Identification of factors associated with diagnostic error in primary care.

BACKGROUND Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason's taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed. METHODS Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician's initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians' perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified. DISCUSSION This work sets out a new approach to studying the diagnostic decision-making process in PC, taking advantage of new technologies which allow immediate recording of the decision-making process.

The History of the European Union (Chinese version)

Descriu i analitza el procés d'integració europea des dels seus inicis, els anys cinquanta, fins als nostres dies. L'objectiu consisteix a oferir una visió de conjunt d'un procés que va començar modestament amb la integració dels mercats del carbó i de l'acer dels sis membres fundadors i que ha derivat en una Unió Europea de 27 estats membres i més de 500 milions d'habitants, amb polítiques comunes, una cooperació estreta en els àmbits més sensibles de la sobirania estatal i una moneda única en setze estats

Genetic and environmental effects on early life-history traits in salmonids

Les changements environnementaux, tels la température ou les maladies infectieuses, peuvent influencer l'évolution en induisant de la sélection, mais ceci à la seule condition qu'il y ait assez de diversité génétique pour les traits en question ou pour l'expression plastique de ces traits. Au cours cette thèse, nous avons étudié l'effet de potentielles pressions environnementales sur différents phénotypes de trois représentants des sous familles des salmonidés: l'ombre commun (Thymallus thymallus; Thymallinae), la truite de rivière {Salmo trutta; Salmoninae) et le corégone Coregonus palaea (Coregoninae). Les salmonidés se prêtent particulièrement bien à ce type d'expériences car étant hautement sensibles aux conditions environnementales, ils montrent une large variabilité dans leurs traits morphologiques, comportementaux ainsi que d'histoire de vie, tout en bénéficiant d'un large intérêt général. Nous avons testé si le sexe de l'ombre commun pouvait être modifié par la température, ce qui pourrait ainsi expliquer un changement abrupte de sex ratio observé dans l'une des plus grandes populations de Suisse. Nous n'avons trouvé aucun indice permettant de conclure que la température puisse induire ce changement chez l'ombre commun ou chez la truite de rivière. De plus nous avons étudié la plasticité de développement ainsi que d'éclosion, et avons observé des différences entre familles ainsi qu'entre populations. Alors que ces différences comportementales entre populations suggéraient une adaptation aux conditions environnementales locales, cette prédiction n'a pas été confirmée par une expérience de transplantation réciproque d'embryons entre cinq rivières de la même région. Cette étude a montré que les embryons ne survivaient pas mieux dans leur rivière d'origine, indiquant donc une absence d'adaptation locale. Nous avons aussi montré que la mortalité embryonnaire était influencée autant par des "bons gènes" que par des "gènes compatibles", que la qualité des mâles pouvait être signalée par leur coloration, et que le fait d'élever des poissons dans une pisciculture pouvait aboutir a des relations contre-intuitives entre la coloration des mâles et la qualité de leur jeunes. Nos résultats contribuent ainsi à une meilleure compréhension de l'effet de diverses pressions environnementales sur la morphologie, le comportement ou les traits d'histoire de vie chez les salmonidés. - Environmental changes, such as changes in temperatures or infection levels, can induce selection and drive evolution if there is sufficient genetic variation for the traits or the plasticity in trait expression. In this thesis, we investigated the influence of potential environmental stressors on various phenotypes in representatives of the three salmonid subfamilies: the European grayling (Thymallus thymallus; Thymallinae), the brown trout (,Salmo trutta; Salmoninae), and the whitefish Coregonus palaea (Coregoninae). Salmonids are ideal study species, as they seem sensitive to changing environmental conditions, show considerable variability in morphological, behavioral, and life history traits, and are of broad public interest. We investigated whether temperature-induced sex reversal could explain the sex-ratio distortion found in one of Switzerland's largest grayling populations. We found no evidence of temperature-induced sex reversal in either graylings or brown trout. We also examined plasticity in embryo development and the timing of hatching. We found variation at the level of family and population. Although behavioral differences between populations suggested adaptation to local environmental conditions, no indications of local adaptation could be found in reciprocal transplant experiments carried out over five rivers in the same region. We also demonstrate that embryo development and viability is influenced by 'good genes' and 'compatible genes', that the genetic quality of sires can be signaled by their grey coloration, and that raising larvae in a hatchery environment can produce counter-intuitive relationships between male phenotypes and offspring viability. Our results contribute to the understanding of how changing environmental conditions affect the phenotypes and the heritability of early life-history traits in salmonids.

Características de la familia de origen y de la familia formada por las médicas y los médicos de familia de Andalucía.

BACKGROUND The origin and formed family characteristics are related to physician's professional career. The purpose of this study was to know and compare by sex the characteristics of the origin family and formed family of women and men family physician in Andalusia. METHODS Cross sectional and multicenter study. SETTING Urban primary health care centres from Andalusian province capitals. PARTICIPANTS Physician of primary health care centres. INCLUSION CRITERIA at least one year using computerized medical history with the same quota patients. Multistage random sample, 88 primary health care centres and 500 physicians, 50% of both sexes (alpha=5%, power=90%, precision=15%). Postal auto administrated questionnaire. VARIABLES sex, age, tutor of resident in family medicine, last father's activity, last mother's activity, number of brothers or sisters, family situation, last couple's activity (if any), to have or not children. RESULTS 73.6 % responses. In no responses there weren't differences of sex neither tutor of resident in family medicine. Mean age: women physicians 49.5 +/- 4.3 and men physician 51.3 +/- 4.9 (p= or < 0.005). Postgraduate formation in family medicine: 42.2% of women and 33.3% of men (p=0.016). Live alone: 6.1% of women physician and 2.7% men physician (p=0.005). Live alone with children 9.9% of women and 2.2% of men (p=0.005). 16.5% of women and 10.2% of men don t have children (p=0.077). 21.1% of men physician s couples work only at home vs. 0.1% of women physician s couples (p= or < 0.005). 46% of women physician s couples is also physician vs. 22% of men physician s couples (p= or < 0.005). No significant differences registered in parent s activities neither in the number of brother or sisters. CONCLUSION There are no significant differences in physician s origin family. However important differences in the characteristics of formed family are observed in both sexes.

Meal-induced thermogenesis in obese children with or without familial history of obesity.

Resting metabolic rate (RMR) and the thermic effect of a meal (TEM) were measured in a group of 26 prepubertal children divided into three groups: (1) children with both parents obese (n = 8, group OB2); (2) children with no obese parents and without familial history of obesity (n = 8, OB0); and (3) normal body weight children (n = 10, C). Average RMR was similar in OB2 and OB0 children (4785 +/- 274 kJ/day vs 5091 +/- 543 kJ/day), but higher (P < 0.05) than in controls (4519 +/- 322 kJ/day). Adjusted for fat-free mass (FFM) mean RMRs were comparable in the three groups of children (4891 +/- 451 kJ/day vs 5031 +/- 451 kJ/day vs 4686 +/- 451 kJ/day in OB2, OB0, and C, respectively). The thermic response to the mixed meal was similar in OB2, OB0 and C groups. The TEM calculated as the percentage of RMR was lower (P < 0.05) in obese than in control children: 10.2% +/- 3.1% vs 10.9% +/- 4.3% vs 14.0% +/- 4.3% in OB2, OB0, and C, respectively. The similar RMR as absolute value as well as adjusted for FFM, and the comparable thermic effect of food in the obese children with or without familial history of obesity, failed to support the view that family history of obesity can greatly influence the RMR and the TEM of the obese child with obese parents.

Efficacy and safety of acupuncture for the treatment of non-specific acute low back pain: a randomised controlled multicentre trial protocol [ISRCTN65814467]

BACKGROUND Low back pain and its associated incapacitating effects constitute an important healthcare and socioeconomic problem, as well as being one of the main causes of disability among adults of working age. The prevalence of non-specific low back pain is very high among the general population, and 60-70% of adults are believed to have suffered this problem at some time. Nevertheless, few randomised clinical trials have been made of the efficacy and efficiency of acupuncture with respect to acute low back pain. The present study is intended to assess the efficacy of acupuncture for acute low back pain in terms of the improvement reported on the Roland Morris Questionnaire (RMQ) on low back pain incapacity, to estimate the specific and non-specific effects produced by the technique, and to carry out a cost-effectiveness analysis. METHODS/DESIGN Randomised four-branch controlled multicentre prospective study made to compare semi-standardised real acupuncture, sham acupuncture (acupuncture at non-specific points), placebo acupuncture and conventional treatment. The patients are blinded to the real, sham and placebo acupuncture treatments. Patients in the sample present symptoms of non specific acute low back pain, with a case history of 2 weeks or less, and will be selected from working-age patients, whether in paid employment or not, referred by General Practitioners from Primary Healthcare Clinics to the four clinics participating in this study. In order to assess the primary and secondary result measures, the patients will be requested to fill in a questionnaire before the randomisation and again at 3, 12 and 48 weeks after starting the treatment. The primary result measure will be the clinical relevant improvement (CRI) at 3 weeks after randomisation. We define CRI as a reduction of 35% or more in the RMQ results. DISCUSSION This study is intended to obtain further evidence on the effectiveness of acupuncture on acute low back pain and to isolate the specific and non-specific effects of the treatment.

Frequency and characteristics of familial melanoma in Spain: the FAM-GEM-1 Study.

INTRODUCTION Familial history of melanoma is a well-known risk factor for the disease, and 7% melanoma patients were reported to have a family history of melanoma. Data relating to the frequency and clinical and pathological characteristics of both familial and non-familial melanoma in Spain have been published, but these only include patients from specific areas of Spain and do not represent the data for the whole of Spain. PATIENTS AND METHODS An observational study conducted by the Spanish Group of Melanoma (GEM) analyzed the family history of patients diagnosed with melanoma between 2011 and 2013 in the dermatology and oncology departments. RESULTS In all, 1047 patients were analyzed, and 69 (6.6%) fulfilled criteria for classical familial melanoma (two or more first-degree relatives diagnosed with melanoma). Taking into account other risk factors for familial melanoma, such as multiple melanoma, pancreatic cancer in the family or second-degree relatives with melanoma, the number of patients fulfilling the criteria increased to 165 (15.8%). Using a univariate analysis, we determined that a Breslow index of less than 1 mm, negative mitosis, multiple melanoma, and a history of sunburns in childhood were more frequent in familial melanoma patients, but a multivariate analysis revealed no differences in any pathological or clinical factor between the two groups. CONCLUSIONS Similar to that observed in other countries, familial melanoma accounts for 6.6% of melanoma diagnoses in Spain. Although no differences in the multivariate analysis were found, some better prognosis factors, such as Breslow index, seem more frequent in familial melanoma, which reflect a better early detection marker and/or a different biological behavior.

Consensus document on allergic conjunctivitis (DECA).

Allergic conjunctivitis (AC) is an inflammatory disease of the conjunctiva caused mainly by an IgE-mediated mechanism. It is the most common type of ocular allergy. Despite being the most benign form of conjunctivitis, AC has a considerable effect on patient quality of life, reduces work productivity, and increases health care costs. No consensus has been reached on its classification, diagnosis, or treatment. Consequently, the literature provides little information on its natural history, epidemiological data are scarce, and it is often difficult to ascertain its true morbidity. The main objective of the Consensus Document on Allergic Conjunctivitis (Documento dE Consenso sobre Conjuntivitis Alérgica [DECA]), which was drafted by an expert panel from the Spanish Society of Allergology and Spanish Society of Ophthalmology, was to reach agreement on basic criteria that could prove useful for both specialists and primary care physicians and facilitate the diagnosis, classification, and treatment of AC. This document is the first of its kind to describe and analyze aspects of AC that could make it possible to control symptoms.

Contribution of recombination to the evolutionary history of HIV.

PURPOSE OF REVIEW: An improved understanding of how recombination affects the evolutionary history of HIV is crucial to understand its current and future evolution. The present review aims to disentangle the manifold effects of recombination on HIV by discussing its effects on the evolutionary history and the adaptive potential of HIV in the context of concepts from evolutionary genetics and genomics. RECENT FINDINGS: The increasing occurrence of secondary contacts between divergent subtype populations (during coinfection) results in increased observations of recombinants worldwide. Recombination is heterogeneous along the HIV genome. Consequences of recombination of HIV evolution are, in combination with other demographic processes, expected to either homogenize the genetic composition of HIV populations (homogenization) or provide the potential for novel adaptations (diversification). New methods in population genomics allow deep characterization of recombinant genome (the segment composition and origin) and their evolutionary trajectories. SUMMARY: HIV recombinants increase worldwide and invade geographical regions where pure subtypes were previously predominant. This trend is expected to continue in the future, as ease to travel worldwide increases opportunities for recombination between divergent HIV strains. While the effects of recombination in HIV are much researched, more effort is required to characterize current HIV recombinant composition and dynamics. This can be achieved with new population genetic and genomic methods.

Inter-informant agreement and prevalence estimates for mood syndromes: Direct interview vs. family history method.

BACKGROUND: The use of the family history method is recommended in family studies as a type of proxy interview of non-participating relatives. However, using different sources of information can result in bias as direct interviews may provide a higher likelihood of assigning diagnoses than family history reports. The aims of the present study were to: 1) compare diagnoses for threshold and subthreshold mood syndromes from interviews to those relying on information from relatives; 2) test the appropriateness of lowering the diagnostic threshold and combining multiple reports from the family history method to obtain comparable prevalence estimates to the interviews; 3) identify factors that influence the likelihood of agreement and reporting of disorders by informants. METHODS: Within a family study, 1621 informant-index subject pairs were identified. DSM-5 diagnoses from direct interviews of index subjects were compared to those derived from family history information provided by their first-degree relatives. RESULTS: 1) Inter-informant agreement was acceptable for Mania, but low for all other mood syndromes. 2) Except for Mania and subthreshold depression, the family history method provided significantly lower prevalence estimates. The gap improved for all other syndromes after lowering the threshold of the family history method. 3) Individuals who had a history of depression themselves were more likely to report depression in their relatives. LIMITATIONS: Low proportion of affected individuals for manic syndromes and lack of independence of data. CONCLUSIONS: The higher likelihood of reporting disorders by affected informants entails the risk of overestimation of the size of familial aggregation of depression.

Advances in Sequence Analysis: Theory, Methods, Applications

This book gives a general view of sequence analysis, the statistical study of successions of states or events. It includes innovative contributions on life course studies, transitions into and out of employment, contemporaneous and historical careers, and political trajectories. The approach presented in this book is now central to the life-course perspective and the study of social processes more generally. This volume promotes the dialogue between approaches to sequence analysis that developed separately, within traditions contrasted in space and disciplines. It includes the latest developments in sequential concepts, coding, atypical datasets and time patterns, optimal matching and alternative algorithms, survey optimization, and visualization. Field studies include original sequential material related to parenting in 19th-century Belgium, higher education and work in Finland and Italy, family formation before and after German reunification, French Jews persecuted in occupied France, long-term trends in electoral participation, and regime democratization. Overall the book reassesses the classical uses of sequences and it promotes new ways of collecting, formatting, representing and processing them. The introduction provides basic sequential concepts and tools, as well as a history of the method. Chapters are presented in a way that is both accessible to the beginner and informative to the expert.

Crises as a disease of the body politick: a metaphor in the history of nineteenth century economics

This paper examines the use of the medical metaphor in the early theories of crises. It first considers the borrowing of medical terminology and generic references to disease which, notwithstanding their relatively trivial character, illustrate how crises were originally conceived as disturbances (often of a political nature) to a naturally healthy system. Then it shows how a more specific metaphor, the fever of speculation, shifted the emphasis by treating prosperity as the diseased phase, to which crises are a remedy. The metaphor of the epidemic spreading of the disease introduced the theme of the cumulative character of both upswing and downswing, while the similitude with intermittent fevers accounted for the recurring nature of crises. Finally, the paper examines how the medical reflections on the causality of diseases contributed to the epistemology of crises theory, and reflects on the metaphisical shift accompanying the transition from the theories of crises to the theories of cycles.

Iowa Licensed Occupations, 2002

Iowa Licensed Occupations is designed to provide job seekers, career counselors, and other interested individuals with information concerning occupations in Iowa that require a license, certificate, or commission issued at the state level.