Influence of soil geochemical and physical properties on chromium(VI) sorption and bioaccessibility

The Department of Defense (DoD) is faced with the daunting task of possible remediation of numerous soil-Cr(VI) contaminated sites throughout the continental U.S. The primary risk driver at these sites is hand-to-mouth ingestion of contaminated soil by children. In the following study we investigate the impact of soil geochemical and physical properties on the sorption and bioaccessibility of Cr(VI) in a vast array of soils relevant to neighboring DoD sites. For the 35 soils used in this study, A-horizon soils typically sorbed significantly more Cr(VI) relative to B-horizon soils. Multiple linear regression analysis suggested that Cr(VI) sorption increased with increasing soil total organic C (TOC) and decreasing soil pH. The bioaccessibility of total Cr (CrT) and Cr(VI) on the soils decreased with increasing soil TOC content. As the soil TOC content approached 0.4%, the bioaccessibility of soil bound Cr systematically decreased from approximately 65 to 10%. As the soil TOC content increased from 0.4 to 4%, the bioaccessibility of Cr(VI) and CrT remained relatively constant at approximately 4% and 10%, respectively. X-ray absorption near edge structure (XANES) spectroscopy suggested that Cr(VI) reduction to Cr(III) was prevalent and that the redox transformation of Cr(VI) increased with increasing soil TOC. XANES confirmed that nearly all bioaccessible soil Cr was the Cr(VI) moiety. Multiple linear regression analysis suggested that the bioaccessibility of Cr(VI) and its reduced counterpart Cr(III), decreased with increasing soil TOC and increasing soil pH. This is consistent with the observation that the reduction reaction and formation of Cr(III) increased with increasing soil TOC and that Cr(III) was significantly less bioaccessible relative to Cr(VI). The model was found to adequately describe CrT bioaccessibility in soils from DoD facilities where Cr(VI) contaminated sites were present. The results of this study illustrate the importance of soil properties on Cr(VI) sorption and bioassessability and help define what soil types have the greatest risk associated with Cr(VI) exposure.

Influence of soil geochemical and physical properties on the sorption and bioaccessibility of chromium(III)

There are numerous Cr(III)-contaminated sites on Department of Defense (DoD) and Department of Energy (DOE) lands that are awaiting possible clean up and closure. Ingestion of contaminated soil by children is the risk driver that generally motivates the likelihood of site remediation. The purpose of this study was to develop a simple statistical model based on common soil properties to estimate the hioaccessibility of Cr(III)-contaminated soil upon ingestion. Thirty-five uncontaminated soils from seven major soil orders, whose properties were similar to numerous U.S. DoD contaminated sites, were treated with Cr(III) and aged. Statistical analysis revealed that Cr(III) sorption (e.g., adsorption and surface precipitation) by the soils was strongly correlated with the clay content, total inorganic C, pH, and the cation exchange capacity of the soils. Soils with higher quantities of clay, inorganic C (i.e., carbonates), higher pH, and higher cation exchange capacity generally sequestered more Cr(III). The amount of Cr(III) bioaccessible from the treated soils was determined with a physiologically based extraction test (PBET) that was designed to simulate the digestive process of the stomach. The bioaccessibility of Cr(III) varied widely as a function of soil type with most soils limiting bioaccessibility to <45 and <30% after I and 100 d soil-Cr aging, respectively. Statistical analysis showed the bioaccessibility of Cr(III) on soil was again related to the clay and total inorganic carbon (TIC) content of the soil. Bioaccessibility decreased as the soil TIC content increased and as the clay content decreased. The model yielded an equation based on common soil properties that could be used to predict the Cr(III) bioaccessibility in soils with a reasonable level of confidence.

Why do patients seek family physicians' services for cold symptoms?

OBJECTIVE

To examine the frequency of presentation to family physicians' offices for cold symptoms, the reasons for presentation, and the duration of symptoms before presentation.

DESIGN

Prospective cross-sectional survey.

PARTICIPANTS

One hundred consecutive patient encounters in each of 15 family practices from January 27 to February 3, 1994, involving both academic and non-academic family physicians in the London region. Data were collected prospectively using a checklist attached to each chart.

MAIN OUTCOME MEASURES

Proportion of patients presenting with cold symptoms, reasons for presentation, number of days patients had had symptoms, billing code.

RESULTS

A total of 1421 checklists were analyzed, 822 from academic practices and 599 from community practices. Proportion of presentations for cold symptoms was 14.8%, but visits coded as common cold represented 5.7%. Median number of days patients waited before presentation was 7.0; older patients tended to wait longer. Many patients were worried about developing complications (51.0%) or were fed up with their symptoms (31.9%). Most patients were between the ages of 20 and 64 (44.6%), and 57.6% of all patients had developed complications requiring treatment.

CONCLUSIONS

The proportion of visits coded as common cold was lower than Ontario averages. Most patients had complications rather than simple colds and had managed their symptoms on their own for a fairly long time.

Distinct contributions of conduct and oppositional defiant symptoms to adult antisocial behavior: evidence from an adoption study

BACKGROUND

We conducted an exploratory multivariate analysis of juvenile behavior symptoms in an adoption data set. One goal was to see if a few DSM-interpretable symptom dimensions economically captured information within the data. A second goal was to study the relationships between any such dimensions, biological and environmental background, and eventual adult antisocial behavior.

METHODS

The data originated from a retrospective adoption study. Probands with a biological background for parental antisocial personality or alcoholism were heavily oversampled. Symptoms were ascertained by proband and adoptive parent interview. We performed, by gender, orthogonal rotated principal component analyses of juvenile behavior disturbance symptoms (females, n = 87; males, n = 88). We used structural equation modeling to examine the relationships hypothesized above.

RESULTS

For both genders, an oppositional defiant disorder (ODD) component and at least 1 conduct component emerged. Regardless of the conduct component scores, the ODD components were significant predictors of adult antisocial behavior. For males, the ODD component was predicted by an antisocial biological background, but not by scores on the Adverse Adoptive Environment Scale. The conduct components were predicted by adoptive environment alone. For females, biological background or biological-environmental interactions predicted each of the components.

CONCLUSIONS

There has been little previous distinction between conduct disorder and ODD in studies of genetic and environmental influences on juvenile behavior. The study suggests that adolescent ODD symptoms may be a distinct antecedent of adult antisocial personality. In males, adolescent ODD symptoms may represent early expression of genetic sociopathic personality traits.

A case of cervical lymph node metastasis resulting from glioblastoma multiforme

This article presents a rare case of metastatic glioblastoma multiforme (GM) to the cervical lymph node. In spite of very aggressive tumor behavior, extracranial metastasis from intra-cerebral GM is rare. Only a few cases are reported in the world literature. This infrequent extracranial metastasis may be due to the fact that patients do not live long enough to manifest metastases or result from the fact that brain tissue has some structural differences from other tissues in the body. This tumor can be easily mistaken for other anaplastic tumors like malignant melanoma, malignant lymphoma, or anaplastic carcinoma. Positive glial fibrillary acidic (GFA) protein stain (an immunoperoxidase stain) of this metastatic tumor can eliminate all other time consuming, expensive, and exhausting procedures for the patient.

Teaching child and adolescent psychiatry to family medicine trainees: a pilot experience

OBJECTIVE

To develop learning objectives for teaching child psychiatry to family medicine trainees and to evaluate the best method of teaching these objectives.

METHOD

For this descriptive study, knowledge, attitude, and skill objectives were presented to trainees at the start of a 6-month rotation, and an evaluation mechanism was developed based on the learning objectives. The method of instruction in each of the training locations was described independently by the child psychiatry consultant and attending family physician. The trainees' evaluations were presented according to training locations.

RESULTS

Family medicine trainees perceived the teaching-consultation method, with live interviews, to be the most helpful and the didactic lecture format to be least helpful.

CONCLUSION

The importance of teaching family medicine residents to recognize mental health problems in children and adolescents, preferably by using live interviews, and the implications for postresidency practice are emphasized.

Depression spectrum disease, I: The role of gene-environment interaction

OBJECTIVE

This study used an adoption study design to separate genetic from environmental factors in the etiology of depression spectrum disease, a type of major depression characterized by families in which male relatives are alcoholic and females are depressed. The genetic etiology hypothesis of depression spectrum disease proposes that an alcoholic genetic diathesis predisposes to depression in females but alcoholism, not depression, in males.

METHOD

The study examined 197 adult offspring (95 male and 102 female) of alcoholic biological parents and used logistic regression models to determine the contribution to major depression in male and female adoptees that could be explained by the genetic alcoholic diathesis combined with an environmental factor that was characterized by psychiatrically or behaviorally disturbed adoptive parents.

RESULTS

Major depression in females was predicted by an alcoholic diathesis only when combined with the disturbed adoptive parent variable. The same regression model failed to predict depression in males. Other possible environmental confounding factors contributing to an increased chance of depression were found in females: fetal alcohol exposure, age at the time of adoption, and a family with an adopted sibling who had a psychiatric problem. These variables did not diminish the significance of the prediction of depression with the alcohol genetic diathesis and disturbed parent model.

CONCLUSIONS

The results show that a genetic factor is present for which alcoholism is at least a marker, and which exerts its effect in women as a gene-environment interaction leading to major depression. This finding suggests that an important etiologic factor in depression spectrum disease is gene-environment interaction.

An adoption study of DSM-IIIR alcohol and drug dependence severity

OBJECTIVE

The objective of this study was to evaluate the role of genetic factors in alcohol and drug dependence at various levels of DSM-IIIR psychoactive substance dependence severity.

METHOD

One-hundred-and-ninety-seven adoptees (95 case adoptees with biological parental alcoholism, drug dependence or antisocial personality disorder and 102 control adoptees) were interviewed for the presence of alcohol abuse or dependence and drug abuse or dependence using the Diagnostic Interview Schedule-DIS IIIR.

RESULTS

Adoptees with five or more DSM-IIIR criteria for alcohol dependence demonstrated evidence of a genetic effect using this adoption paradigm (odds ratio = 2.3, 95% C.I. (1.1, 4.9)). Adoptees with one or more DSM-IIIR criteria for drug dependence demonstrated a genetic effect (odds ratio = 2.4, 95% C.I. (1.3, 4.4).

CONCLUSIONS

This study suggests genetic factors influence the risk for alcohol and drug dependence at different thresholds of severity as determined by DSM-IIIR symptom severity count.

An adoption study of drug abuse/dependency in females

In a sample of 102 women who had been adopted at birth, drug abuse/dependency was found by log-linear analyses to have a major pathway of genetic etiology that started with a biologic parent with antisocial personality and led to an adoptee with conduct disorder and then through aggressivity to drug abuse/dependency, as well as from conduct disorder directly to drug abuse. This result was similar to findings from a male sample collected from the same agencies and at the same time, wherein antisocial biologic parents produced aggressive and conduct-disordered off-spring, who in turn became drug abusers/dependents as adults. Results are compatible with family studies demonstrating that female drug abusers stem from deviant families and themselves demonstrate socially deviant behavior early in life. The present study shows that one element of familial factors is genetic, and that, in addition, the family environment directly affects behavior (aggressivity) that leads to drug abuse/dependency.

Genetic-environmental interaction in the genesis of aggressivity and conduct disorders

BACKGROUND

The purpose of this study was to determine the effect of an adverse adoptive home environment on adoptee conduct disorder, adult antisocial behavior, and two measures of aggressivity, all of which are behaviors that contribute to adult antisocial personality disorder and that also are associated with increased vulnerability to drug abuse and/or dependence.

METHODS

The study used an adoption paradigm in which adopted offspring who were separated at birth from biologic parents with documented (by prison and hospital records) antisocial personality disorder and/or alcohol abuse or dependence were followed up as adults. They and their adoptive parents were interviewed in person. These adoptees were compared with controls whose biologic background was negative for documented psychopathologic behavior. Subjects were 95 male and 102 female adoptees and their adoptive parents.

RESULTS

Multiple regression analysis was used to measure separately genetic and environmental effects. It showed that (1) a biologic background of antisocial personality disorder predicted increased adolescent aggressivity, conduct disorder, and adult antisocial behaviors, and (2) adverse adoptive home environment (defined as adoptive parents who had marital problems, were divorced, were separated, or had anxiety conditions, depression, substance abuse and/or dependence, or legal problems) independently predicted increased adult antisocial behaviors. Adverse adoptive home environment interacted with biologic background of antisocial personality disorder to result in significantly increased aggressivity and conduct disorder in adoptees in the presence of but not in the absence of a biologic background of antisocial personality disorder.

CONCLUSIONS

Environmental effects and genetic-environmental interaction account for significant variability in adoptee aggressivity, conduct disorder, and adult antisocial behavior and have important implications for the prevention and intervention of conduct disorder and associated conditions such as substance abuse and aggressivity.

Effective physician-patient communication and health outcomes: a review

OBJECTIVE

To ascertain whether the quality of physician-patient communication makes a significant difference to patient health outcomes.

DATA SOURCES

The MEDLINE database was searched for articles published from 1983 to 1993 using "physician-patient relations" as the primary medical subject heading. Several bibliographies and conference proceedings were also reviewed.

STUDY SELECTION

Randomized controlled trials (RCTs) and analytic studies of physician-patient communication in which patient health was an outcome variable.

DATA EXTRACTION

The following information was recorded about each study: sample size, patient characteristics, clinical setting, elements of communication assessed, patient outcomes measured, and direction and significance of any association found between aspects of communication and patient outcomes.

DATA SYNTHESIS

Of the 21 studies that met the final criteria for review, 16 reported positive results, 4 reported negative (i.e., nonsignificant) results, and 1 was inconclusive. The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control.

CONCLUSIONS

Most of the studies reviewed demonstrated a correlation between effective physician-patient communication and improved patient health outcomes. The components of effective communication identified by these studies can be used as the basis both for curriculum development in medical education and for patient education programs. Future research should focus on evaluating such educational programs.

Adoption study demonstrating two genetic pathways to drug abuse

BACKGROUND

Studies of adoptees have demonstrated that there are two genetic factors leading to alcohol abuse and/or dependence (abuse/dependence). In addition, environmental factors found in the adoptive family also predict alcohol abuse/dependency independently. One study has found evidence that a similar model of two genetic factors and independent adoptive family factors were involved in drug abuse. Our study was designed to test the hypothesis that genetic factors defined by alcohol abuse/dependency and anti-social personality disorder in biologic parents were etiologic in drug abuse/dependency and that psychiatric problems in adoptive parents were an additional factor associated with drug abuse/dependence.

METHODS

A sample of 95 male adoptees, separated at birth from their biologic parents, were followed up as adults to determine their psychiatric diagnosis and their substance use/abuse in a structured interview administered blind to biologic parent diagnoses. A high-risk, case-control design was used wherein half of the adoptees came from biologic parents known to be alcohol abuser/dependent and/or have antisocial personalities (diagnoses from hospital or prison records). These adoptees were matched for age, sex, and adoption agency to a control group of adoptees whose biologic parents were not found in the hospital and prison record search. Adoptive home environment was assessed by structured interviews, including psychiatric assessment of both adoptive parents.

RESULTS

Data were analyzed by log-linear modeling, which showed evidence of two genetic pathways to drug abuse/dependency. One pathway went directly from a biologic parent's alcoholism to drug abuse/dependency. The second pathway was more circuitous, and started with anti-social personality disorder in the biologic parent and proceeded through intervening variables of adoptee aggressivity, conduct disorder, antisocial personality disorder, and, eventually, ended in drug abuse/dependency. Environmental factors defined by psychiatric conditions in adoptive families independently predicted increased antisocial personality disorder in the adoptee. Adoptees born of alcohol-abusing mothers showed evidence of fetal alcohol syndrome, but controlling for this did not diminish the evidence for the direct genetic effect between an alcohol-abusing biologic parent and drug abuse/dependency in offspring.

CONCLUSIONS

This study confirms the model of two independent genetic factors involved in drug abuse/dependence and previous findings that disturbed adoptive parents are associated with adoptee drug abuse/dependency.

Alcoholism and affective disorder: clinical course of depressive symptoms

OBJECTIVE

This study compared the severity of and the change in depressive symptoms among men with alcohol dependence, affective disorder, or both disorders during 4 weeks of inpatient treatment.

METHOD

After their primary and secondary psychiatric disorders were defined with the use of criteria based on chronology of symptoms, 54 unmedicated men entering treatment for alcohol dependence or affective disorder were assessed for 4 consecutive weeks with the Hamilton Depression Rating Scale.

RESULTS

The findings indicate that the rate of remission of depressive symptoms was consistent with the primary diagnosis. Depressive symptoms remitted more rapidly among the men with primary alcoholism than among those with primary affective disorder. However, a minimum of 3 weeks of abstinence from alcohol appeared to be necessary to consistently differentiate the groups with dual diagnoses on the basis of their current depressive symptoms. Alcohol dependence occurring in conjunction with primary affective disorder did not intensify presenting depressive symptoms or retard the resolution of such symptoms.

CONCLUSIONS

Diagnoses of alcohol dependence and affective disorder based on symptom chronology appear to have prognostic significance with respect to remission of depressive symptoms in men with both diagnoses. Depressive symptoms of dysphoric mood, dysfunctional cognitions, vegetative symptoms, and anxiety/agitation showed different rates and levels of remission across the primary diagnostic groups.

Home care of dying patients. Family physicians' experience with a palliative care support team

Family physicians were asked about their recent experience with caring for dying patients at home and for their evaluation of a recently established Palliative Care Home Support Team. Ninety-four percent of the respondents had cared for at least one dying patient at home during the previous 2 years. About two thirds felt comfortable, competent, confident, supported, and in control. One quarter felt personally drained by the experience, but almost as many found it personally renewing. Of those who had referred patients to the team, two thirds gave the team high ratings for being supportive, helpful, quick to respond, and effective in communication.

Illness after measles-mumps-rubella vaccination

OBJECTIVES

To provide accurate information on the common sequelae of measles-mumps-rubella (MMR) vaccination and to compare post-vaccine symptoms in children vaccinated at 13 and 15 months.

DESIGN

Prospective cluster randomized controlled trial.

SETTING

Twenty-two family practices in southwestern Ontario.

PATIENTS

All 376 infants who were due to receive MMR vaccine in the next year, 253 (67.3%) successfully completed the study.

INTERVENTION

MMR vaccine administered at 13 months by half of the family physicians and at 15 months by the remaining half.

OUTCOME MEASURES

Family physician's physical findings in children 7 days and 30 days after vaccine; reported illnesses by mothers in a daily diary in the month before and after vaccination and medical records of visits to family physicians and hospital admissions in the month before and after vaccination.

RESULTS

Compared with the incidence rates in the corresponding weeks before vaccination, the rates of lymphadenopathy (23.8%) and fever (16.8%) were higher 1 week afterward and the rate of rash (26.9%) was higher 7 to 14 days afterward. Fewer health problems were reported in the third and fourth weeks after vaccination than in the corresponding weeks beforehand. Hospital admissions after vaccination were no more frequent than those before once cause and time of admission were taken into account. The two age groups did not differ in any of the outcomes.

CONCLUSIONS

Mothers should be informed about the possibility of increased physical findings in the weeks after MMR vaccination, especially lymphadenopathy, nasal discharge and rash. Since the occurrence of sequelae does not seem to differ significantly between 13-month-old recipients and 15-month-old recipients, it should not influence the decision of when to administer the vaccine.

Family functioning following adolescent substance abuse treatment

Reciprocal influences of substance abuse and family functioning have been hypothesized from diverse theoretical perspectives. The longitudinal study presented here investigated the relationship between adolescent alcohol and drug use outcome and family functioning following adolescent substance abuse treatment. Consistent with predictions, long-term improving teens (n = 17) experienced better family relations, and less conflict-related behavior within the family, than did teens who returned to an abuse pattern of drug use (n = 37). Two years following treatment, families of improvers demonstrated greater cohesion and expressiveness, and less conflict, than did families of relapsers. Findings highlight a gradual process of adaptation in relations among families of teens treated for alcohol and drug abuse.

Partial dissociation of subgroup C phenotype and in vivo behaviour in feline leukaemia viruses with chimeric envelope genes

Feline leukaemia viruses (FeLVs) are classified into subgroups A, B and C by their use of different host cell receptors on feline cells, a phenotype which is determined by the viral envelope. FeLV-A is the ubiquitous, highly infectious form of FeLV, and FeLV-C isolates are rare variants which are invariably isolated along with FeLV-A. The FeLV-C isolates share the capacity to induce acute non-regenerative anaemia and the prototype, FeLV-C/Sarma, has strongly age-restricted infectivity for cats. The FeLV-C/Sarma env sequence is closely related to that of common, weakly pathogenic FeLV-A isolates. We now show by construction of chimeric viruses that the receptor specificity of FeLV-A/Glasgow-1 virus can be converted to that of FeLV-C by exchange of a single env variable domain, Vr1, which differs by a three codon deletion and nine adjacent substitutions. Attempts to dissect this region further by directed mutagenesis resulted in disabled proviruses. Sequence analysis of independent natural FeLV-C isolates showed that they have unique Vr1 sequences which are distinct from the conserved FeLV-A pattern. The chimeric viruses which acquired the host range and subgroup properties of FeLV-C retained certain FeLV-A-like properties in that they were non-cytopathogenic in 3201B feline T cells and readily induced viraemia in weanling animals. They also induced a profound anaemia in neonates which had a more prolonged course than that induced by FeLV-C/Sarma and which was macrocytic rather than non-regenerative in nature. Although receptor specificity and a major determinant of pathogenicity segregate with Vr1, it appears that sequences elsewhere in the genome influence infectivity and pathogenicity independently of the subgroup phenotype.

A survey method for investigating ethical decision making in family practice

BACKGROUND

The tension between respect for patient autonomy versus concern for patient welfare is a challenging ethical issue for physicians. The purpose of this research was to describe a method for analyzing ethical decisions and to report the results of a survey of ethical decision making among family physicians.

METHODS

We developed a survey instrument that used simulated case scenarios, each of which posed an ethical dilemma. The ethical problems on the survey included the extent to which diagnostic information should be revealed to patients, the extent to which physicians should become involved in patients' life-style issues, and how to deal with patients' family problems. We mailed the questionnaire to 1,300 US family physicians.

RESULTS

Six hundred seventy-four physicians responded. Respondents did not deal with the simulated ethical problems in a uniform manner and often tended to respond more to specific details of a case rather than the overall ethical dilemma posed. Physicians who chose a course of action giving patients more control were motivated by factors that showed respect for patient autonomy. On the other hand, physicians who chose a course of action giving patients less control were not motivated by factors suggesting a concern for patient welfare.

CONCLUSIONS

Based on responses to simulated case scenarios, family physicians did not demonstrate a uniform approach but rather a more contextual one. Respect for patient autonomy was linked to family physicians' reported courses of action.

Ethical decision making by family doctors in Canada, Britain and the United States

Family doctors in Canada and the U.S. and general practitioners in England and Wales were sent a questionnaire containing six cases that raised moral issues. The doctors were asked to select the most appropriate course of action for each case as well as reasons for that decision. The ethical problems concerned how much information to divulge to patients, how extensively a physician should become involved in the lifestyles of patients, and how to deal with a possible family problem. The respondents selected different courses of action for the cases. More U.S. than Canadian or British physicians chose to divulge information, while more British than Canadian or U.S. physicians chose not to become involved in patients' lifestyles. Physicians who chose to divulge information were likely to be young, male, live in a small community, and have no academic affiliation. Physicians who chose not to become involved in lifestyle issues were likely to be young, church attenders, and in group practice in a small community.

An adoption study of attention deficit/hyperactivity/aggression and their relationship to adult antisocial personality

This study used an adoption design to investigate the relationships among genetic background, environmental factors, and clinical outcome of attention deficit/hyperactivity, aggressivity, and adult antisocial personality (ASP) in a sample of 283 male adoptees. A biologic parent adjudged to be delinquent or to have an adult criminal conviction predicted increased attention deficit/hyperactivity in the adopted away sons, as well as increased adult ASP diagnosis. Aggressivity in the adoptee was predicted by attention deficit/hyperactivity, and aggressivity in turn predicted increased adult ASP. Environmental factors of socioeconomic status (SES), and psychiatric problems in adoptive family members correlated significantly with various clinical outcomes of aggressivity, attention deficit/hyperactivity, and ASP. The results suggest that attention deficit/hyperactivity should be considered a syndrome that has a variety of correlated behaviors, such as aggressivity, and that each of these correlated behaviors is influenced by different genetic and environmental factors and their interactions. Depending on the mix of factors, adult ASP can be one of the outcomes.

Retinal detachment in penetrating keratoplasty patients

We reviewed the records of 23 patients who had retinal detachment after penetrating keratoplasty. Seventeen retinas (74%) were reattached successfully. Of the six failures, four patients had hemorrhagic choroidal detachment at the time of keratoplasty. When these complex retinal detachments are subtracted, 17 of 19 patients (89%) had successful retinal reattachments. Of the 17 successes, only seven patients had visual acuity of 20/200 or better. Retinal detachments after penetrating keratoplasty can be repaired with a high rate of success, but visual results remain disappointing.

Patient-centredness in the consultation. 1: A method for measurement

This paper presents a method for assessing the doctor-patient interaction in terms of its patient-centredness. Patient-centredness was defined in terms of doctor responses which enabled patients to express all of their reasons for coming, including symptoms, thoughts, feelings and expectations. The method was tested and found to be valid (correlations for criterion validity rs = 0.51 and 0.89), reliable (inter-rater correlation rs = 0.91, intra-rater correlation rs = 0.88), and sensitive, in that it was able to detect differences among doctors (P less than 0.001) and among doctor responses to different patient offers (P less than 0.001). The method was also found to be practical in that it was inexpensive and could be used for a variety of purposes such as by tutors to give feedback to their students, by examiners as part of the evaluation of candidates' consultation skills, and by students and clinicians alike, for self-assessment. The finding that the score for the first two minutes of the consultation correlated highly with the score for the entire consultation (rs = 0.806) greatly increases the time effectiveness of the method, suggesting that it would be practical for use on a large scale, including student assessment and future studies of the relationship between patient-centredness and patient outcomes.

Ethical decision making by British general practitioners

General practitioners in England and Wales were sent a questionnaire asking how they would handle the ethical problems posed by six case vignettes and their reasons for their decisions. The ethical problems included: how much information to divulge to patients, how extensively a physician should become involved in the lifestyles of patients and how to deal with a possible family problem. The varying patterns of response to the six cases suggested that ethical issues are resolved in a case-by-case, not a theoretical, basis.

Subgrouping conduct disorder by psychiatric family history

The family history of psychiatric disorders, and clinical and demographic characteristics of boys with pervasive aggressive conduct disorder (PACD) were compared to those of boys with situational aggressive conduct disorder and controls. Boys with PACD came from lower socioeconomic backgrounds, had an earlier age of onset, and higher rates of hyperactivity and inattention than boys in the other two groups. Their mothers abused drugs more often than those of boys in the other two groups, while their fathers had more frequent antisocial behavior. Alcohol abuse was more prevalent among fathers of both conduct disorder groups, compared to the fathers of controls.

Patient-centred interviewing part I: understanding patients' experiences

Effective patient care requires attending as much to patients' personal experiences of illnesses as to their diseases. Diseases are ferreted out by using the conventional medical model, but understanding illnesses requires a different approach. A patient-centred method focuses on four principal dimensions of patients' experiences: their ideas about what is wrong with them; their feelings about their illnesses, especially their fears; the impact of their problems on functioning; and their expectations about what should be done. The key to this approach is attention to patients' cues related to these dimensions; the goal is to follow patients' leads, to understand patients' experiences from their own point of view. This method improves patient satisfaction, complicance and outcome, and is applicable to the everyday work of family physicians with "ordinary" patients.

Patient-Centred Interviewing Part II: Finding Common Ground

DEVELOPING AN EFFECTIVE MANAGEMENT PLAN REQUIRES PHYSICIANS AND PATIENTS TO REACH AGREEMENT IN THREE KEY AREAS: the nature of the problems, the goals and priorities of treatment, and the roles of the doctor and patient. Often doctors and patients have widely divergent views in each of these areas. The process of finding a satisfactory resolution is not so much one of bargaining or negotiating but rather of moving towards a meeting of minds or finding common ground. This framework reminds physicians to incorporate patients' ideas, feelings, and expectations into treatment planning.

The effect of psychosocial factors on lung cancer mortality at one year

In this study newly diagnosed male and female lung cancer patients admitted to two Ontario Cancer Foundation treatment clinics were interviewed. Information was obtained on demographic variables, presence of other chronic illness and the following psychosocial attributes: locus of control, social support and personality traits. From the clinic charts, information on stage of disease and pathological diagnosis was obtained. After controlling for the effects of stage and pathological diagnosis, the following psychological variables were found to increase the odds of death from lung cancer among males and females combined at one year after diagnosis: a high need for one aspect of social support, a reserved personality and the extremes of the personality trait soberness vs enthusiasm.

Ethical decision making by Canadian family physicians

Canadian family physicians were sent questionnaires that asked how they would handle the ethical problems posed by six sample cases and what reasons were relevant to their decisions. The ethical problems concerned how much information to divulge to patients, how extensively a physician should become involved in the lifestyles of patients and how to deal with a possible family problem. The study identified characteristics of family physicians that affect their ethical decision making and tested a theoretical model that regards ethical problems as conflicts between respecting patient autonomy and promoting patient welfare. The varied responses suggested that ethical issues are resolved on a case-by-case, rather than a theoretical, basis. Certification in family medicine was the only characteristic associated with a consistent pattern of responses; certificants were more likely than other physicians to involve patients in decisions.

Clinical nuclear cardiology: 2. Nuclear angiography

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Clinical nuclear cardiology: 1. Studies of myocardial perfusion and cellular damage

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The effect of socioeconomic factors on the early prognosis of cancer

Previous studies have suggested that cancer patients of low socioeconomic status (SES) have poorer short and long-term survival than cancer patients of higher SES. In this study male and female patients between the ages of 25 and 70, admitted to two Ontario Cancer Treatment and Research Foundation Clinics with newly diagnosed cancers of a number of common sites, were interviewed to obtain information on education and occupation, and chronic illnesses other than cancer. Information on stage of disease at diagnosis, exact pathologic diagnosis, date of diagnosis, and treatment before and after admission to the clinic was obtained from clinic charts. Using multiple logistic regression analysis to control for the effect of stage and other variables, there was no convincing evidence that cancer patients of low SES measured by either education or occupation had a less favourable outcome at one year after diagnosis from cancers of all sites combined or lung cancer specifically. The data suggested that any single measure of SES affects males and females differently.

Conservation of the c-myc coding sequence in transduced feline v-myc genes

We have cloned the normal feline c-myc locus and determined the nucleotide sequence of all three exons. The feline c-myc gene shows close homology to other mammalian c-myc genes, particularly human c-myc. The feline and human sequences are colinear within the open reading frame for the putative c-myc product but show insertions and deletions relative to each other outside this domain. We have also analyzed a cloned FeLV provirus, CT4, which contains the host-derived myc gene. In this provirus the v-myc sequences are located at the 3' end of the pol gene, replacing pol and env sequences. Nucleotide sequence analysis of CT4 shows an open reading frame for a v-myc gene product which may be expressed without fusion to any viral protein sequences. This contrasts with another FeLV v-myc (LC), in which myc and gag sequences were found to be fused. Unlike previously identified avian v-myc genes, the feline v-myc genes contain exon 1-derived sequences, but these have been truncated or internally deleted. The FeLV CT4 v-myc sequence shows very few coding changes relative to c-myc and the FeLV LC v-myc coding sequence is unchanged relative to c-myc apart from fusion to gag. These results are discussed in relation to the mechanism of transduction and activation of myc by FeLV.

Nucleotide sequences of a feline leukemia virus subgroup A envelope gene and long terminal repeat and evidence for the recombinational origin of subgroup B viruses

Molecular clones of the subgroup A feline leukemia virus FeLV-A/Glasgow-1 have been obtained. Nucleotide sequence analysis of the 3' end of the proviral genome and comparison with the published sequence of FeLV-B/Gardner-Arnstein showed that the most extensive differences are located within the 5' domain of the env gene. Within this domain, several divergent regions of env are separated by more conserved segments. The 3' end of env is highly conserved, with only a single amino acid coding difference in p15env. The proviral long terminal repeats are also highly conserved, differing by only eight base substitutions and one base insertion. Specific probes constructed from the FeLV-A or FeLV-B env genes were used to compare the env genes of various exogenous FeLV isolates and the endogenous FeLV-related proviruses of normal cat DNA. An FeLV-A-derived env probe showed no hybridization to normal cat DNA but detected all FeLV-A and FeLV-C isolates tested. In contrast, an FeLV-B env probe detected independent FeLV-B isolates and a family of endogenous FeLV-related proviruses. Our observations provide strong evidence to support the hypothesis that FeLV-B viruses have arisen by recombination between FeLV-A and endogenous proviral elements in cat DNA.

The patient-centred clinical method. 1. A model for the doctor-patient interaction in family medicine

This article describes a patient-centred clinical method appropriate for family medicine. The method is designed to attain an understanding of the patient as well as his disease. This two-fold task is described in terms of two agendas: the physician's and the patient's. The key to an understanding of the patient's agenda is the physician's receptivity to cues offered by the patient, and behaviour which encourages him to express his expectations, feelings and fears. The physician's agenda is the explanation of the patient's illness in terms of a taxonomy of disease. In the patient-centred clinical method, both agendas are addressed by the physician and any conflict between them dealt with by negotiation. This is contrasted with the disease-centred method in which only the doctor's agenda is addressed. Further articles will describe the patient-centred method in operational terms.

Factors which predict the persistence of aggressive conduct disorder

Fifty-three boys with aggressive conduct disorder were followed up 2 years after their original examination. Twenty-four (45%) no longer had the disorder and were classified as improved. A discriminant function analysis identified characteristics of the boys and their families which accurately predicted the outcome for 85% of the boys. Among the predictors of persisting conduct disorder were a variety of antisocial or aggressive symptoms, firesetting, early age of onset and family deviance.