Impact of Huntington's across the entire disease spectrum: the phases and stages of disease from the patient perspective

Although Huntington's disease (HD) is a neurodegenerative disease characterized by motor, cognitive and behavioural disturbances, there has been little empirical data examining what patients are most concerned about throughout the different stages of disease, which can span many years. Semi-structured face-to-face interviews were individually conducted with 31 people living with different stages of Huntington's, from pre-clinical gene carriers to advanced stage. We examined how often participants raised issues and concerns regarding the impact of Huntington's on everyday life. The Physical/functional theme hardly featured pre-clinically, but was strongly present from Stage 1, rose steadily and peaked at Stage 5. There were no significant changes between stages for the Emotional, Social, and Self themes that all featured across all stages, indicating that these issues were not raised more frequently over the course of the disease. Likewise, the more rarely mentioned Financial and Legal themes also remained similar across stages. However, the Cognitive theme only featured between Stages 1 and 4, and hardly at all pre-clinically and at Stage 5. These findings provide insight into patients' important and unique perspective and have implications for the management and development of interventions across the spectrum of HD stages.

Health-related quality of life in Huntington’s Disease patients: a comparison of proxy assessment and patient self-rating using the disease-specific Huntington’s Disease health-related quality of life questionnaire (HDQoL)

Huntington’s disease (HD) is a fatal, neurodegenerative disease for which there is no known cure. Proxy evaluation is relevant for HD as its manifestation might limit the ability of persons to report their health-related quality of life (HrQoL). This study explored patient–proxy ratings of HrQoL of persons at different stages of HD, and examined factors that may affect proxy ratings. A total of 105 patient–proxy pairs completed the Huntington’s disease health-related quality of life questionnaire (HDQoL) and other established HrQoL measures (EQ-5D and SF-12v2). Proxy–patient agreement was assessed in terms of absolute level (mean ratings) and intraclass correlation. Proxies’ ratings were at a similar level to patients’ self-ratings on an overall Summary Score and on most of the six Specific Scales of the HDQoL. On the Specific Hopes and Worries Scale, proxies on average rated HrQoL as better than patients’ self-ratings, while on both the Specific Cognitive Scale and Specific Physical and Functional Scale proxies tended to rate HrQoL more poorly than patients themselves. The patient’s disease stage and mental wellbeing (SF-12 Mental Component scale) were the two factors that primarily affected proxy assessment. Proxy scores were strongly correlated with patients’ self-ratings of HrQoL, on the Summary Scale and all Specific Scales. The patient–proxy correlation was lower for patients at moderate stages of HD compared to patients at early and advanced stages. The proxy report version of the HDQoL is a useful complementary tool to self-assessment, and a promising alternative when individual patients with advanced HD are unable to self-report.

Incorporation of a S-glycosidic linkage into a glyconucleoside changes the conformational preference of both furanose sugars

A glyconucleoside containing a thioglycoside linkage, namely 1-(3-S-beta-D-ribofuranosyl-2,3-dideoxy-3-thio-beta-D-ribofuranosyl)-thy mine, has been prepared through condensation of a suitably protected derivative of 3'-thiothymidine with an activated ribose sugar. NMR has been used to study the conformation of the S-disaccharide and the unmodified O-disaccharide. A full pseudorotational analysis showed that for the S-disaccharide, the ribose and deoxy ribose sugars have a preference for the south and north pucker, respectively; which is the reverse of what is seen for the O-disaccharide. (c) 2006 Elsevier Ltd. All rights reserved.

General care of the older cancer patient.

With increasing age, there are greater numbers of older people who will be diagnosed with cancer. It must be remembered that such individuals have increased frailty and have a number of geriatric syndromes and conditions particularly pertinent to older age, including incontinence, poor cognition and impaired nutrition. It is often difficult to define the effects of cancer and its treatment or complications, and separate these from the effects of normal ageing and geriatric syndromes. The documentation of poor nutrition and its management must combine knowledge from both geriatric medicine and oncology. Nutrition serves to identify key healthcare professionals who are all essential in any patient at risk or suffering from malnutrition. Incontinence must be actively sought, its cause identified and efforts made to either 'cure' it or, in certain circumstances, 'manage' it. Older patients with cancer are cared for predominantly by older relations and informal care mechanisms and special consideration of their physical and practical needs are paramount. In this area, nurses, doctors, therapists and social workers should work to identify formal and informal mechanisms to support particularly the older carer.

Treatment of the elderly colorectal cancer patient: SIOG expert recommendations.

Colorectal cancer (CRC) is one of the commonest malignancies of Western countries, with approximately half the incidence occurring in patients >70 years of age. Elderly CRC patients, however, are understaged, undertreated and underrepresented in clinical trials. The International Society of Geriatric Oncology created a task force with a view to assessing the potential for developing guidelines for the treatment of elderly (geriatric) CRC patients. A review of the evidence presented by the task force members confirmed the paucity of clinical trial data in elderly people and the lack of evidence-based guidelines. However, recommendations have been proposed on the basis of the available data and on the emerging evidence that treatment outcomes for fit, elderly CRC patients can be similar to those of younger patients. It is hoped that these will pave the way for formal treatment guidelines based upon solid scientific evidence in the future.

Effect of patient age on management decisions in breast cancer: consensus from a national consultation

This qualitative study investigated the attitudes, perceptions, and practices of breast cancer specialists with reference to the effect of patient age on management decisions in breast cancer, and attempted to identify national consensus on this issue. One hundred thirty-three relevant specialists, including 75 surgeons and 43 oncologists, participated in a virtual consultation using e-mailed questionnaires and open-ended discussion documents, culminating in the development of proposed consensus statements sent to participants for validation. A strong consensus was seen in favor of incorporating minimum standards of diagnostic services, treatment, and care for older patients with breast cancer into relevant national guidance, endorsed by professional bodies. Similarly, an overwhelming majority of participants agreed that simple, evidence-based protocols or guidelines on standardizing assessment of biological and chronological age should be produced by the National Institute for Health and Clinical Excellence and the Scottish Medicines Consortium, developed in collaboration with specialist oncogeriatricians, and endorsed by professional bodies. A further recommendation that all breast cancer patient treatment and diagnostic procedures be undertaken in light of up-to-date, relevant scientific data met with majority support. This study was successful in gauging national specialist opinion regarding the effect of patient age on management decisions in breast cancer in the U.K.

System dynamics mapping of acute patient flows

Department of Health staff wished to use systems modelling to discuss acute patient flows with groups of NHS staff. The aim was to assess the usefulness of system dynamics (SD) in a healthcare context and to elicit proposals concerning ways of improving patient experience. Since time restrictions excluded simulation modelling, a hybrid approach using stock/flow symbols from SD was created. Initial interviews and hospital site visits generated a series of stock/flow maps. A ‘Conceptual Framework’ was then created to introduce the mapping symbols and to generate a series of questions about different patient paths and what might speed or slow patient flows. These materials formed the centre of three workshops for NHS staff. The participants were able to propose ideas for improving patient flows and the elicited data was subsequently employed to create a finalized suite of maps of a general acute hospital. The maps and ideas were communicated back to the Department of Health and subsequently assisted the work of the Modernization Agency.

Are clinical documents optimised for patient safety? A critical analysis of patient safety outcomes using the EDA error model

Iatrogenic errors and patient safety in clinical processes are an increasing concern. The quality of process information in hardcopy or electronic form can heavily influence clinical behaviour and decision making errors. Little work has been undertaken to assess the safety impact of clinical process planning documents guiding the clinical actions and decisions. This paper investigates the clinical process documents used in elective surgery and their impact on latent and active clinical errors. Eight clinicians from a large health trust underwent extensive semi- structured interviews to understand their use of clinical documents, and their perceived impact on errors and patient safety. Samples of the key types of document used were analysed. Theories of latent organisational and active errors from the literature were combined with the EDA semiotics model of behaviour and decision making to propose the EDA Error Model. This model enabled us to identify perceptual, evaluation, knowledge and action error types and approaches to reducing their causes. The EDA error model was then used to analyse sample documents and identify error sources and controls. Types of knowledge artefact structures used in the documents were identified and assessed in terms of safety impact. This approach was combined with analysis of the questionnaire findings using existing error knowledge from the literature. The results identified a number of document and knowledge artefact issues that give rise to latent and active errors and also issues concerning medical culture and teamwork together with recommendations for further work.

Empirical test of an agricultural landscape model: the importance of farmer preference for risk aversion and crop complexity

Developing models to predict the effects of social and economic change on agricultural landscapes is an important challenge. Model development often involves making decisions about which aspects of the system require detailed description and which are reasonably insensitive to the assumptions. However, important components of the system are often left out because parameter estimates are unavailable. In particular, measurements of the relative influence of different objectives, such as risk, environmental management, on farmer decision making, have proven difficult to quantify. We describe a model that can make predictions of land use on the basis of profit alone or with the inclusion of explicit additional objectives. Importantly, our model is specifically designed to use parameter estimates for additional objectives obtained via farmer interviews. By statistically comparing the outputs of this model with a large farm-level land-use data set, we show that cropping patterns in the United Kingdom contain a significant contribution from farmer’s preference for objectives other than profit. In particular, we found that risk aversion had an effect on the accuracy of model predictions, whereas preference for a particular number of crops grown was less important. While nonprofit objectives have frequently been identified as factors in farmers’ decision making, our results take this analysis further by demonstrating the relationship between these preferences and actual cropping patterns.

On the typological economy of syntactic transfer: word order and relative clause high/low attachment preference in L3 Brazilian Portuguese

One central question in the formal linguistic study of adult multilingual morphosyntax (i.e., L3/Ln acquisition) involves determining the role(s) the L1 and/or the L2 play(s) at the L3 initial state (e.g., Bardel & Falk, Second Language Research 23: 459–484, 2007; Falk & Bardel, Second Language Research: forthcoming; Flynn et al., The International Journal of Multilingualism 8: 3–16, 2004; Rothman, Second Language Research: forthcoming; Rothman & Cabrelli, On the initial state of L3 (Ln) acquisition: Selective or absolute transfer?: 2007; Rothman & Cabrelli Amaro, Second Language Research 26: 219–289, 2010). The present article adds to this general program, testing Rothman's (Second Language Research: forthcoming) model for L3 initial state transfer, which when relevant in light of specific language pairings, maintains that typological proximity between the languages is the most deterministic variable determining the selection of syntactic transfer. Herein, I present empirical evidence from the later part of the beginning stages of L3 Brazilian Portuguese (BP) by native speakers of English and Spanish, who have attained an advanced level of proficiency in either English or Spanish as an L2. Examining the related domains of syntactic word order and relative clause attachment preference in L3 BP, the data clearly indicate that Spanish is transferred for both experimental groups irrespective of whether it was the L1 or L2. These results are expected by Rothman's (Second Language Research: forthcoming) model, but not necessarily predicted by other current hypotheses of multilingual syntactic transfer; the implications of this are discussed.

Neural correlates of cognitive dissonance and choice-induced preference change

According to many modern economic theories, actions simply reflect an individual's preferences, whereas a psychological phenomenon called “cognitive dissonance” claims that actions can also create preference. Cognitive dissonance theory states that after making a difficult choice between two equally preferred items, the act of rejecting a favorite item induces an uncomfortable feeling (cognitive dissonance), which in turn motivates individuals to change their preferences to match their prior decision (i.e., reducing preference for rejected items). Recently, however, Chen and Risen [Chen K, Risen J (2010) J Pers Soc Psychol 99:573–594] pointed out a serious methodological problem, which casts a doubt on the very existence of this choice-induced preference change as studied over the past 50 y. Here, using a proper control condition and two measures of preferences (self-report and brain activity), we found that the mere act of making a choice can change self-report preference as well as its neural representation (i.e., striatum activity), thus providing strong evidence for choice-induced preference change. Furthermore, our data indicate that the anterior cingulate cortex and dorsolateral prefrontal cortex tracked the degree of cognitive dissonance on a trial-by-trial basis. Our findings provide important insights into the neural basis of how actions can alter an individual's preferences.

Choice-induced preference change in the free-choice paradigm: a critical methodological review

Choices not only reflect our preference, but they also affect our behavior. The phenomenon of choice-induced preference change has been of interest to cognitive dissonance researchers in social psychology, and more recently, it has attracted the attention of researchers in economics and neuroscience. Preference modulation after the mere act of making a choice has been repeatedly demonstrated over the last 50 years by an experimental paradigm called the “free-choice paradigm.” However, Chen and Risen (2010) pointed out a serious methodological flaw in this paradigm, arguing that evidence for choice-induced preference change is still insufficient. Despite the flaw, studies using the traditional free-choice paradigm continue to be published without addressing the criticism. Here, aiming to draw more attention to this issue, we briefly explain the methodological problem, and then describe simple simulation studies that illustrate how the free-choice paradigm produces a systematic pattern of preference change consistent with cognitive dissonance, even without any change in true preference. Our stimulation also shows how a different level of noise in each phase of the free-choice paradigm independently contributes to the magnitude of artificial preference change. Furthermore, we review ways of addressing the critique and provide a meta-analysis to show the effect size of choice-induced preference change after addressing the critique. Finally, we review and discuss, based on the results of the stimulation studies, how the criticism affects our interpretation of past findings generated from the free-choice paradigm. We conclude that the use of the conventional free-choice paradigm should be avoided in future research and the validity of past findings from studies using this paradigm should be empirically re-established. (PsycINFO Database Record (c) 2013 APA, all rights reserved)(journal abstract)

A conceptual framework of patient satisfaction with a pharmacy adherence service

Background Patients do not adhere to their medicines for a host of reasons which can include their underlying beliefs as well as the quality of their interactions with healthcare professionals. One way of measuring the outcome of pharmacy adherence services is to assess patient satisfaction but no questionnaire exists that truly captures patients' experiences with these relatively new services. Objective Our objective was to develop a conceptual framework specific to patient satisfaction with a community pharmacy adherence service based on criteria used by patients themselves. Setting The study was based in community pharmacies in one large geographical area of the UK (Surrey). All the work was conducted between October 2008 and September 2010. Methods This study involved qualitative non-participant observation and semi-structured interviewing. We observed the recruitment of patients to the Medicines Use Review (MUR) service and also actual MUR consultations (7). We also interviewed patients (15). Data collection continued until no new themes were identified during analysis. We analysed interviews to firstly create a comprehensive account of themes which had significance within the transcripts, then created sub-themes within super-ordinate categories. We used a structure-process-outcome approach to develop a conceptual framework relating to patient satisfaction with the MUR. Favourable ethical opinion for this study was received from the NHS Surrey Research Ethics Committee on 2nd June 2008. Results Five super-ordinate themes linked to patient satisfaction with the MUR service were identified, including relationships with healthcare providers; attitudes towards healthcare providers; patients' experience of health, healthcare and medicines; patients' views of the MUR service; the logistics of the MUR service. In the conceptual framework, structure was conceptualised as existing relationships, environment, and time; process was conceptualised as related to recruitment and consultation stages; and outcome as two concepts of immediate patient outcomes and satisfaction on reflection. Conclusion We identified and highlighted factors that can influence patient satisfaction with the MUR service and this led to the development of a conceptual framework of patient satisfaction with the MUR service. This can form the basis for developing a questionnaire for measuring patient satisfaction with this and similar pharmacy adherence services. Impact of findings on practice * Pharmacists and researchers can access the relevant ideas presented here in relation to patient satisfaction with pharmacy adherence services. * Researcher can use the conceptual framework as a basis for measuring the quality of pharmacy adherence services. * Community pharmacists can improve the quality of healthcare they provide by realizing concepts relevant to patient satisfaction with adherence services.

Taxonomic free sorting: a successful method with older consumers and a novel approach to preference mapping

Taxonomic free sorting (TFS) is a fast, reliable and new technique in sensory science. The method extends the typical free sorting task where stimuli are grouped according to similarities, by asking respondents to combine their groups two at a time to produce a hierarchy. Previously, TFS has been used for the visual assessment of packaging whereas this study extends the range of potential uses of the technique to incorporate full sensory analysis by the target consumer, which, when combined with hedonic liking scores, was used to generate a novel preference map. Furthermore, to fully evaluate the efficacy of using the sorting method, the technique was evaluated with a healthy older adult consumer group. Participants sorted eight products into groups and described their reason at each stage as they combined those groups, producing a consumer-specific vocabulary. This vocabulary was combined with hedonic data from a separate group of older adults, to give the external preference map. Taxonomic sorting is a simple, fast and effective method for use with older adults, and its combination with liking data can yield a preference map constructed entirely from target consumer data.