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Patients with peripheral artery disease (PAD) face a range of treatment options to improve survival and quality of life. An evidence-based shared decision-making tool (brochure, website, and recorded patient vignettes) for patients with new or worsening claudication symptoms was created using mixed methods and following the International Patient Decision Aids Standards (IPDAS) criteria. We reviewed literature and collected qualitative input from patients ( n = 28) and clinicians ( n = 34) to identify decisional needs, barriers, outcomes, knowledge, and preferences related to claudication treatment, along with input on implementation logistics from 59 patients and 27 clinicians. A prototype decision aid was developed and tested through a survey administered to 20 patients with PAD and 23 clinicians. Patients identified invasive treatment options (endovascular or surgical revascularization), non-invasive treatments (supervised exercise therapy, claudication medications), and combinations of these as key decisions. A total of 65% of clinicians thought the brochure would be useful for medical decision-making, an additional 30% with suggested improvements. For patients, those percentages were 75% and 25%, respectively. For the website, 76.5% of clinicians and 85.7% of patients thought it would be useful; an additional 17.6% of clinicians and 14.3% of patients thought it would be useful, with improvements. Suggestions were incorporated in the final version. The first prototype was well-received among patients and clinicians. The next step is to implement the tool in a PAD specialty care setting to evaluate its impact on patient knowledge, engagement, and decisional quality. ClinicalTrials.gov Identifier: NCT03190382

The general discourse in most countries is that technological surveillance during pregnancy and childbirth is synonymous with safety, while women's individual experiences are less likely regarded as critical. The aim of this ethnographic study at a birth center in Germany was to describe how midwives and their clients construct risk and safety. The data collection methods included participant observation and semi-structured interviews. ‘Putting the baby back in the body’ was the major theme that emerged, supported by three sub-themes. The women in this study relied on scans at the beginning of pregnancy to make their baby real to them, but became more confident in their capacity to sense their baby after experiencing the first fetal movements. The midwives fostered this confidence by using interactive palpation of the abdomen with the women, thus supporting their individual sensory experience, and, in the midwives’ view, enhancing overall safety during pregnancy and at birth.

In maternal healthcare, structural patriarchy provides only a partial explanation for the violence that women are increasingly expressing, revealed in data showing that women are more likely to express abuse from female rather than male healthcare deliverers. To a large degree, the enforcement of standardised care has contributed to an increased disengagement between those delivering healthcare services and their clients. Personal relationships between midwives and the women they care for are strained, as the threat of litigation along with the intensification and acceptance of medicalised, standardised care focusing on risk has created an atmosphere of mistrust. Technological surveillance also further detaches midwives from their vocational roots, as their skills in supporting physiological pregnancy and birth diminish in favour of what is considered their professional duty: the monitoring of women. To reduce obstetric abuse, vocational practice that resists the ‘othering’ of childbearing women is needed to answer to the individual needs of women, improve outcomes, and create the circumstances at birth for women to have positive, safe, and profound experiences.

Introduction: Patients with peripheral artery disease (PAD) are known to have the highest cardiovascular risk across the spectrum of patients with atherothrombotic disease. Hypertension (HTN) management is currently not a key performance measure for PAD despite being a common risk factor in patients with PAD. As there is lack of data on the management of blood pressure (BP) in PAD, we prospectively studied BP management among patients with new or worsening symptomatic PAD. Methods: In PORTRAIT, patients were evaluated for new or worsening PAD symptoms in 16 PAD clinics across the US, Netherlands and Australia. BP was measured in clinic and at time of enrollment. HTN was defined as prior history of HTN, use of antihypertensives or [SBP ≥140 or DBP ≥90 mmHg per old guidelines; or SBP≥130 or DBP≥80 per new ACC/AHA guidelines]. Untreated HTN was defined as patients with HTN who were not on antihypertensive therapy. HTN with BP Results: Among 1006 participants with documented BP, the prevalence of HTN increased from 96% to 98% based on old and new definitions respectively. BP control decreased from 51% (old) to 31% (new definition). Beta blockers (66.1%) were the most commonly used antihypertensive drug class (Table 1). Overall, 6.5% and 8.3% of HTN patients were untreated based on the old and new definitions respectively. Mean BP was lowest in the US compared to Netherlands and Australia (135/73 ± 21/11 mmHg, 146/76 ± 22/12, 151/80 ± 19/10, p Conclusion: The prevalence of HTN among PAD patients with new or worsening symptoms was high independent of BP cut off. Based on new HTN definition, only 1 in 3 HTN patients in this cohort have controlled BP. There was significant heterogeneity in BP control and rates of untreated hypertension differed by country independent of HTN definition. This suggests an opportunity to improve BP control in PAD patients.

Background: Health status outcomes, including symptoms, functional status, and quality of life, are critically important outcomes from patients’ perspectives. The PORTRAIT study (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) was designed to prospectively define health status outcomes and examine associations between patients’ characteristics and care to these outcomes among those presenting with new-onset or worsened claudication. Methods and Results: PORTRAIT screened 3637 patients with an abnormal ankle-brachial index and new, or worsened, claudication symptoms from 16 peripheral arterial disease (PAD) specialty clinics in the United States, the Netherlands, and Australia between June 2, 2011, and December 3, 2015. Of the 1608 eligible patients, 1275 (79%) were enrolled. Before treatment, patients were interviewed to obtain their demographics, PAD symptoms and health status, psychosocial characteristics, preferences for shared decision-making, socioeconomic, and cardiovascular risk factors. Patients’ medical history, comorbidities, and PAD diagnostic information were abstracted from patients’ medical records. Serial information about patients’ health status, psychosocial, and lifestyle factors was collected at 3, 6, and 12 months by a core laboratory. Follow-up rates ranged from 84.2% to 91%. Clinical follow-up for PAD-related hospitalizations and major cardiovascular events is ongoing. Conclusions: PORTRAIT systematically collected serial PAD-specific health status data as a foundation for risk stratification, comparative effectiveness studies, and clinicians’ adherence to quality-based performance measures. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01419080.

Background: There is no ‘gold-standard’ treatment for Rutherford Grade I (mild-severe claudication) peripheral arterial disease (PAD), with different treatments associated with different benefits and risks. The choice of treatment should therefore be sensitive to patients’ preferences and supported by shared-decision making. It is, however, unknown to what degree patients seeking treatment for claudication symptoms want to be involved in the medical decision process for their PAD treatment. Method: The international PORTRAIT study enrolled 1142 patients with new or an exacerbation of claudication symptoms between June 2, 2011 and September 25, 2015 from 17 PAD specialty clinics. Upon PAD evaluation, patients were interviewed to assess preferences for shared decision making using the Preferences for Shared Decision Making Scale. Information on demographic, socio-economic, and clinical factors were obtained from medical records and interviews. A multivariable log-binomial regression model examined patient- and site-level characteristics associated with an autonomous or shared vs. a passive decision-making role when selecting PAD treatment. Results: Among 1142 patients, 56% (n=638) preferred shared or autonomous decision-making, whereas 44% (n=504) preferred that the doctor alone (passive role) made the decision for their PAD treatment. Whether or not patients preferred a shared/autonomous decision-making role varied greatly across countries (The Netherlands 33%; Australia, 43%; US, 70%; P Conclusion: While the majority of patients prefer an active role in the medical decision process for their PAD treatment, preferences differed markedly by geographic region and education level. US Patients and more educated patients preferred a shared/autonomous decision-making role. Given the observed variability, it is important that providers elicit patients’ wishes regarding their desired involvement in PAD treatment decision-making and tailor their processes to meet patients’ preferences. Future work should also focus on developing care innovations that can increase patient engagement in care.

Childbirth, like other social practices, is influenced and affected by the society in which it occurs. In this entry is a snapshot of nine countries (Ghana, South Africa, China, Philippines, Germany, France, the Netherlands, Brazil, and Peru), representative of four continents throughout the world. Though there are certainly many world regional patterns of childbirth, a detailed account of select countries offers a rich insight into the interconnectedness of childbirth with the social, political and economic system(s) of a given society. They vary widely, but in many cases are similar, in primary providership, model of care, and rates of mortality, morbidity, and cesarean section, among other vital statistics. Keywords: Africa; Asia; children; Europe; women

This report explores representative dilemmas of gay youth in the transition from late adolescence to young adulthood and shows how brief treatment may facilitate efforts to work toward greater authenticity in sense of self and identity, revise maladaptive relational patterns, and strengthen coping capacities. It presents the case of an 18-year-old male who was seen in supportive psychodynamic treatment for 13 sessions in a university counseling service. Developmental and relational deficits, rooted in a stigmatized identity, perpetuated problems in functioning. The relational functions and supportive elements of the therapeutic process are emphasized in discussion of curative factors. Establishment of the selfobject bond with the therapist strengthened self, facilitated coping, and improved social functioning. The author emphasizes the importance of considering the impact of internalized homophobia and self-alienation in assessment of functioning and establishment of treatment goals.

BACKGROUND: This study presents our implementation of a two-specimen requirement with no prior record of ABO/Rh to verify patients' blood type before transfusion. MATERIALS AND METHODS: Blood type verification was introduced, discussed, approved, and implemented over a 12-month period (May 2007 to May 2008). Potential barriers and impact on benchmark indicators were identified and tracked. RESULTS: Inpatient identification and/or specimen labeling for nursing and laboratory phlebotomists baseline corrected error rates were 1:467 and 1:5555, respectively. This study therefore sought and obtained approval to initiate a new policy of blood type verification before blood transfusion. Compliance in turnaround time (TAT) before and after implementation for completion of STAT type and screen/crossmatch within 60 minutes worsened marginally, from 90% to 80%. The impact on use of O–, uncrossmatched blood was found to be manageable. Seven (of 25 total) recorded electronic complaints were received after implementation. The corrected error rate for nurse phlebotomy draws after implementation was 1:630. CONCLUSION: Despite the lack of an instigating event, verification of blood type before blood transfusion was successfully implemented. An impact on resources and benchmark indicators such as TAT can be anticipated and managed. Further process improvement efforts will be needed to ensure safety (e.g., at time of blood transfusion) for patients receiving blood transfusions. ABO/Rh verification may be necessary even after future implementation of bar coding and/or RFID chips, because human errors continue to occur even with systems improvements.

Amyotrophic lateral sclerosis (ALS) is a degenerative motor disease of unknown etiology with insidious onset and a progressive course. It interferes with a wide variety of patient motor activities, which may include those controlled by the lower cranial nerves--swallowing, speech, and respiration. Many health professionals should be involved early on to maintain an optimal quality of life for the patient and family. When possible, other supportive patients, families, and ALS groups should be contacted for emotional support and practical information. Nursing care should be adaptive, and the confidence of the patient maintained in a variety of settings. Research about ALS is often of vital interest to patients and may give them a purpose for living and hope for ultimate benefit to others. Final decisions regarding care should be made by the patient and his primary caregiver.