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Abstract Background We aimed to describe the roles and challenges of family caregivers involved in patients' cancer treatment decision‐making. Methods Family caregiver‐reported data were analyzed from a national survey conducted in the United States by CancerCare® (2/2021–7/2021). Four select‐all‐that‐apply caregiver roles were explored: (1) observer (patient as primary decision‐maker); (2) primary decision‐maker; (3) shared decision‐maker with patient and (4) decision delegated to healthcare team. Roles were compared across five treatment decisions: where to get treatment, the treatment plan, second opinions, beginning treatment and stopping treatment. Ten challenges faced by caregivers (e.g., information, cost, treatment understanding) were then examined. χ2 and regression analyses were used to assess associations between roles, decision areas, challenges and caregiver sociodemographics. Results Of 2703 caregiver respondents, 87.6% reported involvement in patient decisions about cancer treatment, including 1661 who responded to a subsection further detailing their roles and challenges with specific treatment decisions. Amongst these 1661 caregivers, 22.2% reported an observing role, 21.3% a primary decision‐making role, 53.9% a shared decision‐making role and 18.1% a role delegating decisions to the healthcare team. Most caregivers (60.4%) faced ≥1 challenge, the most frequent being not knowing how treatments would affect the patient's physical condition (24.8%) and quality of life (23.2%). In multivariable models, being Hispanic/Latino/a was the strongest predictor of facing at least one challenge (b = −0.581, Wald = 10.69, p

Abstract Background Family caregivers play an increasing role in cancer treatment decision‐making. We examined bias reported by family caregivers in the support they and their patient received from their healthcare team when making these decisions, including associations with distress. Methods Analysis of 2021 national survey data of family caregivers of patients with cancer (N = 2703). Bias experienced in decision support was assessed with the item: “Have you felt that the support you and the person with cancer have received for making cancer‐related decisions by your doctor or healthcare team has been negatively affected by any of the following?” Check‐all‐that‐apply response options included: age, race, language, education, political affiliation, body weight, insurance type or lack of insurance, income, religion, sexual orientation, and gender/sex. Chi‐square and regression analyses assessed associations between bias and caregiver distress (GAD‐2, PHQ‐2). Results Of 2703 caregiver respondents, 47.4% (n = 1281) reported experiencing ≥1 bias(es) when receiving decision support for making cancer‐related decisions. Bias was more prevalent among younger caregivers, males, transwomen/men or gender non‐conforming caregivers, racial/ethnic minorities, and those providing care over a longer time period. The odds of having high anxiety (GAD‐2 scores ≥ 3) were 2.1 times higher for caregivers experiencing one type of bias (adjusted OR, 2.1; 95% CI, 1.6–2.8) and 4.2 times higher for caregivers experiencing ≥2 biases (adjusted OR, 4.2; 95% CI, 3.4–5.3) compared to none. Similar results were found for high depression scores (PHQ‐2 scores ≥ 3). Conclusions Nearly half of caregivers involved in their care recipients' cancer‐related decisions report bias in decision support received from the healthcare team. Experiencing bias was strongly associated with high psychological distress.

Background Inherited cardiomyopathies display variable penetrance and expression, and a component of phenotypic variation is genetically determined. To evaluate the genetic contribution to this variable expression, we compared protein coding variation in the genomes of those with hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM). Methods and Results Nonsynonymous single‐nucleotide variants (nsSNVs) were ascertained using whole genome sequencing from familial cases of HCM (n=56) or DCM (n=70) and correlated with echocardiographic information. Focusing on nsSNVs in 102 genes linked to inherited cardiomyopathies, we correlated the number of nsSNVs per person with left ventricular measurements. Principal component analysis and generalized linear models were applied to identify the probability of cardiomyopathy type as it related to the number of nsSNVs in cardiomyopathy genes. The probability of having DCM significantly increased as the number of cardiomyopathy gene nsSNVs per person increased. The increase in nsSNVs in cardiomyopathy genes significantly associated with reduced left ventricular ejection fraction and increased left ventricular diameter for individuals carrying a DCM diagnosis, but not for those with HCM. Resampling was used to identify genes with aberrant cumulative allele frequencies, identifying potential modifier genes for cardiomyopathy. Conclusions Participants with DCM had more nsSNVs per person in cardiomyopathy genes than participants with HCM. The nsSNV burden in cardiomyopathy genes did not correlate with the probability or manifestation of left ventricular measures in HCM. These findings support the concept that increased variation in cardiomyopathy genes creates a genetic background that predisposes to DCM and increased disease severity.

Abstract Rates of deforestation reported by Brazil's official deforestation monitoring system have declined dramatically in the Brazilian Amazon. Much of Brazil's success in its fight against deforestation has been credited to a series of policy changes put into place between 2004 and 2008. In this research, we posit that one of these policies, the decision to use the country's official system for monitoring forest loss in the Amazon as a policing tool, has incentivized landowners to deforest in ways and places that evade Brazil's official monitoring and enforcement system. As a consequence, we a) show or b) provide several pieces of suggestive evidence that recent successes in protecting monitored forests in the Brazilian Amazon may be doing less to protect the region's forests than previously assumed.

Aim: To conduct a concept analysis of values elicitation in the context of health care and treatment decision-making and formulate a conceptual definition., Background: Values elicitation is a commonly cited term for an activity to help patients identify values and evaluate their application in health care decision-making, yet it remains ambiguous and difficult to differentiate from similar concepts., Design: Concept analysis., Data Source: Three databases, including PubMed, CINAHL Plus, and Scopus, were searched from inception to February 2021., Review Methods: Walker and Avant's eight-stage method was used to identify attributes, cases, antecedents, consequences, and empirical referents and formulate a conceptual definition., Results: The concept analysis identified 3 attributes, 10 consequences, 7 antecedents, and 3 empirical referents. Our analysis defines values elicitation as an intentional process whereby individuals explore their core beliefs, alone or with others, to (1) determine their preference, or a lack thereof, between health or treatment options, and (2) frame decisions., Conclusions: The findings have the potential to influence the identification, discussion, and measurement of values elicitation by nurses and researchers across disciplines. Further exploration of this concept is warranted as the literature continues to emerge., (© 2022 Wiley Periodicals LLC.)

Objectives: ambulance diversion is a dangerous repercussion of emergency department (ED) crowding and can reflect fragmentation and a lack of coordination in designating optimal patient offload sites for prehospital providers. The objective of this study was to evaluate whether proactive destination selection through the Regional Emergency Patient Access and Coordination (REPAC) program would enhance capacity and ED flow management., Methods: the REPAC system provides a dashboard that synthesizes real-time capacity and acuity data for all three adult EDs in the city of Calgary, assigning a color code to reflect receiving status. It assigns destination for the next patient transported by emergency medical services (EMS) by categorizing ED sites as having either a favorable (green/yellow) status or unfavorable (orange/red) status. Three time windows were analyzed: a 6-month window prior to REPAC implementation (pre), the first 6-month window immediately following (post1), and the second 6-month period following (post2). Primary outcomes of interest were the proportion of time spent in favorable versus unfavorable status and EMS avoidances for all adult ED sites in the region (percentage of total time with any center on EMS bypass). Information on total number of ED visits, percentage of patients arriving by EMS transports, admission rates, patient acuity (Canadian Triage and Acuity Score), age, and length of stay (LOS) for admitted and discharged patients was collected. The Kruskal-Wallis test was employed for primary outcome analysis., Results: implementation of the REPAC system resulted in an increase in the proportion of total time region hospitals reported favorable status (57.5% vs. 64.1%) pre versus post1, an effect that was accentuated at 1 year (post2, 78.7%; p < 0.001 for both comparisons). There was a concomitant decrease in EMS avoidances as a result of the REPAC system, 4.4% to 1.8% (pre vs. post1), also further improved at 1 year to 0.6% (p < 0.001 for both comparisons)., Conclusions: proactive EMS destination selection through a real-time integrated electronic surveillance system enhances regional capacity and flow management while significantly reducing ambulance diversions., (2010 by the Society for Academic Emergency Medicine.)

The present study compares the occurrence of a dry, persistent cough with doses of 80 mg of valsartan, 10 mg of lisinopril, or 25 mg of hydrochlorothiazide in patients with a history of angiotensin-converting enzyme inhibitor-induced cough. This was a randomized, double-blind, active-controlled, parallel group, multicenter trial involving 129 adult outpatients with essential hypertension. After confirmation of angiotensin-converting enzyme inhibitor-induced cough during a 2 to 4 week challenge with lisinopril (followed by a washout period of 2 weeks), patients were randomized to receive 6 weeks of double-blind treatment once daily with 80 mg valsartan, 10 mg lisinopril, or 25 mg hydrochlorothiazide. Assessments were made at baseline and after 3 and 6 weeks of treatment. Comparability of response to treatment was assessed by mean sitting diastolic and systolic blood pressure at the end of treatment. The occurrence of a dry, persistent cough was significantly less (P < 0.001) at 3 and 6 weeks with valsartan (19.5%) than with lisinopril (68.9%), with no significant difference between valsartan and hydrochlorothiazide (19.0%). There were no statistically significant differences in reduction of blood pressure among the three treatment groups. The overall incidence of adverse experiences, whether or not treatment-related, was highest for lisinopril (86.7%) compared with valsartan (57.1%), and hydrochlorothiazide (61.9%). A dry cough in the lisinopril group accounted for this difference. There were no clinically significant changes in physical signs or in results of clinical laboratory evaluations during double-blind treatment, except for from metabolic changes in 3 patients receiving hydrochlorothiazide. In hypertensive patients with a history of angiotensin-converting enzyme inhibitor-induced cough, a single daily dose of 80 mg of valsartan produced therapeutic efficacy comparable to lisinopril but with significantly less cough.

Referral of pregnancies complicated by suspected fetal anomalies to level III perinatal centres for further evaluation and management is increasing as use of real-time ultrasound spreads, but the sensitivity and specificity of the prenatal diagnoses made in this population are unknown. We undertook a prospective study that followed pregnancies referred to a designated programme dealing with suspected fetal abnormalities. Follow-up of 257 pregnancies revealed that 282 separate anomalies were accurately diagnosed in 212 cases. Normal anatomy was correctly predicted in 42 cases, 16 per cent of the referred population. False-positive and false-negative rates were 1.5 per cent (4/257) and 2 per cent (1/46), respectively. However, 37 per cent of those infants born with anomalies had additional problems not prenatally detected by ultrasound. These results indicate that prenatal ultrasound diagnoses are remarkably accurate overall but that they may be insensitive to associated anomalies in individual cases.

Otorrhea is the most frequent complication of the use of tympanostomy tubes. When it occurs after the immediate postoperative period, otorrhea is probably the result of external contamination of the middle ear or acute otitis media. We analyzed data from 627 operations upon 1248 ears of 491 children with chronic secretory otitis media and found that delayed onset (longer than 7 weeks) postoperative otorrhea occurred after 26.4 percent of the 382 operations in which tympanostomy tubes were used. The average number of episodes of otorrhea per case was 1.46 and ranged from 1 to 9. The rate of otorrhea occurrence in patients with tubes in place was significantly higher in the summer months. Otorrhea also occurred after 9.0 percent of 245 myringotomy procedures. The average number of episodes was 1.32 and ranged from 1 to 3. Treatment of postoperative otorrhea increases the health care costs of surgical treatment of chronic otitis media with effusion; this problem should be included in the calculation of cost-effectiveness.