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Background: There is little information about risk acceptance of multiple sclerosis (MS) patients to various MS therapies., Objective: To determine MS patients׳ tolerance to risky therapies and identify associated characteristics., Methods: MS patients from the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry׳s online cohort were invited to complete questionnaires on decision making and risk tolerance (RT) to two therapeutic scenarios: a theoretical cure for MS [CureMS], with permanent reversal of all MS symptoms but a risk of immediate painless death; and natalizumab [NAT], a real-life scenario with benefits and risks as defined by Phase III trial results., Results: The median RT for both scenarios was 1:10,000; 15-23% of respondents were not willing to take any risk for their MS therapy. Participants with greater disability or not taking any MS therapy showed a greater RT, while females and those caring for dependents had a lower RT. Females and older age were predictors of lower RT, while increasing disability and greater blunting attitude with respect to information seeking behavior were predictors of higher RT., Conclusion: MS patients displayed a wide range of RT for MS therapies. Our study identified gender, age, disability and information seeking behavior to be associated with RT., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background and Purpose: Matching nurse assignments with patient acuity has critical implications for providing safe, effective, and efficient care. Despite this, we lack well-established methods for accurate assessment of acuity. This study aimed to evaluate the reliability and validity of the Oncology Acuity Tool (OAT), which is used for determining nurse assignments., Methods: Inter-rater reliability and concurrent validity were assessed via surveys of current users of the tool. Content validity data were collected from expert oncology nurses. Predictive validity was assessed by tracking patients who sustained either of two acute events., Results: Findings included high inter-rater reliability, moderately strong concurrent validity, and moderate content validity. Acuity significantly predicted rapid response team consults but not falls., Conclusions: The OAT demonstrated sufficient reliability and validity for measuring acuity prospectively in this population.

Background: Most patients with dementia will, at some point, need a proxy health care decision maker. It is unknown whether persons with various degrees of cognitive impairment can reliably report their health-related preferences., Methods: The authors performed health state valuations (HSVs) of current and hypothetical future health states on 47 pairs of patients with mild to moderate cognitive impairment and their caregivers using computer-based standard gamble, time tradeoff, and rating scale techniques., Results: Patients' mean (SD) age was 74.6 (9.3) years. About half of the patients were women (48%), as were most caregivers (73%), who were on average younger (mean age= 66.2 years, SD= 12.2). Most participants were white (83%); 17% were African American. The mean (SD) Mini-Mental State Examination (MMSE) score of patients was 24.2 (4.6) of 30. All caregivers and 77% of patients (36/47) completed all 18 components of the HSV exercise. Patients who completed the HSV exercise were slightly younger (mean age [SD]= 74.1 [8.5] v. 75.9 [11.8]; P = 0.569) and had significantly higher MMSE scores (mean score [SD] = 25.0 [4.3] v. 21.4 [4.4]; P = 0.018). Although MMSE scores below 20 did not preclude the completion of all 18 HSV ratings, being classified as having moderate cognitive impairment was associated with a lower likelihood of completing all scenario ratings (44% v. 82%). Patient and caregiver responses showed good consistency across time and across techniques and were logically consistent., Conclusion: Obtaining HSVs for current and hypothetical health states was feasible for most patients with mild cognitive impairment and many with moderate cognitive impairment. HSV assessments were consistent and reasonable.

Background: Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C (HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not be a problem in the absence of their HCV diagnosis., Objective: This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear., Design: We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N = 50) and healthcare providers (N = 14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program., Results: We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients. Patient respondents who reported hearing "stop completely" were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in "medical language" than were GI providers., Conclusions: To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV.

Background: Prolonged QTc (corrected QT) interval and torsades de pointes (TDP) are associated with hypocalcemia, hypomagnesemia, hypokalemia, possibly alkalosis and may result in syncope and sudden cardiac death., Hypothesis: The purpose of this study was to determine the prevalence of prolonged QTc intervals on admission electrocardiograms (ECGs) and its correspondence with simultaneous admission electrolyte values, adjusted for admission diagnoses, comorbidities, other ECG abnormalities, and medications potentially associated with QTc prolongation., Methods: Consecutive patients (N=258) admitted to a general medical service with the admission electrolytes and ECGs. For each ECG, QTc was classified in 10 msec. intervals from QTc > or = 450 to QTc > or = 500 msec. as determined by the electronically measured QTc (Marquette ECG system). Medical records were reviewed for prespecified admission diagnoses, comorbidities and medications associated with QTc prolongation. The correspondence of admission electrolyte abnormalities and QTc prolongation was evaluated using univariate and multivariate statistical methods., Results: The prevalence of abnormal QTc intervals varied by the criterion applied, ranging from 25.2%, using the most lenient criterion of abnormality (QTc > or =450 msec.), to 3.5%, when the most restrictive criterion was applied (QTc > or = 500 msec.). In univariate analyses, there were no significant associations between QTc intervals and admission values for any of the electrolytes. In multivariate analyses, after adjusting for age, gender, ECG abnormalities and other covariates, none of the admission electrolyte values were significantly associated with prolonged QTc., Conclusions: Using conventional criteria, electronically measured prolonged QTc intervals were quite common at the time of admission among general medicine service patients, hospitalized for non-cardiac complaints. Admission electrolyte values were not associated with QTc intervals. We conclude that the association of metabolic derangements and QTc abnormalities may not be as strong as is widely believed.

Objective: To determine which primary cesarean delivery risk factors are important to practicing physicians., Study Design: A sample of current members of the American College of Obstetrician Gynecologists were surveyed about the risk factors for primary cesarean delivery that they thought were most important. Data on demographic and practice characteristics were also collected. Sample size was determined by theoretical saturation., Results: Theoretical saturation was reach at 60 responses. A total of 290 surveys were returned. The 10 most common factors listed by physicians as preexisting patient risk factors for primary cesarean delivery were, in descending order of importance, medical problems, maternal obesity, macrosomic infant, malpresentation, multiple gestation, maternal age, Bishop score, patient's fear, preterm labor, and postdate pregnancy. Six of the 10 factors listed by respondents are in previously published risk-adjustment models., Conclusion: Our study suggested that the addition of obesity and birth weight to previously published risk-adjustment models should improve representation of practicing obstetricians' views.

Purpose: There is a growing consensus that quality of care for frail elders should include family and be evaluated in terms of patient-centered, family-focused care (PCFFC). Family caregivers are in a unique and sometimes sole position to evaluate such care. In the context of caring for physically frail elders, this study examined the extent to which objective burden was associated with caregiver perceptions of PCFFC and the extent to which it mediated the influence of other variables on perceptions of PCFFC., Design and Methods: In a study of frail elderly veterans receiving care in U.S. Department of Veterans Affairs ambulatory primary care clinics, informal caregivers assessed quality of care with 13 questions. Factor analysis of these items revealed an eight-item scale that specifically assessed PCFFC (alpha =.90). Regression analysis identified variables associated with caregiver (N = 210) assessments of PCFFC and the potential mediating effect of objective burden., Results: Caregiver assessments of PCFFC were positively associated with care recipient instrumental activity of daily living limitations (p =.04) and perspectives on the quality of their own patient care (p <.001). Greater objective burden was negatively associated with caregiver assessments of PCFFC (p <.001) and mediated (i.e., reduced) the relationship between care recipient perceptions of the quality of their own patient care and caregiver assessments of PCFFC (DeltaR(2) =.06)., Implications: These findings support recommendations for conducting caregiver assessments as part of routine care and highlight the importance of measuring objective burden and expectations for PCFFC in assisting physically frail elders. Primary care providers will require additional training in order to effectively implement and translate such caregiver assessments into clinical practice improvement.