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BACKGROUND: Medical records are important for facilitating the process and quality of care. However, little is known about their current state in primary care practices. This article describes features of medical record systems in diverse practices and examines their association with preventive service delivery rates. METHODS: Medical records were reviewed from a consecutive sample of outpatients seen by 198 family physicians in 79 community-based practices in Northeast Ohio. The physicians were participants in a clinical trial designed to increase preventive service delivery. Research nurses performed baseline medical record reviews and used ethnographic field notes and a practice environment checklist to provide global assessments of features of medical records. RESULTS: In 79 practices, 3462 medical records were reviewed. Medical records were rated as highly easy to use in 52% of practices; outpatient visit notes were dictated in 54%. Nine percent of practices grouped individual charts by family. Patient notes were computerized in 1% of practices, although several practices had previously tried and abandoned computerized systems. Flow sheets for immunization, screening, and counseling were present on 71%, 63%, and 16% of charts and were used on 34%, 33%, and 3% of charts, respectively. The presence and use of flow sheets were associated with higher preventive service delivery rates. CONCLUSION: Medical record organization, completeness, and use vary widely, and computerized records remain rare. The association of flow sheet presence and use with preventive service delivery rates shows the potential importance of medical records for enhancing the process and outcome of patient care. [ABSTRACT FROM AUTHOR]

Abstract Background Precise and efficient methods for gene targeting are critical for detailed functional analysis of genomes and regulatory networks and for potentially improving the efficacy and safety of gene therapies. Oligomerized Pool ENgineering (OPEN) is a recently developed method for engineering C2H2 zinc finger proteins (ZFPs) designed to bind specific DNA sequences with high affinity and specificity in vivo. Because generation of ZFPs using OPEN requires considerable effort, a computational method for identifying the sites in any given gene that are most likely to be successfully targeted by this method is desirable. Results Analysis of the base composition of experimentally validated ZFP target sites identified important constraints on the DNA sequence space that can be effectively targeted using OPEN. Using alternate encodings to represent ZFP target sites, we implemented Naïve Bayes and Support Vector Machine classifiers capable of distinguishing "active" targets, i.e., ZFP binding sites that can be targeted with a high rate of success, from those that are "inactive" or poor targets for ZFPs generated using current OPEN technologies. When evaluated using leave-one-out cross-validation on a dataset of 135 experimentally validated ZFP target sites, the best Naïve Bayes classifier, designated ZiFOpT, achieved overall accuracy of 87% and specificity+ of 90%, with an ROC AUC of 0.89. When challenged with a completely independent test set of 140 newly validated ZFP target sites, ZiFOpT performance was comparable in terms of overall accuracy (88%) and specificity+ (92%), but with reduced ROC AUC (0.77). Users can rank potentially active ZFP target sites using a confidence score derived from the posterior probability returned by ZiFOpT. Conclusion ZiFOpT, a machine learning classifier trained to identify DNA sequences amenable for targeting by OPEN-generated zinc finger arrays, can guide users to target sites that are most likely to function successfully in vivo, substantially reducing the experimental effort required. ZiFOpT is freely available and incorporated in the Zinc Finger Targeter web server (http://bindr.gdcb.iastate.edu/ZiFiT).

The Xcounts algorithm for calculating air concentrations of radioactive xenon isotopes (Eslinger et al., 2023) has been extended to estimate 127 Xe in addition to 131m Xe, 133m Xe, 133 Xe, and 135 Xe. The algorithm was applied to 119 samples collected with a SAUNA Q B system (Ringbom et al., 2023) during a two-month atmospheric tracer release experiment. The algorithm identified two samples with 127 Xe present from a single 1.5 h release about 3.5 km upwind of the sampler and no false detections of 127 Xe were observed in the other samples., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025. Published by Elsevier Ltd.)

The prevalence of isotopes of radioxenon in the atmosphere poses a problem for the International Monitoring System (IMS) of the Comprehensive Nuclear-Test-Ban Treaty (CTBT). The atmospheric radioxenon background has accumulated due to emissions from civil nuclear facilities and as a result, the IMS frequently detects isotopes that might be considered a signal of a nuclear explosion. The UK National Data Centre (NDC) at the Atomic Weapons Establishment (AWE) analyses all data from the IMS radionuclide network and through a new 'event analysis' pipeline, works to determine the source of each detection of interest. The pipeline consists of sample screening, sample association and source reconstruction methods. There are various methods to determine which detections are worthy of further analysis, such as activity concentration magnitude, number of isotopes detected, isotopic activity ratios or consecutive detections. Once the detections have been identified, atmospheric transport and dispersion modelling (ATDM) simulations can be used to identify and characterise the source. Not all sources are known to the Treaty-verification community so work to identify new emitters and their impact on the IMS is critical to the international effort to monitor for nuclear explosions. This work presents a study of the phenomenon of consecutive 133 Xe detections (here referred to as 'plumes'), which are frequently identified on the IMS. We consider the likelihood of a plume from various radionuclide release scenarios and conduct an analysis of a database of IMS measurement data, using the outputs of the automatic Radionuclide (RN) and Event Analysis Pipelines., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Case: The golf club deformity is the most notable malreduction that occurs after distal femur fracture fixation. This can lead to disruption of the patient's knee biomechanics, arthritis, and functional deterioration. There is a lack of consensus for optimal treatment of these malunions among the orthopaedic community. We present a technique that uses an osteotomy and ring external fixation with computer-assisted deformity correction and retrograde intramedullary nailing to secure correction., Conclusion: Our case shows a potential means to achieve a reliable and objective method of measuring, correcting, and securing the fixation of a golf club deformity., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C474)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

In this study, we analyze the relationship between polypharmacy and surgical treatment in a population at a single teaching institution. The design of the study is a case-control analysis of hip fractures. The setting is at a single teaching institution located in Galveston, Texas, USA. Over a 5-year period, we conducted a retrospective review of patients within our medical record who underwent surgery for a hip fracture, identified by current procedural terminology codes 27235 and 27236. Our primary variable was a prescription of opioids, benzodiazepines, or both 30 days preoperatively and surgery performed. The main outcome measures were prescription of controlled medications and surgical class. We used descriptive analysis to summarize each variable as mean or frequency for continuous and categorical variables and subsequently assessed the association between demographic variables and drug prescription and surgical class. Of the 378 patients who met our inclusion criteria, 68.0% were females and 32.0% were males. The average age was 77.8 years. Most patients had a displaced hip fracture (61%). Most patients underwent a hip hemiarthroplasty (233, 61.6%) versus either a closed reduction with percutaneous pinning (125, 33.1%) or hip open reduction internal fixation (20, 5.3%). There was no significant difference between polypharmacy and hip fracture surgery; however, reported alcohol use was significant in both groups. In our patient population, opioid and/or benzodiazepine prescriptions were not significantly linked to hip fracture surgery, but documented alcohol use was found to be significant in both groups. We noted a higher prevalence of opioid and benzodiazepine prescriptions than was previously reported. As patients age, we should be cautious about the effects of polypharmacy and alcohol use and their impacts on the elderly., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

A radiochemically pure solution of 91 Y was produced by the thermal neutron fission of 235 U followed by successive chemical separations to remove fission product impurities. The gamma emission rate of the 91 Y 1205 keV gamma was measured using multiple high purity germanium gamma spectrometers previously calibrated for counting efficiency using a certificated mixed nuclide gamma standard. The activity concentration of the 91 Y was subsequently standardised by liquid scintillation counting. From the combination the activity concentration and gamma emission intensity, the absolute intensity of the 1205 keV gamma emission was derived as 0.2297(39)%. This data agrees within the quoted uncertainties with the absolute intensity of 0.26(4)% published in nuclear data sheets A=91 (Baglin, 2013), but reduces the uncertainty by an order of magnitude., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

The International Monitoring System (IMS) is a unique global network of sensors, tuned to measure various phenomenology, with the common goal of detecting a nuclear explosion anywhere in the world. One component of this network collects measurements of radioactive particulates and gases (collectively known as radionuclides) present in the atmosphere; through this, compliance with the Comprehensive Nuclear-Test-Ban Treaty (CTBT) can be verified. The radionuclide sub-network consists of 120 sensors across 80 locations, supported by 16 measurement laboratories. All radionuclide stations make use of a form of γ-ray spectroscopy to measure radionuclides from samples; this remains largely unchanged since the network was first established 25 years ago. Advances in sampling and spectroscopy systems can yield improvements to the sensitivity of the network to detect a nuclear explosion. This paper summarises the status of the IMS radionuclide network, the current suite of technology used and reviews new technology that could enhance future iterations, potentially improving the verification power of the IMS., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

A network of specialist laboratories support the International Monitoring System (IMS) of the Comprehensive Nuclear-Test-Ban Treaty (CTBT) with re-measurements of radionuclide samples, including xenon gas. The measurement of four xenon fission product radionuclides ( 133 Xe, 135 Xe, 131m Xe and 133m Xe) can be used to detect an underground nuclear explosion. Laboratories use a range of techniques to measure the radionuclides, including beta-gamma (β-γ) coincidence spectrometry. These highly-sensitive measurements are capable of detecting concentrations of down to 500 atoms of 133 Xe in a few cm 3 of xenon. In some detector systems, detection of the metastable isomers ( 131m Xe and 133m Xe) can be more challenging due to interferences between the signatures of different radionuclides. Recent work has shown that using high-purity Germanium (HPGe) high-resolution gamma detectors, these interferences can be reduced, lowering the dependence of the detection limits on radionuclide sample isotopic composition. One downside of these detectors is the reduction in detection efficiency, which impacts the overall detection sensitivity; so assessing different detector systems is a priority for radionuclide laboratories. This work presents a coincidence detector system comprising of a plastic scintillator gas cell and a large-crystal high-purity germanium detector. The energy resolution, coincidence detection efficiency, MDA and interference factors are determined from measurements of synthetic radioxenon gas samples., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Background: Nourishing Beginnings is an integrated referral and service delivery model supporting Medicaid-eligible pregnant individuals by providing increased nutritional food access throughout pregnancy up to three months postpartum, through community health workers (CHW), who simultaneously address and provide support for social service needs of the client., Methods: To study the impact of possible interventions on food security, the program includes two distinct interventions each paired with traditional CHW services, nutrition educational materials, and provision of basic essential cooking tools. Interventions consist of either bi-weekly home food delivery from the local food bank or bi-weekly financial assistance with healthy food access navigation. The study population consists of 160 pregnant individuals (18 or older,<22 weeks pregnant; 80 per intervention arm) who were referred to a countywide Pathways Community HUB (HUB), a community-based care coordination network that uses an evidence-based model to connect at-risk individuals to resources that address medical, social, economic, and behavioral health needs. Key data collection occurs at baseline, eight weeks after intervention begins, near delivery (36-38 weeks gestation), and three months postpartum. Intervention groups are compared to each other as well as against HUB historical controls and a concurrent matched sample from local Medicaid data., Conclusion: The goal of Nourishing Beginnings is to improve long-term health outcomes (i.e., maternal and infant) both directly and mediated through a set of proximal outcomes, including prenatal care, food security, diet and nutrition, reported race discrimination and psychosocial factors including depression, stress, healthy eating self-efficacy, and social support. Clinical Trials #: NCT05341960., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

A high-resolution β - γ coincidence spectrometry system has been set-up and calibrated at the UK CTBT Radionuclide Laboratory (known as GBL15) at AWE. The system has been configured specifically to measure the signatures of radioxenon isotopes that can be indicative of a nuclear explosion. The high purity germanium (HPGe) and PIPSBox detectors have been placed in an ultra-low-background lead shield to reduce the background count-rate and new software allows the combination of signals from four detectors (two HPGe detectors and two silicon-based detectors) to cover a larger solid angle. Measurements of samples of radioxenon isotopes are used to realise an improved detection efficiency and background acquisitions have demonstrated the achievable detection limits to reach 1.3 mBq for 133 Xe and ≤0.3 mBq for the metastable isomers 131m Xe and 133m Xe. Due to the improved energy resolution in both photon and electron detectors, the detection sensitivity remains high in the presence of interfering signals from other radioxenon isotopes, such as those that may be present due to the significant levels of atmospheric radioxenon in parts of the world. This paper summarises the detector setup, efficiency calibration measurements and determination of the limits of detection. This work demonstrates the benefits of high-resolution coincidence detector systems for re-measurement of samples from the CTBT International Monitoring System (IMS) - improved detectability of metastable isomers 131m Xe and 133m Xe in the presence of 133 Xe, compared to the current laboratory system., (Crown Copyright © 2022. Published by Elsevier Ltd. All rights reserved.)

The United Kingdom (UK) National Data Centre (NDC) operates a series of custom-developed software tools for the automatic processing, analysis, archiving and interpretation of radionuclide (RN) data from the International Monitoring System (IMS) - the primary instrument for verification of the Comprehensive Nuclear-Test-Ban Treaty (CTBT). The software in-use at the NDC includes an RN Pipeline for the retrieval, analysis, categorisation and archiving of noble gas and particulate radionuclide data. On the identification of a treaty-relevant radionuclide detection or plume of radioxenon, a 'radionuclide detection event' is formed. A series of atmospheric transport and dispersion simulations are activated, and the data is added to the 'RN Event' database where the detection is compared with forward simulations from known or suspected radionuclide emitters. The field of regard for a radionuclide detection event is cross-checked with others to identify possible associated detections, and finally a source reconstruction tool (known as FREAR) is used to determine the source parameters - location, magnitude, emission start time and emission stop time., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Gaseous fission products have been produced via thermal neutron irradiation of a highly-enriched uranium target and extracted using a custom gas processing system for measurement on a prototype, high-resolution β - γ coincidence detection system. The gas was extracted and measured in two stages in order to measure the prompt and β - -delayed fission products. This paper presents an overview of the system used to produce gaseous fission products, and the results of the advanced coincidence spectrometry techniques used to identify and quantify decays from the radionuclides produced, including the noble gases 85 Kr, 85m Kr, 88 Kr, 133 Xe, 135 Xe, 133m Xe and 135m Xe, as well as 133 I and 88 Rb. The measurements were validated by determination of the nuclear decay half-lives, specifically for the ground state decay of 135 Xe, which was found to be 9.15(49) hours and consistent with the literature value. This work demonstrates the UK capability to produce gaseous radionuclides for quality assurance and calibration purposes in Radionuclide Laboratories supporting the Comprehensive Nuclear-Test-Ban Treaty (CTBT)., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Radioxenon activity concentrations are monitored globally using the International Monitoring System (IMS) of the Comprehensive Nuclear-Test-Ban Treaty Organisation, improving the monitoring community's ability to detect radionuclide signatures from an underground nuclear test (UNT). An IMS-like noble gas system is in operation at AWE (Aldermaston, UK) and can collect and measure radioxenon isotopes in environmental air samples. When operated in this mode, data produced is analysed at the UK National Data Centre (NDC) and significant detection events are flagged for further investigation. This work discusses a number of significant detection events analysed using the operational system deployed at the UK NDC, which includes atmospheric transport simulations and a real-time stack-monitoring data feed from the nearest medical isotope production facility in Belgium. A comparison of the expected radionuclide contributions with measured detections is presented, including a comparison of the isotopic ratios for the radioxenon isotopes of interest ( 133 Xe, 131m Xe, 133m Xe, 135 Xe)., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Introduction: The We Run This City (WRTC) Youth Marathon Program is a community-supported, school-based fitness program designed to increase physical activity in a large, urban school district by engaging middle school youth to train 12 to 14 weeks to run or walk 1.2 miles, 6.2 miles, or 13.1 miles of the Rite Aid Cleveland Marathon. The objective of our study was to evaluate the effect of the intervention on adolescent health., Methods: We assessed changes in obesity, health, and fitness, measured before training and postintervention, among 1,419 sixth- to eighth-grade students participating in WRTC for the first time, with particular interest in the program's effect on overweight (85th-94th body mass index percentile) or obese (≥95th percentile) students. We collected data from 2009 through 2012, and analyzed it in 2016 and 2017. Outcomes of interest were body mass index (BMI), waist-to-hip ratio (WHR), elevated blood pressure, and fitness levels evaluated by using the Progressive Aerobic Cardiovascular Endurance Run (PACER) test and the sit-to-stand test., Results: We saw significant improvements overall in fitness and blood pressure. Controlling for demographics, program event, and training dosage, BMI percentile increased among normal weight participants and decreased among overweight and obese participants (P < .001). WHR increased among obese participants, whereas reductions in blood pressure among those with elevated blood pressure were associated with higher amounts of training and lower baseline BMI., Conclusion: Even small amounts of regular physical activity can affect the health and fitness of urban youths. School-community partnerships offer a promising approach to increasing physical activity by supporting schools and making a school-based activity inclusive, fun, and connected to the broader fitness community.

Rationale, Aims, and Objectives: This study examines the degree to which a "Hawthorne effect" alters outpatient-visit content., Methods: Trained research nurses directly observed 4454 visits to 138 family physicians. Multiple data sources were used to examine the Hawthorne effect including differences in medical record documentation for observed visits and the prior visit by the same patient, time use during visits on the first versus the second observation day of each physician, and report by the patient, physician, and observer of the effect of observation., Results: Visits on the first versus the second observation day were longer by an average of 1 minute (P < .001); there were time-use differences for 4 of 20 behaviour categories evaluated. No effect of the observer on the interaction was reported by 74% of patients and 55% of physicians. Most of those that reported an affect indicated it was slight. Patients with non-White race, lower-educational level, and poorer health were more likely to report being affected by the observer., Conclusions: In a study that was designed to minimize the Hawthorne effect, the presence of an observer had little effect on most patient-physician visits but appeared to at least slightly effect a subgroup of vulnerable patients., (© 2017 John Wiley & Sons, Ltd.)

The Florida Patient Safety and Presuit Mediation Program (FLPSMP) is a mandatory mediation program designed to provide deserving patients with fast, fair compensation while limiting the healthcare provider expenses incurred during traditional litigation. Mediation occurs before litigation begins; therefore, patients with meritorious claims receive compensation often years earlier than they would with extended litigation. This early mediation fosters confidential and candid communication between doctors and patients, which promotes early fact-finding and candid discussion. The program went into effect across the University of Florida (UF) Health system on January 1, 2008. In an article previously published in this journal, we discussed the positive trend observed 2 years after the implementation of the FLPSMP. This article incorporates 5 years of data, which includes new benchmarks with state and national data, to demonstrate that the program can be used successfully as a medical malpractice solution., (© 2014 American Society for Healthcare Risk Management of the American Hospital Association.)

Context: An important phase of HIV prevention research is replicating successful interventions with different groups and in different settings., Methods: Be Proud! Be Responsible!, a successful intervention originally targeting black urban males and carried out in nonschool settings, was presented in health classes at urban and suburban schools with diverse student bodies. A group-randomized intervention study, which included 1,357 ninth and 10th graders from 10 paired schools in a Midwestern metropolitan area, was conducted in 2000-2002. Half the schools received the intervention, and half received a general health promotion program. Students' reports of their sexual behavior and selected cognitive mediators were analyzed immediately following the programs and four and 12 months later., Results: Compared with students who received the control curriculum, students exposed to the intervention reported significantly greater knowledge of HIV, other STDs and condoms; greater confidence in their ability to control sexual impulses, to use condoms and to negotiate the use of condoms; and stronger intentions to use condoms. Stratified analyses revealed that the strongest intervention impacts were on knowledge and efficacy among males and students attending suburban schools. The intervention had no impact on sexual initiation, frequency of intercourse or condom use., Conclusions: Schools are a logical and viable setting for the dissemination and acquisition of information about HIV, including prevention strategies. However, the behavioral impact of an intervention may not be easily transferable when the program is taught outside a carefully controlled, nonschool setting.

Purpose: We undertook a study to examine the impact of experiences shared between patient and physician and the value patients place on continuity of care., Methods: Data on 4,454 patients collected in The Direct Observation of Primary Care (DOPC) study conducted between October 1994 and August 1995 were analyzed to assess the value patients place on continuity, length of patient-physician relationship, and experiences shared between patient and physician., Results: A significant interaction was yielded between duration of relationship and experiences shared between patient and physician (P = .03). For all lengths of relationship with the physician, the value that patients have for continuity increased when patients indicated experiences shared with the physician. For patients who did not report experiences shared with the physician, the longer the relationship, the greater the value placed on continuity., Conclusions: The results of this study point to the importance of the experiences shared between patients and physicians and the value that patients place on continuity with their regular physician.

The effect of a rapidly changing healthcare system on personnel turnover in community family practices has not been analyzed. We describe physician and staff turnover and examine its association with practice characteristics and patient outcomes. A cross-sectional evaluation of length of employment of 150 physicians and 762 staff in 77 community family practices in northeast Ohio was conducted. Research nurses collected data using practice genograms, key informant interviews, staff lists, practice environment checklists, medical record reviews, and patient questionnaires. The association of physician and staff turnover with practice characteristics, patient satisfaction, and preventive service data was tested. During a 2-year period, practices averaged a 53% turnover rate of staff. The mean length of duration of work at the current practice location was 9.1 years for physicians and 4.1 years for staff. Longevity varied by position, with a mean of 3.4 years for business employees, 4.0 years for clinical employees, and 7.8 years for office managers. Network-affiliated practices experienced higher turnover than did independent practices. Physician longevity was associated with a practice focus on managing chronic illness, keeping on schedule, and responding to insurers' requests. No association was found between turnover and patient satisfaction or preventive service delivery rates. Personnel turnover is pervasive in community primary care practices and is associated with employee role, practice network affiliation, and practice focus. The potentially disruptive effect of personnel turnover on practice functioning, finances, and longitudinal relationships with patients deserves further study despite the reassuring lack of association with patient satisfaction and preventive service delivery rates.

Faced with a rapidly changing healthcare environment, primary care practices often have to change how they practice medicine. Yet change is difficult, and the process by which practice improvement can be understood and facilitated has not been well elucidated. Therefore, we developed a model of practice change using data from a quality improvement intervention that was successful in creating a sustainable practice improvement. A multidisciplinary team evaluated data from the Study To Enhance Prevention by Understanding Practice (STEP-UP), a randomized clinical trial conducted to improve the delivery of evidence-based preventive services in 79 northeastern Ohio practices. The team conducted comparative case-study analyses of high- and low-improvement practices to identify variables that are critical to the change process and to create a conceptual model for the change. The model depicts the critical elements for understanding and guiding practice change and emphasizes the importance of these elements' evolving interrelationships. These elements are (1) motivation of key stakeholders to achieve the target for change; (2) instrumental, personal, and interactive resources for change; (3) motivators outside the practice, including the larger healthcare environment and community; and (4) opportunities for change--that is, how key stakeholders understand the change options. Change is influenced by the complex interaction of factors inside and outside the practice. Interventions that are based on understanding the four key elements and their interrelationships can yield sustainable quality improvements in primary care practice.

Background: Despite increasing recognition of women's health needs, little is known about how primary care physicians spend time with women. Therefore, we examined differences in time use and preventive service delivery during outpatient visits by male and female patients., Methods: As part of a multimethod study of 138 family physicians, 3384 outpatient visits by adults were directly observed, medical records were reviewed, and patient surveys were performed. Time use was assessed by the Davis Observation Code, which classifies every 15 seconds into 20 behavioral categories. Receipt of health habit counseling recommended by the U.S. Preventive Services Task Force was assessed by direct observation, and eligibility was determined by chart review. Logistic regression and multivariate analysis of variance (ANOVA) were used to compare time use and preventive service delivery in visits by women vs. men., Results: Sixty-four percent of adult visits were from women. Women reported poorer physical health, had higher rates of anxiety (12.5% vs. 7.4% in men), and depression (21.9% vs. 8.4% in men), a higher percent of visits for well care (10.2% vs. 8.8% in men), and more drugs prescribed (64.8% vs. 61% in men) and raised more emotional issues than men (14.7% vs. 7.5%). After controlling for visit and patients characteristics, visits by women had a higher percent of time spent on physical examination, structuring the intervention, patient questions, screening, and emotional counseling. Visits by men involved a higher percent of time spent on procedures and health behavior counseling. More eligible men than women received exercise, diet, and substance abuse counseling. Patients of female physicians exhibited gender differences in only one category of how time was spent (substance abuse), whereas among patients of male physicians, gender differences were noted in 10 of the 20 categories., Conclusions: Outpatient visits by women differ from those of men in ways that reflect women's unique healthcare needs but also raise concern about unequal delivery of health habit counseling for diet and exercise.

Objective: To determine whether outpatient visits by elders seeing community family physicians differ in length or content from visits by younger patients; socioemotional preferences predict visit content; and satisfaction correlates with visit content differentially across age., Methods: In a multimethod cross-sectional study of 84 community family practices in northeastern Ohio, 3453 adult patient visits with 138 community family physicians were observed; 2362 of these patients completed self-report questionnaires. Three age groups were compared: 18 to 64, 65 to 74, and over 74 years. Length and content of the physician-patient encounter was determined using the Davis Observation Code (DOC); satisfaction was assessed using the MOS 9-item Visit Rating Scale., Results: Controlling for reason for visit and demographics, visit length averaged 10.7 minutes for each group. Visit content differed significantly on 13 of 20 DOC codes between one of the older groups and the younger group; in 4 instances, content varied between the 2 older groups. Although visit content varied as predicted by socioemotional theory, no consistent patterns of association between visit content and satisfaction emerged., Discussion: Older patient visits differ from those of younger patients as might be predicted by socioemotional selectivity theory; however, there was little association of visit content with patient satisfaction.

Background: The long-term effect of most interventions has not been studied. Changes due to interventions to improve patient care may revert to baseline after the intervention stimulus ends. This analysis reports the 24-month follow-up of a practice-tailored intervention to increase preventive service delivery rates., Design: Group randomized clinical trial with 24-month follow-up of intervention sites., Setting/participants: Seventy-seven community family practices in northeast Ohio., Intervention: Practice-individualized facilitation of implementation of tools and approaches., Main Outcome Measures: Summary scores of health habit counseling, screening, and immunization services recommended by the U.S. Preventive Services Task Force that were up to date for consecutive patients during randomly selected chart review days., Results: Previously reported increases in global preventive service delivery rates, health habit counseling, and screening rates at 12 months were sustained after 24 months., Conclusions: A practice-individualized approach can result in sustainable increases in rates of preventive service delivery, even 1 year after the outside intervention stimulus ends. Tailoring of approaches to the unique characteristics of each practice may result in institutionalization of changes.

Background: Inconsistent findings on the value of continuity of care can stem from variability in its importance to different subsets of patients. We therefore examined the association among patient and visit characteristics and extent to which the patient valued continuity of care (PVC). We hypothesized that continuity would be more important to patients who are older, sicker, and female, who have established a relationship with their physician, and whose visit addresses more complex problems., Methods: A study of 4,454 consecutive outpatient visits to 138 community-based family physicians used a 3-item measure (alpha = 0.67) of PVC. The patient's report of (1) the adequacy of primary care for the visit and (2) satisfaction with the physician on that visit was assessed with multiple measures. Analyses examined the associations among PVC and patient-reported satisfaction with the physician and adequacy of the visit., Results: Extremes of age, female sex, less education, Medicare and Medicaid insurance, number of chronic conditions and medications, number of visits to the practice, and worse self-reported health status were associated with higher value placed on continuity (P < .001 for all except sex, where P = .015). Patients who value continuity and did not see a regular physician rated adequacy of the visit lower (for 7 attributes of the visit) than those seeing their own physician. Satisfaction with the physician for the visit was greatest among patients who value continuity and saw their regular physician., Conclusions: Continuity of physician care is associated with more positive assessments of the visit and appears to be particularly important for more vulnerable patients. Health care systems and primary care practices should devote additional effort to maintaining a continuity relationship with these vulnerable patients.

Objective: To identify differences in time use during acute and chronic care visits., Population: Patients coming to outpatient offices of physician members of a practice-based research network in Ohio., Measures: Direct observation and coding of physician activities during acute and chronic care visits., Results: Time use varied by visit type with more time spent on compliance assessment, negotiation, and nutrition advice during chronic care visits. Acute care visits included more time for procedures, physical examination, feedback on test results and health education., Conclusion: Physicians structure their use of time to fit the differing goals of acute and chronic care visits.

Background: We know little about the activities that occur during asthma-related visits with primary care physicians. A better understanding of how time is spent during visits for asthma may facilitate the design of programs to enhance asthma disease management., Objective: To describe the content of asthma visits made to family physicians., Methods: Research nurses directly observed consecutive outpatient visits during two separate days in the offices of 138 community family physicians. Time was classified into 20 different behavioral categories using the Davis Observation Code, and compared for visits for asthma, visits for other chronic conditions, and visits for non-asthma-related acute illnesses during 3035 visits by patients of all ages., Results: Visits for asthma shared several characteristics with visits for other chronic conditions but were longer than visits for other chronic illnesses or for acute illness. Asthma visits were distinguished from both acute care and other chronic care visits by a greater percentage of time spent discussing patient compliance, evaluating patient knowledge, and providing smoking assessment and cessation advice., Conclusions: Visits for asthma are structured differently than acute care visits and specifically address issues important to asthma self-management. Future quality improvement initiatives should recognize, affirm, and enhance many current behaviors by family physicians, while working to expand specific areas of care that still fall short of asthma care guidelines.

Background: Despite the large potential of dietary changes to reduce morbidity and mortality, the frequency, time spent, and factors associated with nutrition counseling in primary care are not well studied., Methods: In a cross-sectional study of 84 family physician practices in northeast Ohio, nutrition counseling was measured by direct observation on 2 days for all consecutive ambulatory visits. The frequency, time spent, and patient and visit characteristics associated with nutrition counseling were determined., Results: Among 138 family physicians, only 6% included nutrition counseling in the majority (>50%) of patient encounters. Among 3475 consecutive outpatient visits in adults, nutrition counseling occurred in 24% of all patient visits, 17% of visits for acute illnesses, 30% of chronic illness visits, and 41% of well-care visits. The average time spent on nutrition counseling was 55 seconds, ranging from <20 seconds to >6 minutes. Nutrition counseling occurred in 45% of visits for diabetes, 25% of visits for cardiovascular disease, 31% of visits for hypertension, 26% of prenatal visits, and 33% of visits by obese patients (body mass index >30). Nutrition counseling was more likely to occur during visits by patients who were older or had diabetes mellitus, during visits for well care or chronic illness, and during longer visits., Conclusion: Despite considerable variability from physician to physician, nutrition counseling occurs in approximately one fourth of all office visits to family physicians. The observed efforts by family physicians to focus nutrition counseling on high-risk patients may increase its impact.

Significant disparities in health care based on patient socioeconomic status have been documented. The extent to which physician behavior accounts for these differences is not known. We examined the impact of patient socioeconomic status, measured by years of education, on physician behavior assessed by direct observation of office visits, chart audits, and patient reports among 138 family physicians in 84 practices. Outcomes included time use measured with the Davis Observation Code, delivery of preventive services recommended by the US Preventive Services Task Force, satisfaction assessed with the MOS 9-item Visit Rating Scale, and delivery of attributes of primary care measured by the Components of Primary Care Index. After controlling for patient characteristics among 2538 visits by adult patients who returned questionnaires, a high school education or less was associated with slightly greater proportion of time spent on physical examination and providing nutrition counseling, and less time on patient questions, assessing patient health knowledge, negotiation, and exercise counseling. This indicates that physicians adopt a more directive style with less educated patients. Screening tests were provided at lower rates among less educated patients, but there were no differences in rates of health habit counseling or immunization services delivered and no differences in delivery of patient-reported components of primary care. Less educated patients had similar overall visit satisfaction, but were slightly less likely to have their expectations met. These show that patients' education has relatively small, but potentially important, effects on the outpatient delivery of primary care.

Objectives: To determine whether family physicians provide different ambulatory care to patients with health insurance from managed care organization (MCO) versus fee-for-service (FFS) plans., Study Design: Multimethod cross-sectional observational study., Patients and Methods: A total of 4454 patients made office visits to 138 family physicians in northeastern Ohio. Direct observation with the Davis Observation Code and a structured checklist were used to assess the process of care. Patient satisfaction was measured with the Medical Outcomes Study 9-Item Visit Rating Form., Results: Among 1588 patients with MCO insurance and 876 with FFS insurance, no differences were noted in the number of visits per year, length of visits, percentage of visits for well care, or the percentage of visits in which medicines were prescribed in analyses controlling for patient mix. Visits by patients with MCO insurance were more likely to involve referrals to another physician than visits by patients with FFS insurance. Patient satisfaction and time use during visits were comparable for the 2 groups., Conclusions: Managed care insurance appears to increase involvement of the primary care provider in the referral process. However, in a healthcare market with moderate managed care penetration in which the same physicians see patients with different types of insurance, the process of care is affected little by type of insurance coverage.

Background: Health behavior advice can potentially prevent a large burden of illness, but the acceptability of this advice to patients is not well understood. This study assessed whether physician discussion of behavioral risk factors decreases patient satisfaction with the outpatient visit., Methods: In a cross-sectional study of 2,459 consecutive adult outpatient visits to 138 community family physicians in Northeast Ohio, the association of health habit counseling, measured by direct observation, with patient satisfaction, assessed by a modified subscale of the MOS 9-item visit rating scale, was calculated by logistic regression., Results: In analyses controlling for patient mix, discussion of diet, exercise, alcohol and other substance use, sexually transmitted disease, and HIV prevention was not associated with patient satisfaction. Patients who were asked about their tobacco use or counseled about quitting were more likely to be very satisfied with the physician., Conclusions: Discussion of health behavior change, as practiced by community family physicians, is not associated with diminished patient satisfaction. In fact, tobacco use assessment and cessation counseling are associated with greater satisfaction., (Copyright 2001 American Health Foundation and Elsevier Science.)

Background: Although data are available on rates of delivery of preventive services by primary care physicians, the proportion of services delivered because of related symptoms or signs, rather than for primary or secondary prevention of disease is not known., Methods: Research nurses directly observed 4454 consecutive visits to 138 practicing family physicians. Direct observation was used to identify delivery of 36 different services recommended by the U.S. Preventive Services Task Force and to assess whether delivery of these services was associated with related signs or symptoms., Results: One or more preventive services were delivered in 33% of visits, with rates ranging from 0.2% (HIV prevention) to 19.9% (tobacco counseling). In contrast to pure prevention, services were frequently performed for assessment or care of symptoms or signs, with the ratio ranging from 0% (eye examination; car seat, poison control, and HIV prevention counseling) to 66.7% (hearing test). Physicians varied considerably in the frequency at which their delivery of recommended preventive services was associated with patient symptoms, from 0% to 100% for screening services and from 0% to 100% for counseling services., Conclusions: Because of the illness focus of most primary care visits, preventive service delivery is often associated with related signs or symptoms. Care of illnesses appears to present an important impetus and perhaps teachable moments for providing preventive care. Clinician variability in preventive service delivery for patient symptoms shows an opportunity to improve the primary and secondary prevention focus of practice to meet public health prevention goals.

Racial disparities in the process and outcome of health care may be partially explained by differences in time use during outpatient visits by African-American and white patients. This study was undertaken to determine whether physicians use their time in clinical encounters with African-American patients differently than with white patients. This study was a multimethod, cross-sectional study conducted between October 1994 and August 1995 in 84 family practices in northeast Ohio. Participants were 4,352 white and African-American outpatients visiting 138 physicians. Time use during the patient visit was measured by the Davis Observation Code, which categorizes every 20-second interval into 20 different behavioral categories. Among 3,743 white and 509 African-American patients, after adjustment for potential confounders, visits by African-American patients were slightly longer than visits with white patients (10.7 vs. 10.1 minutes, p = 0.027). After further adjustment for multiple comparisons, physicians spent a lower proportion of time intervals with African-American patients as compared to white patients planning treatment (29.0% vs. 32.1%, p < 0.001), providing health education (16.4% vs. 19.7%, p < 0.001), chatting (5.2% vs. 7.6%, p < 0.001), assessing patients' health knowledge (0.8% vs. 1.2%, p < 0.001), and answering questions (5.8% vs. 6.9%, p = 0.002). Physicians spent relatively more time intervals with African-American patients discussing what is to be accomplished (9.3% vs. 7.6%, p < 0.001) and providing substance use assessment and advice (0.8% vs. 0.4%, p = 0.001). In conclusion, physicians spend time differently with African-American as compared with white patients. These differences may represent appropriate tailoring of services to meet unique needs, but could also represent racial bias.

Objective: Poor quality of diabetes care has been ascribed to the acute care focus of primary care practice. A better understanding of how time is spent during outpatient visits for diabetes compared with visits for acute conditions and other chronic diseases may facilitate the design of programs to enhance diabetes care., Research Design and Methods: Research nurses directly observed consecutive outpatient visits during two separate days in 138 community family physician offices. Time use was categorized into 20 different behaviors using the Davis Observation Code (DOC). Time use was compared for visits for diabetes, other chronic conditions, and acute illnesses during 1,867 visits by patients > or =40 years of age., Results: Of 20 DOC behavioral categories, 10 exhibited differences among the three groups. Discriminant analysis identified two distinct factors that distinguished visits for chronic disease from visits for acute illness and visits for diabetes from those for other chronic diseases. Compared with visits for other chronic diseases, visits for diabetes devoted a greater proportion of time to nutrition counseling, health education, and feedback on results and less time to chatting. Compared with visits for acute illness, visits for diabetes were longer and involved a higher proportion of dietary advice, negotiation, and assessment of compliance., Conclusions: Visits for diabetes are distinct from visits for other chronic diseases and acute illnesses in ways that may facilitate patient self-management. Novel quality-improvement interventions could support and expand existing differences between family physicians' current approaches to care of diabetes and other chronic and acute illnesses.

Background: The potential of primary care practice settings to prevent disease and morbidity through health habit counseling, screening for asymptomatic disease, and immunizations has been incompletely met. This study was designed to test a practice-tailored approach to increasing preventive service delivery with particular emphasis on health habit counseling., Design: Group randomized clinical trial and multimethod process assessment., Setting/participants: Seventy-seven community family practices in northeast Ohio., Intervention: After a 1-day practice assessment, a nurse facilitator met with practice clinicians and staff and assisted them with choosing and implementing individualized tools and approaches aimed at increasing preventive service delivery., Main Outcome Measure: Summary scores of the health habit counseling, screening and immunization services recommended by the U.S. Preventive Services Task Force up to date for consecutive patients during randomly selected chart review days., Results: A significant increase (p=0.015) in global preventive service delivery rates at the 1-year follow-up was found in the intervention group (31% to 42%) compared to the control group (35% to 37%). Rates specifically for health habit counseling (p=0.007) and screening services (p=0.048) were increased, but not for immunizations., Conclusions: An approach to increasing preventive service delivery that is individualized to meet particular practice needs can increase global preventive service delivery rates.

Background: Participatory decision-making (PDM), a widely held ideal, depends on physician facilitation of patient participation. However, little is known about how PDM facilitation is actualized in outpatient primary care., Objectives: The objective of this study was to describe the prevalence of physician facilitation of PDM in community family practices and associated physician, patient, and visit characteristics., Research Design: This was a cross-sectional observational study., Subjects: The study included 3,453 patients seen by 138 family physicians in 84 community practices., Main Outcome Measures: Research nurses directly observed PDM facilitation in consecutive adult outpatient visits. The association between PDM facilitation and patient, physician, and visit characteristics was assessed with multilevel multivariable regression., Results: PDM facilitation occurred during 25% of observed patient visits. Rates varied considerably among physicians, from 0% to 79% of visits. Patient satisfaction was not associated with PDM facilitation. In multivariable analyses, employed physicians, chronic illness visits, longer visit duration, and visits involving referral were independently associated with PDM facilitation. Visits in which greater time was spent planning treatment and conducting health education were also more likely to involve facilitation of PDM., Conclusions: Community family physicians facilitate PDM at highly variable rates but focus it on patients with the greatest medical needs and most complex levels of decision making. This selective approach appears to meet patient expectations, because PDM facilitation and patient satisfaction are not associated. If patient participation is to be more widely incorporated into outpatient primary care, it must be addressed within the complexity and multiple demands of community practice.

Background: Data on preventive service delivery in primary care practice have been limited by indirect methods of measurement. This study describes directly observed rates of preventive service delivery during outpatient visits to community family physicians., Methods: In a multimethod cross-sectional study, research nurses directly observed consecutive patient visits in the offices of 138 family physicians in Northeast Ohio. Patient eligibility for services recommended by the U.S. Preventive Services Task Force was determined from medical record review. Service delivery was assessed by direct observation of outpatient visits. Rates of delivery of specific preventive services were computed. Global summary measures were calculated for health habit counseling, screening, and immunization services., Results: Among 4,049 visits by established patients with available medical records, wide variation was observed among rates of different preventive services delivered during well-care visits. During illness visits, rates were uniformly low for all preventive services. Counseling services were delivered at only slightly lower rates during illness visits compared to well visits. Patients were up to date on 55% of screening, 24% of immunization, and 9% of health habit counseling services., Conclusion: Rates of preventive service delivery are low. Illness visits are important opportunities to deliver preventive services, particularly health habit counseling, to patients. Preventive service delivery summary scores are useful in providing a patient population perspective on the delivery of preventive services and in focusing attention on delivery of a comprehensive portfolio of services., (Copyright 2000 American Health Foundation and Academic Press.)

Purpose: To identify characteristics of physicians, patients, and visits associated with obtaining family history information in community family practice., Methods: Research nurses directly observed 4,454 patient visits to 138 family physicians and reviewed office medical records., Results: Family history was discussed during 51% of visits by new patients and 22% of visits by established patients. Physicians' rates of family history-taking varied from 0% to 81% of visits. Family history was more often discussed at well care rather than illness visits. The average duration of family history discussions was <2.5 minutes., Conclusions: These data can form the basis for realistic interventions to increase the use of family history in primary care.

Background: Previous research has identified 2 styles of family physicians' focus on the patient's family: (1) using the family history as the context of care of the patient; and (2) maintaining a family orientation with the family as the unit of care. The purpose of our study was to determine whether these styles affect patient outcomes and time use during outpatient visits., Methods: In a cross-sectional study, data on 4454 outpatient visits to 138 community family physicians were collected using direct observation, patient and physician questionnaires, and medical record review. We computed partial correlations between the physician's family practice style score and patient outcomes for delivery of preventive services, patient visit satisfaction, and patient-reported delivery of specific components of primary care. We controlled for relevant patient characteristics., Results: The patients of the physicians using either practice style had similar levels of satisfaction with coordination of care and interpersonal communication, and their value of continuity of care was comparable. Patients of physicians with a family-history style, however, rated their physicians lower on a measure of in-depth knowledge of the patient and family but higher on preventive services delivery. Differences in time use during the visit reflected how these styles were manifested during the outpatient visit., Conclusions: The different styles physicians use to focus on the family affect the process and outcomes of patient care. This difference may be explained by the developmental life cycle of family physicians, as younger physicians may be more focused on family history and older physicians may have a more family-oriented focus. Physicians may need to find alternate ways of meeting those patient needs not well met by their predominant practice style.

Objective: To compare the concordance of family physicians' billing for evaluation and management services with medical record documentation., Design: Multi-method, cross-sectional observation study., Setting: Eighty-four family practices in northeast Ohio., Participants: Four thousand fifty-four outpatients visiting 138 family physicians., Main Outcome Measure: The degree of concordance between evaluation and management Current Procedural Terminology codes billed by physicians, with those codes assigned by trained research nurses using American Medical Association criteria to code medical records for the same visits., Results: Discrepancies between the multifactorial nature of family practice outpatient visits and the Current Procedural Terminology coding criteria, which dictate overcoding for depth rather than breadth, made coding difficult (multiple-rater kappa statistic between research nurses = 0.36). Among 4137 outpatient visits with complete billing information, 57% of the Current Procedural Terminology codes generated by medical record review were concordant with the actual billing code assigned by physicians. Undercoding and overcoding occurred at a similar frequency (21% and 19%, respectively) and differed by more than 1 code in fewer than 4% of visits. Visits by new patients were more likely to be inaccurately coded than visits by established patients., Conclusions: Record documentation by community family physicians largely reflects the level of services billed using evaluation and management codes. Undercoding is as common as overcoding. Efforts from regulatory agencies should be redirected from penalizing physicians for overcoding to focusing on the development of coding criteria that reflect the multifactorial nature of outpatient primary care practice.

Background: Although physical activity is important for the prevention and management of a variety of common chronic diseases, the prevalence and patient and visit characteristics associated with provision of physical activity advice by community family physicians is not well understood., Methods: In a cross-sectional multi-method study of 138 family physicians in northeast Ohio, exercise advice was measured by direct observation and patient report of consecutive patient visits to 138 practicing family physicians. The association of exercise advice with patient and visit characteristics, assessed by direct observation, medical record review, patient exit questionnaire, and billing data, was determined by logistic regression analysis., Results: In 4,215 visits by patients older than 2 years of age, exercise counseling was observed during 927 visits (22.3%), but reported by only 13% of patients returning questionnaires. The mean time spent counseling about exercise was 0.78 minutes, with a range of 0.33 to 6.00 minutes (SD = 0.67). Exercise advice was more common during longer visits, visits for well care, and visits by patients who were older, male, and had chronic illnesses for which lack of physical activity is a risk factor., Conclusions: Exercise counseling is relatively common during outpatient visits to family physicians, and is more commonly given to patients with risk factors. Multiple patient visits over time present opportunities to integrate exercise counseling among the competing demands of primary care practice.

The purpose of the present study was to use an Eimeria maxima light microscopic lesion scoring (MLS) system to measure magnitudes of E. maxima infection in sections of broiler chick intestine, and to help make decisions regarding the efficacy of an E. maxima abatement programme. Chicks with whole-body pallor, elevated feed conversion ratios (10 points higher than normal) and reduced body sizes (0.1 kg smaller than normal) had light microscopic lesions caused by E. maxima infections. These intestine segments had high Eimeria maxima MLSs. High scores, coupled with the fact that there was no microscopic evidence for the presence of gastrointestinal pathogens other than E. maxima, allowed us to conclude that E. maxima was the cause of the signs observed. When changes in the pharmacotherapy of the coccidiosis abatement programme were made (substitution of one ionophore coccidiostat for another ionophore coccidiostat), the MLSs were significantly (P < 0.01) reduced, and chicks returned to their normal colour (yellow) and normal target body size (2.091 kg) on a normal feed conversion ratio (2.06). It was decided that the MLS is suitable for use in health programmes that depend upon detection of E. maxima in broilers.

Seventy-five 3-day-old broiler chicks and twenty specific pathogen-free leghorn chicks were injected with 0.5 ml of a homogenate, prepared from organs from broilers diagnosed with naturally-occurring multicentric histiocytosis (MH). Equal numbers of uninjected broiler and leghorn chicks (controls) were maintained in adjacent pens. Ten weeks later, nine broilers had well-developed gross and microscopic MH lesions. The distribution and histological appearance of lesions in these experimental chicks was similar to lesions described in naturally occurring field cases. Six leghorns had gross lesions similar to those found in their broiler counterparts; however, in the leghorns, the cellular masses contained more lymphocytes and, additionally, masses were found in the gizzard musculature. One gizzard contained a sarcoma. Broiler chickens with MH weighed less than their control counterparts and were more likely to be anaemic. Sequences specific for reticuloendotheliosis viruses (REV) were found in the MH homogenate, in organs from most affected experimental leghorns and broilers, and in organs from a control broiler. However, REV were not isolated from these tissues, nor were specific antibodies for REV or avian leukosis/sarcoma viruses (ALV) found in chick serum. Leukosis/sarcoma viruses were isolated from some MH-affected experimental leghorns and broilers. Sequences specific for Marek's disease herpesvirus were not identified by polymerase chain reaction. The aetiology of MH remains unknown.

Objectives: To determine the rate of health-habit counseling of adolescents seeing community family physicians and to identify the factors associated with the delivery of recommended preventive counseling services., Design: Cross-sectional multimethod study emphasizing direct observation of patient visits., Setting: Community family practices in northeast Ohio., Patients or Other Participants: Adolescents (n = 445) aged 11 to 21 years who were being seen for outpatient visits to community family physicians (n = 119) during 2 days of observation by trained research nurses., Main Outcome Measure: Direct observation of the delivery of clinical preventive counseling services recommended by the Guidelines for Adolescent Preventive Services., Results: During the 445 visits made by adolescents, the most frequently delivered counseling service was exercise advice (13%). At least 1 health-habit counseling service was delivered during 38% of visits. In multivariable analyses, older patient age was strongly associated with increased service delivery. Visits for well care, longer visits, and new patient visits were also associated with the provision of counseling. Visits including preventive counseling services were on average 2.5 minutes longer than visits without preventive counseling., Conclusions: The rates of delivery of preventive counseling services in clinical practice were low, raising concern about the feasibility of current recommendations. The practical implementation of prevention guidelines may require a greater use of well-care visits and longer patient visits than are currently used in community family practice.

Both lungs of a 5-wk-old broiler chicken contained miliary, round, white tumors. Microscopically, these masses were composed of compactly arranged cells with round to oval nuclei and indistinct cytoplasmic borders. Immunohistochemically, tumor cells were positive for vimentin but negative for cytokeratin, S-100 protein, neuron-specific enolase, smooth muscle actin, and muscle-specific actin. Ultrastructurally, tumor cells were separated by collagen bands and some contained collagen fibrils. These results suggest that the primitive mesenchymal cells composing these sarcomas may have originated from precursors of interstitial cells or fibroblasts of the interparabronchial or interatrial septa. DNA was extracted from paraffin-embedded tissues and probed for sequences specific for Marek's disease virus, reticuloendotheliosis viruses, exogenous avian leukosis viruses, and subgroup J avian leukosis viruses. Only sequences specific for subgroup J avian leukosis viruses were identified in the DNA extracted from tumors and surrounding lung.

Background: This study's purpose was to identify patient and visit characteristics associated with the use of illness visits as opportunities for the delivery of preventive services and to determine if time is allocated differently during illness visits that make use of these opportunities., Methods: Research nurses directly observed the delivery of preventive services during consecutive patient visits on 2 separate days in the offices of 138 family physicians. Data on patient eligibility for preventive services were collected by medical record review. Time use during patient visits was categorized using the Davis Observation Code (DOC). Patient characteristics, visit characteristics, and time use were compared during illness visits in which at least one service recommended by the US Preventive Services Task Force was delivered to eligible patients, compared with illness visits during which no recommended preventive services were delivered., Results: Preventive services were delivered during 32% of 3547 illness visits. Adults, overweight patients, those who smoke or drink alcohol, new patients, and patients with fewer visits in the past year were more likely to receive preventive services. Patient request was also associated with increased delivery of preventive services. The presence of another family member, visits for an acute illness, and the prescription of a drug were associated with a decreased likelihood of a patient's receiving preventive services. When preventive services were delivered during illness visits, less time was spent on chatting, procedures, and physical examination, and more time was spent on history-taking., Conclusions: Family physicians take greater advantage of opportunities for the delivery of preventive services during the illness visits of high-risk patients. The results of our study suggest strategies that could be used to expand the opportunistic delivery of preventive services to other patients and types of visits.