Sources of Uncertainty and Their Association with Medical Decision Making: Exploring Mechanisms in Fanconi Anemia

Background

Effects of different sources of medical uncertainty on people’s health-related cognitions, emotions, and decision making have yet to be systematically examined.

Purpose

The aim of this study is to examine how uncertainties arising from different sources are associated with decision making regarding stem cell transplantation in Fanconi anemia, a rare, inherited bone marrow failure syndrome that typically presents during childhood.

Methods

Data were collected through a cross-sectional survey of 178 parents of 126 Fanconi anemia patients.

Results

Two distinct sources of uncertainty were associated with decision outcomes: probability was associated with a lower likelihood of choosing stem cell transplantation, and ambiguity due to conflicting expert opinions was associated with greater decision-making difficulty. Concern about transplantation may mediate these associations.

Conclusions

Different sources of uncertainty have different effects on Fanconi anemia treatment decisions, which may be mediated by parents’ emotional reactions. Further research is needed to elucidate these effects and help Fanconi anemia families cope with uncertainty.     

Comparison of Dexmedetomidine–Ketamine with Isoflurane for Anesthesia of Chinchillas (Chinchilla lanigera)

The objective of this study was to compare isoflurane with a combination of dexmedetomidine and ketamine, administered intramuscularly, for anesthesia in chinchillas (Chinchilla lanigera). In a prospective, complete crossover study, adult chinchillas (n = 8; age, 2 to 5 y) were anesthetized with a combination of dexmedetomidine (0.015 mg/kg IM) and ketamine (4 mg/kg IM). Atipamezole (0.15 mg/kg) was injected subcutaneously 45 min after dexmedetomidine–ketamine administration. For comparison, anesthesia also was induced and maintained with isoflurane in 100% oxygen, delivered by facemask. Anesthetic and physiologic parameters were recorded during each anesthesia, including various reflexes, heart rate, respiratory rate, body temperature, and SpO₂. Food intake, fecal output, and body weight were recorded daily for 6 d after each anesthetic trial. Induction time, heart rate, respiratory rate, and body temperature did not differ significantly between the 2 anesthetic protocols. Recovery times were shorter and SpO₂ was higher in animals that received isoflurane delivered in 100% oxygen. Food intake and fecal output were reduced in the dexmedetomidine–ketamine group for as long as 3 d after anesthesia, whereas isoflurane had no signifcant effect on food intake or fecal output. Both anesthetic protocols provided effective anesthesia in chinchillas. However, when anesthetized with dexmedetomidine–ketamine, chinchillas received room air and became hypoxemic. Future studies are needed to evaluate the effect of oxygen supplementation on anesthetic recovery and on the recovery of food intake and fecal output in chinchillas.Abbreviation: DK, dexmedetomidine–ketamineChinchillas are used extensively in research to study otitis media, hearing loss, and ototoxicity.^1,11,19,25 In addition, chinchillas are becoming increasingly popular as companion animals and, therefore, are more frequently presented for veterinary care. Common diseases of chinchillas include dental disease, gastrointestinal disorders, and ocular disorders.^13,14 Chemical immobilization is often required to perform diagnostic (for example, radiography, CT), therapeutic, or experimental procedures.^3,5,7,21 Research regarding the efficacy and safety of anesthetic protocols in chinchillas is limited and currently recommended protocols rely largely on extrapolation from other species or anecdotal reports.^13,21,27Isoflurane is used routinely in chinchillas for the induction and maintenance of anesthesia. A study investigating the echocardiographic effects of isoflurane in chinchillas found significant effects on several echocardiographic parameters, but no complications or other side effects were reported.¹² Isoflurane typically is delivered by facemask to chinchillas, given that endotracheal intubation is technically challenging and therefore not performed routinely.^10,21 However, using a facemask increases the risk of exposure of the veterinary staff to waste gases, which is a significant occupational health concern.^20,23 Therefore, alternative anesthetic protocols that reduce waste-gas exposure are desired, such as exclusively using injectable anesthetic drugs for induction and maintenance of anesthesia. Intravascular access is challenging to obtain in conscious chinchillas, and thus parenteral, nonvascular protocols provide the most accommodating route for anesthesia induction and maintenance.¹⁴ Only one study in chinchillas has investigated the effects of various injectable anesthetics: a combination of medetomidine (0.06 mg/kg) and ketamine (5 mg/kg) was compared with other parenteral protocols.¹⁴ Although anesthesia was successful with this protocol, the authors reported respiratory and cardiac depression in the animals. Furthermore, although atipamezole is commonly administered in clinical and research settings to promote rapid recovery and prevent complications, such as hypothermia, it was not used in the cited study.¹⁴To our knowledge, no studies have been published that assess the effects of anesthetic protocols on recovery of food intake and fecal output in chinchillas. The objective of this study was to compare the anesthesia induced in chinchillas by using either dexmedetomidine and ketamine or isoflurane and to evaluate the effects of both anesthetic protocols on subsequent food intake, fecal output, and body weight.     

Effectiveness of a Comprehensive Psychoeducational Intervention With Pregnant and Parenting Adolescents: A Pilot Study

PROBLEM: Little is known about the effectiveness of a comprehensive psychoeducational intervention on depression, self-esteem, and parenting attitudes/beliefs of at-risk pregnant and parenting adolescents. METHODS: Adolescents (N = 41) attending either a residential treatment facility (RTF) or a rural alternative school (RAS) participated in a psychoeducational parenting group using Bavolek's Nurturing Program during Phase I. Phase II included health promotion issues, infant massage, and CPR. FINDINGS: Using the Parenting Semantic Differential and the AAPI-2, there was significant improvement in parenting attitudes and beliefs. No significant change was found in self-esteem. CONCLUSIONS: A comprehensive psychoeducational parenting group can be effective in changing parenting attitudes and beliefs, which suggests an ultimate improvement in health promotion and disease prevention in adolescent women and their children.     

Interaction between human polymorphonuclear leukocytes and Streptococcus milleri group bacteria.

Because Streptococcus milleri group (SMG) bacteria--Streptococcus constellatus, Streptococcus intermedius, and Streptococcus anginosus--exhibit a striking propensity to cause abscesses, the interaction of these organisms with human polymorphonuclear leukocytes (PMNL) was examined. After incubation in pooled normal human serum, SMG stimulated less chemotaxis than did Staphylococcus aureus, in contrast to viridans streptococci, which caused greater chemotaxis than did S. aureus. PMNL ingested greater numbers of SMG and viridans streptococci than S. aureus but killed these organisms more slowly and less completely. Relative resistance to killing by PMNL is expected in organisms that cause abscesses, and inhibition of chemotaxis may contribute to pathogenicity, because delayed arrival of PMNL gives a head start to proliferating bacteria. This study helps explain the capacity of SMG to cause abscesses. It is unclear, however, why viridans streptococci, bacteria that rarely produce abscesses, share some of these same properties.     

A case study of the long-term sustainability of an oral health program for persons experiencing homelessness

Stakeholders engaged in funding health programs and investing in human capital are concerned that their investments lead to beneficial long-term outcomes and do not fade from existence when funding streams dry up. However, dissemination and implementation researchers often pay little attention to what happens after programs are implemented. An essential function of the public health nurse operating at the executive management or leadership level is to evaluate overall effectiveness, quality, and sustainability of programs and to design systems-level quality initiatives and evaluation plans that foster program sustainability. This article applies a conceptual framework for sustainability to an oral health program serving persons experiencing homelessness, exploring the essential programmatic, community, and organizational factors that have positively impacted the long-term sustainability of the program. Lessons learned from a model program that has thrived in a political and economic resource poor climate may assist the public health nurse in planning and developing health programs that can withstand the test of time even in the most challenging of circumstances.