treated with caution. Further studies that include populations with low health literacy are needed before decisive claims can be made.

Crystal structure analyses of azasulfuryltripeptides reveal potential for γ-turn mimicry.

Azasulfurylpeptides feature an amino acid residue in which the CαH and the carbonyl are replaced respectively by a nitrogen atom and a sulfonyl group. Insight into the conformational preferences of azasulfurylpeptides containing an azasulfurylglycine (AsG) residue has been pursued using X-ray analysis in the solid state. Crystals of N-(Boc)-Pro-AsG-Val-OMe (10) and N-(Cbz)-Ala-AsG-D-Phe-Ot-Bu (11) showed tetrahedral geometries about the sulfur atom with the ω torsion angle preferring a staggered conformation. Furthermore, the ϕ and ψ torsion angles of the central azasulfuryl residue were respectively within close proximity to those of ideal inverse and classical γ-turns. In the crystal lattice, azasulfurylpeptide 11 engaged in intermolecular hydrogen bonds between the sulfonyl oxygen and hydrazide hydrogen in an antiparallel orientation.

Palliative care costs in Canada: A descriptive comparison of studies of urban and rural patients near end of life.

BACKGROUND: Significant gaps in the evidence base on costs in rural communities in Canada and elsewhere are reported in the literature, particularly regarding costs to families. However, it remains unclear whether the costs related to all resources used by palliative care patients in rural areas differ to those resources used in urban areas. AIM: The study aimed to compare both the costs that occurred over 6 months of participation in a palliative care program and the sharing of these costs in rural areas compared with those in urban areas. DESIGN: Data were drawn from two prior studies performed in Canada, employing a longitudinal, prospective design with repeated measures. SETTING/PARTICIPANTS: The urban sample consisted of 125 patients and 127 informal caregivers. The rural sample consisted of 80 patients and 84 informal caregivers. Most patients in both samples had advanced cancer. RESULTS: The mean total cost per patient was CAD 26,652 in urban areas, while it was CAD 31,018 in rural areas. The family assumed 20.8% and 21.9% of costs in the rural and urban areas, respectively. The rural families faced more costs related to prescription medication, out-of-pocket costs, and transportation while the urban families faced more costs related to formal home care. CONCLUSION: Despite the fact that rural and urban families assumed a similar portion of costs, the distribution of these costs was somewhat different. Future studies would be needed to gain a better understanding of the dynamics of costs incurred by families taking care of a loved one at the end of life and the determinants of these costs in urban versus rural areas.

The impact of DECISION+2 on patient intention to engage in shared decision making: secondary analysis of a multicentre clustered randomized trial.

BACKGROUND: Training health professionals in shared decision making (SDM) may influence their patients' intention to engage in SDM. OBJECTIVE: To assess the impact of DECISION+2, a SDM training programme for family physicians about the use of antibiotics to treat acute respiratory infections (ARIs), on their patients' intention to engage in SDM in future consultations. DESIGN: Secondary analysis of a multicentre clustered randomized trial. SETTING AND PARTICIPANTS: Three hundred and fifty-nine patients consulting family physicians about an ARI in nine family practice teaching units (FPTUs). INTERVENTION: DECISION+2 (two-hour online tutorial, two-hour workshop, and decision support tools) was offered in the experimental group (five FPTUs, 162 physicians, 181 patients). Usual care was provided in the control group (four FPTUs, 108 physicians, 178 patients). OUTCOME MEASURE: Change in patients' intention scores (range -3 to +3) between pre- and post-consultation. RESULTS: The mean ± SD [median] scores of intention to engage in SDM were high in both study groups before consultation (DECISION+2 group: 1.4 ± 1.0 [1.7]; control group: 1.5 ± 1.1 [1.7]) and increased in both groups after consultation (DECISION+2 group: 2.1 ± 1.1 [2.7]; control group: 1.9 ± 1.2 [2.3]). Change of intention, classified as either increased, stable or decreased, was not statistically associated with the exposure to the DECISION+2 programme after adjusting for the cluster design (proportional odds ratio = 1.5; 95% confidence interval = 0.8-3.0). CONCLUSION: DECISION+2 had no significant impact on patients' intention to engage in SDM for choosing to use antibiotics or not to treat an ARI in future consultations. Patient-targeted interventions may be necessary to achieve this purpose.

Shared decision-making behaviours in health professionals: a systematic review of studies based on the Theory of Planned Behaviour.

BACKGROUND: Shared decision making (SDM) requires health professionals to change their practice. Socio-cognitive theories, such as the Theory of Planned Behaviour (TPB), provide the needed theoretical underpinnings for designing behaviour change interventions. OBJECTIVE: We systematically reviewed studies that used the TPB to assess SDM behaviours in health professionals to explore how theory is being used to explain influences on SDM intentions and/or behaviours, and which construct is identified as most influential. SEARCH STRATEGY: We searched PsycINFO, MEDLINE, EMBASE, CINAHL, Index to theses, Proquest dissertations and Current Contents for all years up to April 2012. INCLUSION CRITERIA: We included all studies in French or English that used the TPB and related socio-cognitive theories to assess SDM behavioural intentions or behaviours in health professionals. We used Makoul & Clayman's integrative SDM model to identify SDM behaviours. DATA EXTRACTION AND SYNTHESIS: We extracted study characteristics, nature of the socio-cognitive theory, SDM behaviour, and theory-based determinants of the SDM behavioural intention or behaviour. We computed simple frequency counts. MAIN RESULTS: Of 12,388 titles, we assessed 136 full-text articles for eligibility. We kept 20 eligible studies, all published in English between 1996 and 2012. Studies were conducted in Canada (n = 8), the USA (n = 6), the Netherlands (n = 3), the United Kingdom (n = 2) and Australia (n = 1). The determinant most frequently and significantly associated with intention was the subjective norm (n = 15/21 analyses). DISCUSSION: There was great variance in the way socio-cognitive theories predicted SDM intention and/or behaviour, but frequency of significance indicated that subjective norm was most influential.

Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument.

BACKGROUND: We have no clear overview of the extent to which health-care providers involve patients in the decision-making process during consultations. The Observing Patient Involvement in Decision Making instrument (OPTION) was designed to assess this. OBJECTIVE: To systematically review studies that used the OPTION instrument to observe the extent to which health-care providers involve patients in decision making across a range of clinical contexts, including different health professions and lengths of consultation. SEARCH STRATEGY: We conducted online literature searches in multiple databases (2001-12) and gathered further data through networking. INCLUSION CRITERIA: (i) OPTION scores as reported outcomes and (ii) health-care providers and patients as study participants. For analysis, we only included studies using the revised scale. DATA EXTRACTION: Extracted data included: (i) study and participant characteristics and (ii) OPTION outcomes (scores, statistical associations and reported psychometric results). We also assessed the quality of OPTION outcomes reporting. MAIN RESULTS: We found 33 eligible studies, 29 of which used the revised scale. Overall, we found low levels of patient-involving behaviours: in cases where no intervention was used to implement shared decision making (SDM), the mean OPTION score was 23 ± 14 (0-100 scale). When assessed, the variables most consistently associated with higher OPTION scores were interventions to implement SDM (n = 8/9) and duration of consultations (n = 8/15). CONCLUSIONS: Whatever the clinical context, few health-care providers consistently attempt to facilitate patient involvement, and even fewer adjust care to patient preferences. However, both SDM interventions and longer consultations could improve this.

Visual and automated assessment of matrix metalloproteinase-14 tissue expression for the evaluation of ovarian cancer prognosis.

The purpose of this study was to evaluate whether the membrane type 1 matrix metalloproteinase-14 (or MT1-MMP) tissue expression, as assessed visually on digital slides and by digital image analysis, could predict outcomes in women with ovarian carcinoma. Tissue microarrays from a cohort of 211 ovarian carcinoma women who underwent a debulking surgery between 1993 and 2006 at the CHU de Québec (Canada) were immunostained for matrix metalloproteinase-14. The percentage of MMP-14 staining was assessed visually and with the Calopix software. Progression was evaluated using the CA-125 and/or the RECIST criteria according to the GCIG criteria. Dates of death were obtained by record linkage with the Québec mortality files. Adjusted hazard ratios of death and progression with their 95% confidence intervals were estimated using the Cox model. Comparisons between the two modalities of MMP-14 assessment were done using the box plots and the Kruskal-Wallis test. The highest levels of MMP-14 immunostaining were associated with nonserous histology, early FIGO stage, and low preoperative CA-125 levels (P<0.05). In bivariate analyses, the higher level of MMP-14 expression (>40% of MMP-14-positive cells) was inversely associated with progression using visual assessment (hazard ratio=0.39; 95% confidence interval: 0.18-0.82). A similar association was observed with the highest quartile of MMP-14-positive area assessed by digital image analysis (hazard ratio=0.48; 95% confidence interval: 0.28-0.82). After adjustment for standard prognostic factors, these associations were no longer significant in the ovarian carcinoma cohort. However, in women with serous carcinoma, the highest quartile of MMP-14-positive area was associated with progression (adjusted hazard ratio=0.48; 95% confidence interval: 0.24-0.99). There was no association with overall survival. The digital image analysis of MMP-14-positive area matched the visual assessment using three categories (>40% vs 21-40 vs <20%). Higher levels of MMP-14 immunostaining were associated with standard factors of better ovarian carcinoma prognosis. In women with serous carcinoma, high expression of MMP-14 was associated with lower progression.