More than any other cancer, prostate cancer screening with the prostate-specific antigen (PSA) tests increases the risk a man will have to face a diagnosis of prostate cancer. The best evidence from ...screening trials suggests a small but finite benefit from prostate cancer screening in terms of prostate cancer-specific mortality, about 1 fewer prostate cancer death per 1000 men screened over 10 years. The more serious harms of prostate cancer screening, such as erectile dysfunction and incontinence, result from cancer treatment with surgery or radiation, particularly for men whose PSA-detected cancers were never destined to cause morbidity or mortality.
A 25-year-old woman with a history of acute intermittent porphyria was admitted with abdominal pain and jerking movements of the arm and leg. Symptoms did not abate with hemin treatment. A diagnosis ...was made.
The degree to which microbes in the water column associate with settleable particles has important implications for microbial transport in receiving waters, as well as for microbial removal via ...sedimentation (i.e. detention basins). The partitioning behavior of several bacterial, protozoan and viral indicator organisms is explored in three urban streams under both storm and dry weather conditions. The fraction of organisms associated with settleable particles in stormwater is estimated through use of a centrifugation technique which is calibrated using suspensions of standard particles (e.g., glass, latex).
The fraction of organisms associated with settleable particles varies by type of microbe, and the partitioning behavior of each organism generally changes between dry weather and storm conditions. Bacterial indicator organisms (fecal coliforms,
Escherichia coli, enterococci) exhibited relatively consistent behavior, with an average of 20–35% of organisms associated with these particles in background samples and 30–55% in storm samples.
Clostridium perfringens spores exhibited the highest average level of particle association, with storm values varying from 50% to 70%. Results related to total coliphage partitioning were more variable, with 20–60% associated with particles during storms. These estimates should be valuable in surface water quality modeling efforts, many of which currently assume that all microbes exist as free (unattached) organisms.
Shared decision-making (SDM) can help patients make good decisions about preventive health interventions such as cancer screening. We illustrate the use of SDM in the case of a 53-year-old man who ...had a new patient visit with a primary care physician and had never been screened for colorectal cancer (CRC). The patient had recently recovered from a serious COVID-19 infection requiring weeks of mechanical ventilation. When the primary care physician initially offered a screening colonoscopy, the man expressed great reluctance to return to the hospital for the exam. The PCP then offered a stool test, which could be completed at home, but emphasized that if it were positive, a colonoscopy would be required. He agreed to complete the stool test, and unfortunately, it was positive. He then agreed to undergo colonoscopy, which uncovered a large rectal cancer. The carcinoma had invaded the mesorectal fat but there were no metastases. After undergoing neoadjuvant chemotherapy followed by a low anterior resection of the tumor, he has no evidence of recurrence so far. Many clinicians favor colonoscopy for CRC screening, but evidence suggests that patients who are offered more than one reasonable option are more likely to undergo screening. If screening had been delayed in this patient until he was willing to accept a screening colonoscopy, there was the potential the cancer may have been more advanced when diagnosed, with a worse outcome. Shared decision-making was a key approach to understanding the patient’s feelings related to this screening decision and making a decision consistent with his preferences.
Background. A goal of shared decision making (SDM) is to ensure patients are well informed and receive preferred treatments. However, the relationship between SDM and health outcomes is not clear. ...Objective. The purpose was to examine whether patients who are well informed and receive their preferred treatment have better health outcomes. Design, Setting, and Participants. A prospective cohort study at an academic medical center surveyed new patients with knee or hip osteoarthritis, herniated disc, or spinal stenosis 1 week after seeing a specialist and again 6 months later. Main Outcomes and Measures. The survey assessed knowledge, preferred treatment, and quality of life (QoL). The percentage of patients who were well informed and received preferred treatment was calculated (informed, patient centered IPC). A follow-up survey assessed QoL, decision regret, and satisfaction. Regression analyses with generalized estimating equations to account for clustering tested a priori hypotheses that patients who made IPC decisions would have higher QoL.Results. Response rate was 70.3% (652/926) for initial and 85% (551/648) for follow-up. The sample was 63.9 years old, 52.8% were female, 62.6% were college educated, and 49% had surgery. One-third (37.4%) made IPC decisions. Participants who made IPC decisions had significantly better overall (0.05 points (SE 0.02) for EQ-5D, P = 0.004) and disease-specific quality of life (4.22 points SE 1.82 for knee, P = 0.02; 4.46 points SE 1.54 for hip, P = 0.004; and 6.01 points SE 1.51 for back, P < 0.0001), higher satisfaction and less regret. Limitations. Observational study at a single academic center with limited diversity. Conclusions. Well-informed patients who receive their preferred treatment also had better health outcomes and higher satisfaction.
Association with particles in the water column can have a significant impact on microbial fate and transport. This study analyzed multiple stormwater samples taken throughout the duration of three ...separate storms (at two different sites) to evaluate the fraction of microbes partitioning to denser “settleable” particles and to examine how partitioning behavior varied over the course of a storm. Intra-storm sampling also allowed for estimates of microbial loading rates (both total and particle-associated) and cumulative storm-induced microbial load.
Five different indicator organisms were examined, with the fraction of microbes associated with settleable particles assessed via a calibrated centrifugation method. Partitioning behavior varied across microorganism type, with an average of 40% of fecal coliforms,
Escherichia coli, and enterococci associating with settleable particles, compared to approximately 65% of
Clostridium perfringens spores and only 13% of total coliphage. Partitioning remained fairly constant for each type of organism throughout storm events. Nonetheless, higher concentrations of both settleable particles and microbes entering the water column soon after the onset of a storm led to higher loading rates of settleable microbes in the storm's earliest stages, a trend that could have important implications for the design of stormwater management structures (e.g., detention basins). Estimates of cumulative storm-induced microbial loading suggested that one day's worth of storm loading can be the equivalent of months, or even years, of dry-weather loading.
Shared decision making is a core component of population health strategies aimed at improving patient engagement. Massachusetts General Hospital's integration of shared decision making into practice ...has focused on the following three elements: developing a culture receptive to, and health care providers skilled in, shared decision making conversations; using patient decision aids to help inform and engage patients; and providing infrastructure and resources to support the implementation of shared decision making in practice. In the period 2005-15, more than 900 clinicians and other staff members were trained in shared decision making, and more than 28,000 orders for one of about forty patient decision aids were placed to support informed patient-centered decisions. We profile two different implementation initiatives that increased the use of patient decision aids at the hospital's eighteen adult primary care practices, and we summarize key elements of the shared decision making program.
Due to the relatively high cost and inconvenience of upper endoscopic biopsy and the rising incidence of esophageal adenocarcinoma, there is currently a need for an improved method for screening for ...Barrett's esophagus. Ideally, such a test would be applied in the primary care setting and patients referred to endoscopy if the result is suspicious for Barrett's. Tethered capsule endomicroscopy (TCE) is a recently developed technology that rapidly acquires microscopic images of the entire esophagus in unsedated subjects. Here, we present our first experience with clinical translation and feasibility of TCE in a primary care practice. The acceptance of the TCE device by the primary care clinical staff and patients shows the potential of this device to be useful as a screening tool for a broader population.
Background
For adults aged 76–85, guidelines recommend individualizing decision-making about whether to continue colorectal cancer (CRC) testing. These conversations can be challenging as they need ...to consider a patient’s CRC risk, life expectancy, and preferences.
Objective
To promote shared decision-making (SDM) for CRC testing decisions for older adults.
Design
Two-arm, multi-site cluster randomized trial, assigning physicians to Intervention and Comparator arms. Patients were surveyed shortly after the visit to assess outcomes. Analyses were intention-to-treat.
Participants and Setting
Primary care physicians affiliated with 5 academic and community hospital networks and their patients aged 76–85 who were due for CRC testing and had a visit during the study period.
Interventions
Intervention arm physicians completed a 2-h online course in SDM communication skills and received an electronic reminder of patients eligible for CRC testing shortly before the visit. Comparator arm received reminders only.
Main Measures
The primary outcome was patient-reported SDM Process score (range 0–4 with higher scores indicating more SDM); secondary outcomes included patient-reported discussion of CRC screening, knowledge, intention, and satisfaction with the visit.
Key Results
Sixty-seven physicians (Intervention
n
=34 and Comparator
n
=33) enrolled. Patient participants (
n
=466) were on average 79 years old, 50% with excellent or very good self-rated overall health, and 66% had one or more prior colonoscopies. Patients in the Intervention arm had higher SDM Process scores (adjusted mean difference 0.36 (95%CI (0.08, 0.64),
p
=0.01) than in the Comparator arm. More patients in the Intervention arm reported discussing CRC screening during the visit (72% vs. 60%,
p
=0.03) and had higher intention to follow through with their preferred approach (58.0% vs. 47.1,
p
=0.03). Knowledge scores and visit satisfaction did not differ significantly between arms.
Conclusion
Physician training plus reminders were effective in increasing SDM and frequency of CRC testing discussions in an age group where SDM is essential.
Trial Registration
The trial is registered on
clinicaltrials.gov
(NCT03959696).
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