[Information given to patients and their participation in clinical decision-making]

OBJECTIVES

To evaluate the information provided by physicians during consultations, the information requested by patients, and patients' participation in decision-making.

DESIGN

Descriptive, cross-sectional study based on observations of visits to the doctor's office and subsequent telephone interview.

SETTING

Primary care centers in Toledo, Spain.Participants. 152 clinical interviews.Interventions. Questionnaire with items on age, sex, types of information provided by the physician, information requested by the patient, and evaluation of the patient's participation in decision-making and degree of satisfaction.

MAIN MEASURES AND RESULTS

Mean age of the patients was 41.1 years, and 55.9% were women. The type of information given most frequently to patients was related to treatment (88.3%). Of the 152 patients whose visits were observed, 55 (36.2%) did not request additional information. The information requested most frequently when not provided spontaneously by the physician concerned treatment (35.3%) and cause of the symptoms (29.7%). Almost all patients (94.0%) considered the information received to be sufficient. However, 22.7% stated that when they left the doctor's office there was something they wished they had asked about, and 18.6% said they understood the doctor's explanations "in part." According to the observers, 69.4% of the patients did not take part in the decision about their treatment.

CONCLUSIONS

The information provided by the physician was not as complete as it might have been. Patients usually ask few questions, and a large percentage of patients had something they wished they had asked about, or did not fully understand the information. Patients' participation in decision-making was low.

[Cancer diagnosis: do we want to know the truth?]

OBJECTIVE

To find people's desire for information and their other attitudes when faced with a cancer diagnosis.

DESIGN

Transversal, descriptive study.

SETTING

Irun, Oñati and Asteasu Health Centres, Gipuzkoa, Spain.

PARTICIPANTS

From the appointments for 19 clinics in March-May 2002, a randomised, prospective and systematic sample, stratified by lists, was extracted (n=725). A modified Fernández Díaz questionnaire was administered. It had personal details and 8 questions with closed replies on aspects of communication (5) and attitudes to death (3).

RESULTS

81.3% (95% CI, 78.4-84.1) wanted to know their diagnosis. 68.9% (95% CI, 65.5-72.2) chose the doctor to tell them. Of these, 36.6% chose the specialist and 26.6%, the general practitioner. If the person affected was a family member, 46.6% (95% CI, 42.9-50.2) would always tell the person; 38.6% (95% CI, 35-42.1), only if the person asked; and 9.6%, never (95% CI, 7.4-11.7). 49.3% (95% CI, 45.6-52.9) would prefer to die at home. The greatest fear for 44% (95% CI, 40.3-47.6) was pain.

CONCLUSIONS

Most people want to be informed of their diagnosis. Neither an urban or rural environment nor having had family members with cancer affects their view. If the person affected by cancer is a family member, very few people favour not telling him/her at all. Sufferers want the doctor to tell them the information, prefer to die at home and pain is what worries them most.

The great ideas of biology

Four of the great ideas of biology are discussed: the cell as the basic structural and functional unit of life, the gene as the mechanism of heredity, evolution by natural selection, and life as chemistry. A fifth idea is explored whereby biological organisation is explained in terms of logical and informational processes and structures.

Clinical issues in shared decision-making applied to breast cancer

OBJECTIVES

To assess (1) the clinical issues addressed during the medical encounter; (2) the feasibility of the process of shared decision-making in clinical practice and (3) patients' desires concerning the question of 'who should take the decision in breast cancer treatments?'

DESIGN

Qualitative pilot study based on clinical encounters using decision boards and information booklets.

SETTING

Centre Léon Bérard, a comprehensive cancer centre in the Rhône-Alpes region of France.

PARTICIPANTS

One breast cancer surgeon and 22 breast cancer patients.

MAIN OUTCOME MEASURES

Analysis of patients' reactions to a shared decision-making process concerning surgery and chemotherapy, and analysis of its practical feasibility (i.e. duration of the consultations).

RESULTS

(1) Twenty-one patients participated in the decision regarding surgery; all chose conservative treatment; 15 patients had their own say about chemotherapy (nine chose no chemotherapy, six chose chemotherapy). (2) Participating in treatment choice generated anxiety for a majority of patients. Some were dissatisfied because they had to make a choice and consequently to give up the other option. Finally, some were uncertain about making the right choice. Nevertheless, most were satisfied with the information given and the possibility of participating to the treatment decision-making process. (3) The total duration of the entire process of shared decision-making is consistent with the time spent with patients with such a severe disease.

DISCUSSION/CONCLUSION

Most of the patients expressed their satisfaction regarding the possibility to participate in treatment decision-making, knowing that offering treatment choice is very unusual in France. From this pilot study it appears that shared decision-making is feasible in clinical practice. Nevertheless, a quantitative study based on a large sample of patients is necessary to: (1) confirm this hypothesis, (2) ensure that patients are willing to participate in their treatment decision-making, and (3) measure the potential benefits related to this participation.

Decoding spike trains instant by instant using order statistics and the mixture-of-Poissons model

In the brain, spike trains are generated in time and presumably also interpreted as they unfold in time. Recent work (Oram et al., 1999; Baker and Lemon, 2000) suggests that in several areas of the monkey brain, individual spike times carry information because they reflect an underlying rate variation. Constructing a model based on this stochastic structure allows us to apply order statistics to decode spike trains instant by instant as spikes arrive or do not. Order statistics are time-consuming to compute in the general case. We demonstrate that data from neurons in primary visual cortex are well fit by a mixture of Poisson processes; in this special case, our computations are substantially faster. In these data, spike timing contributed information beyond that available from the spike count throughout the trial. At the end of the trial, a decoder based on the mixture-of-Poissons model correctly decoded about three times as many trials as expected by chance, compared with approximately twice as many as expected by chance using the spike count only. If our model perfectly described the spike trains, and enough data were available to estimate model parameters, then our Bayesian decoder would be optimal. For four-fifths of the sets of stimulus-elicited responses, the observed spike trains were consistent with the mixture-of-Poissons model. Most of the error in estimating stimulus probabilities is attributable to not having enough data to specify the parameters of the model rather than to misspecification of the model itself.

Information and support for women following the primary treatment of breast cancer

OBJECTIVE

To examine the need for, use of and satisfaction with information and support following primary treatment of breast cancer.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Cohort of 266 surviving women diagnosed with breast cancer over a 25-month period at a tertiary hospital, Adelaide, Australia. Time since diagnosis ranged from 6 to 30 months.

MAIN OUTCOME MEASURES

Need for, use of and satisfaction with information and support.

RESULTS

Women reported high levels of need for information about a variety of issues following breast cancer treatment. Ninety-four percentage reported a high level of need for information about one or more issues, particularly recognizing a recurrence, chances of cure and risk to family members of breast cancer. However, few women (2-32%) reported receiving such information. The most frequently used source of information was the surgeon followed by television, newspapers and books. The most frequently used source of support was family followed by friends and the surgeon. Few women (<7%) used formal support services or the Internet. Women were very satisfied with the information and support that they received from the surgeon and other health professionals but reported receiving decreasing amounts of information and support from them over time.

CONCLUSIONS

Women experience a high need for information about breast cancer related issues following primary treatment of breast cancer. These needs remain largely unmet as few women receive information about issues that concern them. The role of the surgeon and other health professionals is critical in narrowing the gap between needing and receiving information.

Use of the Internet by women with breast cancer

BACKGROUND

Recently, many cancer patients have been using the Internet for information with which to make informed choices. We are not aware of any studies that investigate this Internet use among breast cancer patients or women.

OBJECTIVE

We investigate the prevalence and predictors of Internet use for medical information among women with breast cancer.

METHODS

We used a cross-sectional design and approached 251 women with breast cancer being treated at a university-based hospital. We successfully interviewed 188 (74.9%), through mailed self-report questionnaires. Medical information was obtained from the hospital tumor registry. We used t tests and chi-square tests to assess differences in Internet use for breast health issues and binary logistic regression to estimate the odds ratio (OR) for predictors of Internet use for breast health issues.

RESULTS

In our sample, 41.5% of patients used the Internet for medical information. Internet users differed from nonusers on income level, educational level, and by race/ethnicity. After controlling for the other predictors, Internet users had a higher income (OR = 3.10; 95% CI = 1.09-8.85) and tended to be more educated (OR = 2.59; 95% CI = 0.87-7.74) than nonusers. There was also a suggestion that those of nonwhite ethnicity were less likely to use the Internet (OR = 0.39; 95% CI = 0.14-1.11). Increasing age, length of time since diagnosis, and breast cancer stage had no effect.

CONCLUSIONS

A substantial proportion of breast cancer patients used the Internet as a source of information. Patients with higher income or education, and patients of white race/ethnicity are more likely to use the Internet for breast health issues.

Do Internet interventions for consumers cause more harm than good? A systematic review

OBJECTIVE

To systematically review the effect of consumer use of online health information on decision-making, attitudes, knowledge, satisfaction and health outcomes and utilization.

SEARCH STRATEGY

Electronic databases searched included the Cochrane Controlled Trials Register, MEDLINE, PREMEDLINE (to 14 March 2001), CINAHL, Australian Medical Index, Health and Society, National Institutes of Health Clinical Trials Database and CenterWatch.

INCLUSION CRITERIA

All post-1995 comparative studies (including controlled studies, before and after studies, and interrupted time series analyses) of Internet users vs. non-Internet users and other communications mediums, and Internet characteristics such as e-mail vs. other communication mediums, were included. Outcomes included consumer decision-making, attitudes, knowledge, satisfaction and measurable changes in health status or health utilization.

DATA EXTRACTION AND SYNTHESIS

One reviewer screened all papers then two reviewers independently assessed studies against the selection criteria and any discrepancies were resolved by discussion with a third reviewer. No attempt was made to combine the data for further statistical analysis.

MAIN RESULTS

We identified 10 comparative studies. Studies evaluated the effectiveness of using the Internet to deliver a smoking cessation programme, cardiac and nutrition educational programmes, behavioural interventions for headache and weight loss, and pharmacy and augmentative services. All studies showed some positive effects on health outcomes, although the methodological quality of many studies was poor.

CONCLUSIONS

Despite widespread consumer Internet use to obtain health-care information, there is almost a complete lack of evidence of any effects this may have on health outcomes.

Feature selectivity and interneuronal cooperation in the thalamocortical system

Action potentials are a universal currency for fast information transfer in the nervous system, yet few studies address how some spikes carry more information than others. We focused on the transformation of sensory representations in the lemniscal (high-fidelity) auditory thalamocortical network. While stimulating with a complex sound, we recorded simultaneously from functionally connected cell pairs in the ventral medial geniculate body and primary auditory cortex. Thalamic action potentials that immediately preceded or potentially caused a cortical spike were more selective than the average thalamic spike for spectrotemporal stimulus features. This net improvement of thalamic signaling indicates that for some thalamic cells, spikes are not propagated through cortex independently but interact with other inputs onto the same target cell. We then developed a method to identify the spectrotemporal nature of these interactions and found that they could be cooperative or antagonistic to the average receptive field of the thalamic cell. The degree of cooperativity with the thalamic cell determined the increase in feature selectivity for potentially causal thalamic spikes. We therefore show how some thalamic spikes carry more receptive field information than average and how other inputs cooperate to constrain the information communicated through a cortical cell.

Teaching resource and information management using an innovative case-based conference

Physicians play a critical role in controlling resource use in medicine. This paper describes an innovative, interdisciplinary conference that teaches housestaff and medical students about resource and information management in the hospital setting. The objectives are to help foster communication between physicians and other members of the health care team, to improve the understanding of hospital reimbursement, and to influence attitudes toward practicing cost effectiveness. The conference structure includes the following components: case presentation by the treating physician and follow-up information provided by the primary care physician, a review of the itemized hospital bill, discussion of coding issues, discussion of hospital reimbursement comparing case data to institutional and state averages, and a summary of key take-home points and lessons.

Light adaptation in Drosophila photoreceptors: I. Response dynamics and signaling efficiency at 25 degrees C

Besides the physical limits imposed on photon absorption, the coprocessing of visual information by the phototransduction cascade and photoreceptor membrane determines the fidelity of photoreceptor signaling. We investigated the response dynamics and signaling efficiency of Drosophila photoreceptors to natural-like fluctuating light contrast stimulation and intracellular current injection when the cells were adapted over a 4-log unit light intensity range at 25 degrees C. This dual stimulation allowed us to characterize how an increase in the mean light intensity causes the phototransduction cascade and photoreceptor membrane to produce larger, faster and increasingly accurate voltage responses to a given contrast. Using signal and noise analysis, this appears to be associated with an increased summation of smaller and faster elementary responses (i.e., bumps), whose latency distribution stays relatively unchanged at different mean light intensity levels. As the phototransduction cascade increases, the size and speed of the signals (light current) at higher adapting backgrounds and, in conjunction with the photoreceptor membrane, reduces the light-induced voltage noise, and the photoreceptor signal-to-noise ratio improves and extends to a higher bandwidth. Because the voltage responses to light contrasts are much slower than those evoked by current injection, the photoreceptor membrane does not limit the speed of the phototransduction cascade, but it does filter the associated high frequency noise. The photoreceptor information capacity increases with light adaptation and starts to saturate at approximately 200 bits/s as the speed of the chemical reactions inside a fixed number of transduction units, possibly microvilli, is approaching its maximum.

Light adaptation in Drosophila photoreceptors: II. Rising temperature increases the bandwidth of reliable signaling

It is known that an increase in both the mean light intensity and temperature can speed up photoreceptor signals, but it is not known whether a simultaneous increase of these physical factors enhances information capacity or leads to coding errors. We studied the voltage responses of light-adapted Drosophila photoreceptors in vivo from 15 to 30 degrees C, and found that an increase in temperature accelerated both the phototransduction cascade and photoreceptor membrane dynamics, broadening the bandwidth of reliable signaling with an effective Q(10) for information capacity of 6.5. The increased fidelity and reliability of the voltage responses was a result of four factors: (1) an increased rate of elementary response, i.e., quantum bump production; (2) a temperature-dependent acceleration of the early phototransduction reactions causing a quicker and narrower dispersion of bump latencies; (3) a relatively temperature-insensitive light-adapted bump waveform; and (4) a decrease in the time constant of the light-adapted photoreceptor membrane, whose filtering matched the dynamic properties of the phototransduction noise. Because faster neural processing allows faster behavioral responses, this improved performance of Drosophila photoreceptors suggests that a suitably high body temperature offers significant advantages in visual performance.

Does provision of an evidence-based information change public willingness to accept screening tests?

OBJECTIVE: To investigate whether the willingness of the general population to undergo a screening test of questionable effectiveness for pancreatic cancer is influenced by the quality and the extent of the information provided. DESIGN: Randomised study. SETTING: Switzerland. PARTICIPANTS: Representative sample (N=1000) of the general population aged over 20. INTERVENTIONS: Participants were randomly allocated into two groups (N=500 each), with one group to receive basic and the other extended quality of information. The information was presented in two hypothetical scenarios about implicit and explicit benefits and adverse events of the screening test. Response rates were, respectively, 80.2% (N=401) and 93.2% (N=466). MAIN OUTCOME MEASURES: Stated willingness to undergo the screening test. RESULTS: Out of the 401 participants receiving the basic information scenario, 241 (60%) stated their willingness to accept the test, as compared to the 63/466 (13.5%) exposed to the extended one (P < 0.001). After adjusting for respondent characteristics through a logistic regression model, the 'information effect', expressed in terms of odds-ratio (OR), shows that provision of additional information was related to a 91% (OR 0.09; 95CI: 0.07 - 0.13) relative reduction in the likelihood of accepting the screening test. CONCLUSION: The quality and the extent of the information provided about the implicit and explicit benefits and adverse events on hypothetical scenarios of a screening test may dramatically change the willingness of people to participate in the testing. This study suggests that provision of full information on the yield of health care interventions plays an important role in protecting the public from being exposed to procedures of questionable effectiveness.

Internet information on urology

Keeping up with all the current information in the field of urology is not as difficult anymore, with the many sources available on the World Wide Web. But which sites will give you the most and best data? Where can you go for continuing medical education? For sources of patient education information? For a list of upcoming meetings? Check below for recommendations on general medical, urology-specific, and reference resources.

Use of Queueing Delay Information in Recruitment

The collection and handling of colony resources such as food, water, and nest-construction material is often divided into subtasks in which the material is passed from one worker to another. This is known as task partitioning. If tasks are partitioned with direct transfer of material between foragers and receivers, queueing delays can occur as individuals search or wait for a transfer partner. Changes in environmental conditions and relative number of foragers and receivers affect these delays as well as colony ergonomic efficiency. These delays are used in recruitment in both honeybees and Polybia wasps. This study investigates the distribution of queueing delays and the information content and quality of those delays using a stochastic-simulation model. Information quality increases with colony size. When the relative proportions of foragers and receivers are suboptimal, the group in excess has better information. Individuals can increase information quality of delays by two mechanisms: averaging over consecutive trips and averaging over multiple transfers within a trip where direct transfer occurs. We suggest that multiple transfer occurs in the honeybee in order to improve information quality.

A survey of women's preferences regarding alternative surgical treatments for menorrhagia

BACKGROUND: Menorrhagia represents a major health burden to a large number of women in the UK. A range of medical and surgical treatments is now available for the condition, but each has its own advantages and limitations. METHODS: A postal survey was undertaken of women with apparently uncomplicated menorrhagia referred to one of two NHS hospitals. The aim was to elicit women's preferences for the characteristics of surgical treatment and, specifically, to assess how they traded-off the characteristics of hysterectomy and minimal access surgery. RESULTS: A total of 221 women returned their questionnaire and were included in the study (59% of those sent out). The characteristics most frequently rated as 'very important' were getting back to usual activities as soon as possible (57%), experiencing the least pain and discomfort (46%), spending a short time in hospital (46%) and stopping periods for good (43%). The single characteristic most frequently rated as the most important by women was stopping periods for good (28%). Similar proportions of women preferred abdominal hysterectomy (43%) and endometrial resection (41%) when these were described to them. When asked to think about specific treatments of which they were aware, strong positive (43%) and negative (42%) preferences were indicated. Women's main information source was their general practitioner (70%), but only 44% considered themselves well-informed about menorrhagia and its treatment. CONCLUSIONS: Many women referred to hospital with menorrhagia have conflicting objectives for treatment, feel under-informed about therapies and have not formed treatment preferences. It is important to develop well-structured and accessible sources of information for women and methods to elicit their treatment preferences, and to evaluate the impact of such tools on treatment selection and outcomes.