Patient contracts for chronic medical conditions: Scoping review

ObjectiveTo describe how and why patient contracts are used for the management of chronic medical conditions.Data sourcesA scoping review was conducted in the following databases: MEDLINE, Embase, AMED, PsycInfo, Cochrane Library, CINAHL, and Nursing & Allied Health. Literature from 1997 to 2017 was included.Study selectionArticles were included if they were written in English and described the implementation of a patient contract by a health care provider for the management of a chronic condition. Articles had to present an outcome as a result of using the contract or an intervention that included the contract.SynthesisOf the 7528 articles found in the original search, 76 met the inclusion criteria for the final review. Multiple study types were included. Extensive variety in contract elements, target populations, clinical settings, and cointerventions was found. Purposes for initiating contracts included behaviour change and skill development, including goal development and problem solving; altering beliefs and knowledge, including motivation and perceived self-efficacy; improving interpersonal relationships and role clarification; improving quality and process of chronic care; and altering objective and subjective health indices. How contracts were developed, implemented, and assessed was inconsistently described.ConclusionMore research is required to determine whether the use of contracts is accomplishing their intended purposes. Questions remain regarding their rationale, development, and implementation.     

Clinical correlation and molecular evaluation confirm that the MLH1 p.Arg182Gly (c.544A>G) mutation is pathogenic and causes Lynch syndrome

Approximately 25 % of mismatch repair (MMR) variants are exonic nucleotide substitutions. Some result in the substitution of one amino acid for another in the protein sequence, so-called missense variants, while others are silent. The interpretation of the effect of missense and silent variants as deleterious or neutral is challenging. Pre-symptomatic testing for clinical use is not recommended for relatives of individuals with variants classified as ‘of uncertain significance’. These relatives, including non-carriers, are considered at high-risk as long as the contribution of the variant to disease causation cannot be determined. This results in continuing anxiety, and the application of potentially unnecessary screening and prophylactic interventions. We encountered a large Irish Lynch syndrome kindred that carries the c.544A>G (p.Arg182Gly) alteration in the MLH1 gene and we undertook to study the variant. The clinical significance of the variant remains unresolved in the literature. Data are presented on cancer incidence within five kindreds with the same germline missense variant in the MLH1 MMR gene. Extensive testing of relevant family members in one kindred, a review of the literature, review of online MMR mutation databases and use of in silico phenotype prediction tools were undertaken to study the significance of this variant. Clinical, histological, immunohistochemical and molecular evidence from these families and other independent clinical and scientific evidence indicates that the MLH1 p.Arg182Gly (c.544A>G) change causes Lynch syndrome and supports reclassification of the variant as pathogenic.     

Peroxyacetyl Nitrate Inhalation

The eyes of rhesus monkeys and humans were exposed to long-pulsed ruby and neodymium, Q-switched ruby and neodymium, and helium-neon (He-Ne) lasers to determine retinal damage thresholds. Rabbit eyes were exposed to a carbon dioxide (CO₂) laser to determine corneal damage thresholds. The data were gathered simulating accidental field exposures.

The experimental data show that the white human fundus is appreciably less sensitive to damage from laser radiation compared to the rhesus monkey fundus. In general, the human threshold data obtained are considerably higher than some of the recommended safe levels.

Corneal damage levels caused by CO₂ laser radiation were reported. The data were shown to be consistent with a simple thermal model.

We emphasize that we are presenting experimental observations and are not recommending energy levels for “safe” laser exposures.     

Regulating and Motivating the Driver

This report evaluates the possibility that atmospheric iodine (I) can make a significant contribution to I nutrition and concludes that the combustion of gas and oil can increase atmospheric H. Sedimentation treatment of water supplies extracts some I from raw water, and sewage plants concentrate I and return it to the environment via sewage effluent. The I cycle in nature is discussed, and it is concluded that minute amounts of I usually are present in the atmosphere but are not usually in significant enough amounts to contribute substantially to bodily I requirements.