BACKGROUND & AIMS: :The bone dysplasias are a heterogeneous group of disorders arising from intrinsic abnormality of bone and cartilage growth and function. All are genetic. Most result in extreme small stature (dwarfism). Historically, emphasis was primarily on diagnostic identification of specific disorders in infants (including differentiating lethal and non-lethal forms), and on the clinical history to be anticipated in infants and children with each of these specific processes. Even in children there is exceedingly limited information of quality and virtually no controlled studies of the effects of intervention. For the most part, information about affected adults is even less complete and even less rigorous. Presented here are a series of examples of medical and adaptive issues in adults affected by one or another of the genetic skeletal dysplasias. Topics discussed include: approach to adults with no specific diagnosis; medical issues that cross diagnostic boundaries (osteoarthritis in the "E" disorders, obstructive apnea, issues in pregnancy in women with dwarfing disorders, activities of daily living, and quality of life assessments); diagnosis-specific problems of adulthood (spinal stenosis in achondroplasia, hearing loss in osteogenesis imperfecta, and malignancy risk in multiple exostoses); adult problems that must be addressed in childhood in order to be prevented (achondroplasia and kyphosis, and cervical spine abnormalities in Morquio syndrome); survival conundrums (why some live unexpectedly and others die unexpectedly). Emphasis is placed on the difficulties intrinsic to trying to learn about needs and expectations in generally rare genetic processes.

背景与目标： : 骨发育不良是由骨和软骨生长和功能的内在异常引起的一组异质性疾病。都是遗传的。大多数导致身材极度矮小 (侏儒症)。从历史上看，重点主要是对婴儿特定疾病的诊断鉴定 (包括区分致死性和非致死性形式)，以及在这些特定过程中预期的婴儿和儿童的临床病史。即使在儿童中，质量信息也非常有限，并且几乎没有关于干预效果的对照研究。在大多数情况下，有关受影响成年人的信息甚至不那么完整，甚至不那么严格。这里介绍了一系列受一种或另一种遗传骨骼发育不良影响的成年人的医学和适应性问题的例子。讨论的主题包括: 没有特定诊断的成年人的方法; 跨越诊断边界的医学问题 (“E” 疾病中的骨关节炎，阻塞性呼吸暂停，患有矮化疾病的妇女的怀孕问题，日常生活活动和生活质量评估); 成人的诊断特异性问题 (软骨发育不全的椎管狭窄，成骨不全症的听力损失以及多个外生骨的恶性风险); 儿童时期必须解决的成人问题 (软骨发育不全和后凸畸形，以及Morquio综合征的颈椎异常); 生存难题 (为什么有些人意外地生活而另一些人意外地死亡)。重点放在试图了解通常罕见的遗传过程中的需求和期望所固有的困难上。

BACKGROUND & AIMS: :In this professional autobiography, the author describes factors contributing to important decisions in his academic geriatric psychiatry career. Major inflection points included embarking on clinical research and later deciding to focus more on leadership roles in education and in faculty affairs. The discussion then examines themes that have emerged in reviewing this career arc, including the value of: the variety and social connectedness inherent in the academic life; cultivation of interpersonal relationships and best efforts as much as possible; an open mind ready to (collegially) seize new opportunities; and family, friends, and avocational pursuits as complements to one's profession. The author hopes that this public life review is of help to others planning or reflecting on their own career paths. .

背景与目标： : 在这本专业自传中，作者描述了导致他的老年精神病学学术生涯做出重要决定的因素。主要的拐点包括开始临床研究，后来决定更多地关注教育和教职员工的领导角色。然后，讨论探讨了回顾这一职业弧线时出现的主题，包括以下主题的价值: 学术生活中固有的多样性和社会联系; 培养人际关系和尽最大努力; 开放的思想准备 (大学) 抓住新的机会; 和家人，朋友，和职业追求作为职业的补充。作者希望这篇公共生活回顾对他人规划或反思自己的职业道路有帮助。 。

BACKGROUND & AIMS: BACKGROUND:In our aging society, palliative care should be a standard component of health care. However, currently it is only provided to a small proportion of patients, mostly to those with cancer, and restricted to the terminal phase. Many general practitioners (GPs) say that one of their most significant challenges is to assess the right moment to start anticipatory palliative care. The "Surprise Question" (SQ1: "Would I be surprised if this patient were to die in the next 12 months"?), if answered with "no", is an easy tool to apply in identifying patients in need of palliative care. However, this tool has a low specificity. Therefore, the aim of our pilot study was to determine if adding a second, more specific "Surprise Question" (SQ2: "Would I be surprised if this patient is still alive after 12 months"?) in case SQ1 is answered in the negative, prompts GPs to plan for anticipatory palliative care. METHODS:By randomization, 28 GPs in the south-eastern part of the Netherlands were allocated to three different groups. They all received a questionnaire with four vignettes, respectively representing patients with advanced organ failure (A), end stage cancer (B), frailty (C), and recently diagnosed cancer (D). GPs in the first group did not receive additional information, the second group received SQ1 after each vignette, and the third group received SQ1 and SQ2 after each vignette. We rated their answers based on essential components of palliative care (here called RADIANT score). RESULTS:GPs in group 3 gave higher RADIANT scores to those vignettes in which they would be surprised if the patients were still alive after 12 months. In all groups, vignette B had the highest mean RADIANT score, followed by vignettes A and C, and the lowest on vignette D. Seventy-one percent of GPs in groups 2 and 3 considered SQ1 a helpful tool, and 75% considered SQ2 helpful. CONCLUSIONS:This innovative pilot study indicates that the majority of GPs think SQ2 is a helpful additional tool. The combination of the two "Surprise Questions" encourages GPs to make more specific plans for anticipatory palliative care.

背景与目标：

BACKGROUND & AIMS: OBJECTIVE:To compare the accuracy in scoring of vignettes of 2 cognitive screening tests-the Mini Mental State Examination (MMSE) and the Short Orientation Memory Concentration Test (S-OMC). DESIGN:Within group comparison. SETTING:Academic institution. PARTICIPANTS:A total of 74 student nurses. METHOD:Participants received instruction on the scoring of each test and were then asked to score 6 videotaped clinical vignettes. MAIN OUTCOME MEASURES:Scores allocated by participants on the vignettes for the MMSE and S-OMC. RESULTS:The proportion of participants assigning the correct total score to the vignettes was low (MMSE 53.2%, S-OMC 66.7%), and the difference in accuracy between tests was significant (P = .005). The total scores that were assigned resulted in misclassification across all 4 caseness cutoffs within each test (MMSE 0.9%-5.9%; S-OMC 1.4%-2.7%). The differences in correct caseness placement between the 2 tests were significant only for the moderate impairment cutoff, where the S-OMC achieved greater correct caseness placement. CONCLUSIONS:The high proportion of scoring mistakes overall has implications for the use of both the tests in routine clinical practice but in particular for the MMSE. An increased awareness is needed in clinical settings and among tests developers, of the likelihood of, and implications arising from, variations in scoring accuracy. In the current study, the S-OMC was scored more accurately than the MMSE.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:There is little evidence as to why or why not insurees decide to seek medical services. Steps prior to the entry of the insuree into the professional health care system have not been sufficiently examined and can only be partially described by secondary data of the statutory health insurance (SHI). We report the first investigation using case vignettes based on the generic health-related quality of life questionnaire EQ-5D as part of a choice study to assess insurees' stated preferences in health services utilization. METHODS:We invited 1500 randomly selected citizens (age 30 to 70 years) from the East German state of Saxony-Anhalt by postal mail to participate in the choice study. Attributes of the case vignettes involved in choice tasks were the five dimensions of the EQ-5D. We used multilevel mixed effects logit regression analysis with the dependent variables: preference to seek medical services (model 1) and preferred time until consultation (model 2) for the assessed case vignette. The EQ-5D attributes of the case vignettes and participant characteristics served as the independent variables. We also included the respondent's certainty of choosing from the choice set, and the order of questions of the questionnaire as control variables. RESULTS:Of the 1500 questionnaires 683 were evaluable (net response rate 48.0%). On the level of the case vignettes, problems in all five dimensions of the EQ-5D were statistically significant factors of the estimated likelihood to seek medical services (model 1). On the respondent level, there was a significant relationship between the preference for medical consultation for the assessed case vignette and the respondent's gender, age, educational level, the existence of a regular doctor, and the certainty of choosing from the choice set. Problems in four of the five dimensions of the EQ-5D (except anxiety/depression) of the case vignettes were significantly associated with the preferred time until consultation (model 2). On the respondent level, gender, educational level, the certainty of choosing from the choice set, and the order of questions of the questionnaire were significant determinants of the time until consultation. CONCLUSIONS:Our study offers a promising new approach for the national and cross-national study of preferences in health services utilization from the insurees' perspective.

背景与目标：

BACKGROUND & AIMS: OBJECTIVES:In early-stage dementia, awareness at the meta-representational level involving a person's appraisal of his/her own condition and its implications has usually been assessed by interview, but contextual factors may influence responding. We examined the utility of an indirect, vignette-based method of eliciting awareness. METHOD:Three vignettes describing early-stage dementia, established dementia and healthy ageing were used to elicit views of the problem and the kinds of advice that might be helpful for the characters depicted. Responses were obtained from 91 people with early-stage Alzheimer's, vascular or mixed dementia, 87 carers and 80 older controls. For the participants with dementia, awareness was assessed in separate in-depth interviews and rated on a five-point scale for comparison purposes. RESULTS:Participants with dementia were often able to correctly identify the problems described in the vignettes, although scoring lower than carers or controls. Participants with dementia were also able to offer advice for those depicted, although to a lesser extent than carers or controls. Ability to offer advice was greater where MMSE scores were higher. For participants with dementia, vignette scores were moderately correlated with ratings derived from interviews, and those showing limited or no awareness offered fewer items of advice than those showing some or good awareness. In addition, 29% of participants with dementia spontaneously pointed out similarities between their own condition and that of the person depicted. CONCLUSIONS:The vignette method may be useful where resources preclude the use of in-depth interviews, and may supplement in-depth interviews as part of a multi-dimensional assessment of awareness.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Antibiotic prescription is frequently inappropriate in hospitals. Our objective was to evaluate whether the quality of antibiotic prescription could be measured using case vignettes to assess physicians' knowledge. METHODS:The study was conducted in 2 public teaching hospitals, where 33/41 units and 206/412 physicians regularly prescribing antibiotics to inpatients agreed to participate. A cross-sectional survey of knowledge was performed using 4 randomly assigned case vignette sets. Curative antibiotic prescriptions were then evaluated using standard criteria for appropriateness at initiation (day 0), after 2-3 days of treatment (days 2-3), and at treatment completion. We compared knowledge of the physicians with their observed prescriptions in the subset of 106 physicians who completed the case vignettes and prescribed antibiotics at least once. RESULTS:The median global case vignette score was 11.4/20 (interquartile range, 8.9-14.3). Of the 483 antibiotic prescriptions, 314 (65%) were deemed appropriate at day 0, 324 (72%) on days 2-3, and 227 (69%) at treatment completion. Prescriptions were appropriate at all 3 time points in only 43% of patients. Appropriate prescription was positively and independently associated with emergency prescription on day 0, documented infection on days 2-3, and 1 of the 2 hospitals at treatment completion. In addition, appropriateness at the 3 evaluation times was positively associated with prescription in anesthesiology or the intensive care unit. Case vignette scores above the median were significantly and independently associated with appropriate antibiotic prescription on days 2-3 and at treatment completion. CONCLUSIONS:Case vignettes are effective for identifying physicians or hospitals whose knowledge and practice regarding antibiotic prescription require improvement.

背景与目标：

BACKGROUND & AIMS: :We examined the factors associated with the evaluation of health description vignettes and how Japanese people make decisions related to the eight health dimensions (mobility, emotions, pain, relationship with others, sleep and energy, vision, recognition/remembering abilities, and self-care). We investigated a dataset of 4,959 respondents (≥ 18 years) from the Japanese World Health Survey. Ordered probit models were used to identify factors associated with all health dimensions. On all dimensions, older people appraised extreme problems as less problematic than young people did. Compared with men, women reported greater severity in the case of extreme problems on three health dimensions: emotion, pain, and sleep/energy. The study also found negative effects of alcohol consumption in almost all dimensions. Doctors and other health care workers should be careful when assessing severity of health problems in older individuals; in this population, health problems may be more severe than reported.

背景与目标： : 我们研究了与健康描述小插曲评估相关的因素，以及日本人如何做出与八个健康维度 (流动性，情绪，疼痛，与他人的关系，睡眠和能量，视力，识别/记忆能力和自我护理) 相关的决策。我们调查了来自日本世界卫生调查的4,959名受访者 (≥ 18岁) 的数据集。有序概率模型用于识别与所有健康维度相关的因素。在各个方面，老年人认为极端问题比年轻人少。与男性相比，女性在三个健康方面的极端问题 (情感，疼痛和睡眠/能量) 的严重程度更高。该研究还发现，几乎所有方面都对饮酒产生负面影响。在评估老年人健康问题的严重程度时，医生和其他医护人员应谨慎; 在这一人群中，健康问题可能比报告的更严重。

BACKGROUND & AIMS: RATIONALE, AIMS AND OBJECTIVES:To assess the criterion validity of paper-and-pencil vignettes to assess guideline adherence by physiotherapists in the Netherlands. The evidence-based physiotherapy practice guideline for low back pain was used as an example. METHODS:Four vignettes were constructed and pre-tested. Three vignettes were found to represent an adequate case-mix. They described one patient with specific low back pain, one with non-specific low back pain and a normal recovery process and one with non-specific low back pain and a delay in the recovery process. Invited to participate were 113 primary care physiotherapists who had joined an randomized controlled trial study 8 months before, in which guideline adherence had been measured by means of semi-structured treatment recording forms. The criterion validity was determined with Spearman's r(s), using Cohen's classification for the behavioural sciences to categorize its effect size. RESULTS:Of the 72 physiotherapists who agreed to participate, 39 completed the questions on the vignettes. In the end, both adherence measures were available for 34 participants, providing 102 vignettes and 268 recording forms. Mean guideline adherence scores were 57% (SD = 17) when measured by vignettes and 74% (SD = 15) when measured by recording forms. Spearman's r(s) was 0.31 (P = 0.036), which, according to Cohen's classification, is a medium effect size. CONCLUSION:Vignettes are of acceptable validity, and are an inexpensive and manageable instrument to measure guideline adherence among large groups of physiotherapists. Further validation studies could benefit from the use of standardized patients as a gold standard, a more diverse case mix to better reflect real physiotherapy practice, and the inclusion of longitudinal vignettes that cover the patients' course of treatment.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:National surveillance systems depend on accurate and reproducible diagnosis of infections. AIM:To investigate the effect of accuracy of diagnosing healthcare-associated infections (HCAIs) on HCAI rates in a national healthcare-associated surveillance system. METHODS:Data from the validation process from the intensive care unit (ICU) surveillance component of the German Krankenhaus Infektions Surveillance System (KISS; Hospital Infection Surveillance System) were used to calculate the accuracy of diagnosing HCAI for each individual surveillance person (SP) responsible for surveillance of HCAI in the ICU of his or her hospital. Multivariate analyses were performed to identify factors that were attributed to surveillance accuracy. FINDINGS:A total of 189 SPs responsible for surveillance in 218 ICUs assessed 30 case vignettes. The chance of belonging to the group of SPs with high accuracy was increased by being a physician (odds ratio: 3.14; P = 0.02) and by being an external SP (odds ratio: 4.69; P ≤ 0.01). ICU HCAI rates depend on the sensitivity of the ICU's SP [incidence rate ratio (IRR): 1.28 (1.07, 1.53); P ≤ 0.01]. High sensitivity increases healthcare-associated urinary tract infection rates [IRR: 1.33 (1.02, 1.75); P = 0.03] and bloodstream infection rates [IRR: 1.33 (1.06, 1.68); P = 0.01]. High specificity was not a significant factor. CONCLUSION:In light of the link between sensitivity of diagnosing HCAI by case vignettes and the ICU HCAI rates, this validation method can be recommended for validation of other surveillance systems.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Clinical vignettes have been used widely to compare quality of clinical care and to assess variation in practice, but the effect of different response formats has not been extensively evaluated. Our objective was to compare three clinical vignette-based survey response formats - open-ended questionnaire (A), closed-ended (multiple-choice) questionnaire with deceptive response items mixed with correct items (B), and closed-ended questionnaire with only correct items (C) - in rheumatologists' pre-treatment assessment for tumor-necrosis-factor (TNF) blocker therapy. METHODS: STUDY DESIGN:Prospective randomized study. SETTING:Rheumatologists attending the 2004 French Society of Rheumatology meeting. Physicians were given a vignette describing the history of a fictitious woman with active rheumatoid arthritis, who was a candidate for therapy with TNF blocking agents, and then were randomized to receive questionnaire A, B, or C, each containing the same four questions but with different response formats, that asked about their pretreatment assessment. MEASUREMENTS:Long (recommended items) and short (mandatory items) checklists were developed for pretreatment assessment for TNF-blocker therapy, and scores were expressed on the basis of responses to questionnaires A, B, and C as the percentage of respondents correctly choosing explicit items on these checklists. STATISTICAL ANALYSIS:Comparison of the selected items using pairwise Chi-square tests with Bonferonni correction for variables with statistically significant differences. RESULTS:Data for all surveys distributed (114 As, 118 Bs, and 118 Cs) were complete and available for analysis. The percentage of questionnaire A, B, and C respondents for whom data was correctly complete for the short checklist was 50.4%, 84.0% and 95.0%, respectively, and was 0%, 5.0% and 5.9%, respectively, for the long version. As an example, 65.8%, 85.7% and 95.8% of the respondents of A, B, and C questionnaires, respectively, correctly identified the need for tuberculin skin test (p < 0.0001). CONCLUSION:In evaluating clinical practice with use of a clinical vignette, a multiple-choice format rather than an open-ended format overestimates physician performance. The insertion of deceptive response items mixed with correct items in closed-ended (multiple-choice) questionnaire failed to avoid this overestimation.

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BACKGROUND & AIMS: BACKGROUND:Clinical vignettes are often used to elicit information about health conditions in research studies. This review summarizes the components of clinical vignettes describing Alzheimer's disease (AD) or other dementias. The purpose is to provide recommendations for the development of standardized vignettes that may be used in future studies. METHODS:MEDLINE, EMBASE, PsycINFO, ASSIA, CINAHL were searched from their inception to June 2014. Primary English-language studies employing vignettes to describe AD or similar disorders (including other dementias and Parkinson's disease) were included in the review. Included studies had to describe the content of the vignettes in the published manuscripts. The characteristics of the included studies and the vignettes were extracted in tabular form and summarized qualitatively. RESULTS:Forty-two studies were included in the review. Twenty-four of the studies contained at least one AD vignette, 11 had vignettes focusing on non-AD dementias, and seven contained vignettes describing conditions other than dementia. In total, 58 vignettes were obtained from the 42 included studies. CONCLUSIONS:Key aspects to consider when constructing vignettes for AD or other dementias include writing the vignettes from a third-person perspective and presenting hypothetical patients as being at least 65 years of age. Researchers should develop standardized vignettes for use across studies.

背景与目标：

BACKGROUND & AIMS: AIMS AND OBJECTIVES:To explore hospitalised heart failure (HF) patients' self-care decisions. BACKGROUND:Heart failure self-care is integral to maintain and manage health, and may prevent unnecessary HF hospitalisations. Nevertheless, self-care remains challenging for patients, and using vignettes offer a new perspective to understand patient HF self-care decision-making. DESIGN:This qualitative descriptive analysis was conducted as part of a mixed methods study. METHODS:We conducted semi-structured interviews (N = 20) to elicit patient decisions about self-care in responses to three vignettes, which varied in symptom severity. Content analysis was used to extract quotes describing participant responses. RESULTS:Participants were on average 60 years old, primarily male, African American, unemployed and highly symptomatic (NYHA Class III or IV). Overall, participants were able to identify when symptoms required a decision to seek urgent medical attention, but had difficulty identifying the appropriate decision to make in response to less acute symptoms such as swelling. CONCLUSIONS:Symptoms other than shortness of breath were challenging for patients to interpret and manage appropriately. Understanding how to apply HF knowledge to alleviate symptoms was also difficult. RELEVANCE TO CLINICAL PRACTICE:Vignettes may be a helpful tool to prompt patient-healthcare provider communication about self-care management and prompt discussions about appropriate self-care decisions in response to varying levels of symptom severity.

背景与目标：

BACKGROUND & AIMS: UNLABELLED:The diagnosis and management of osteoporosis have become increasingly more complex as new drugs enter the marketplace and meta-analyses of randomized trials with "other" agents become more prolific. We describe five common clinical scenarios encountered in the practice of osteoporosis medicine and various road maps that could lead to successful therapy. INTRODUCTION:The diagnosis and treatment of osteoporosis have changed dramatically in the last decade. Advances in diagnostic technologies and a range of newer treatment options have provided the clinician with a wide array of choices for treating this chronic disease. Despite the issuance of several "guidelines" and practice recommendations, there still remains confusion among clinicians about basic approaches to the management of osteoporosis. This paper should be used as a case-based approach to define optimal therapeutic choices. MATERIALS AND METHODS:Five representative cases were selected from two very large clinical practices (Bangor, ME; Pittsburgh, PA). Diagnostic modalities and treatment options used in these cases were selected on an evidence-based analysis of respective clinical trials. Subsequent to narrative choices by two metabolic bone disease specialists (SG and CR), calculation of future fracture risk and selection of potential alternative therapeutic regimens were reviewed and critiqued by an epidemiologist (DB). RESULTS:A narrative about each case and possible management choices for each of the five cases are presented with references to justify selection of the various therapeutic options. Alternatives are considered and discussed based on literature and references through July 2003. The disposition of the individual patient is noted at the end of each case. CONCLUSIONS:A case-based approach to the management of osteoporosis provides a useful interface between guidelines, evidence-based meta-analyses, and clinical practice dilemmas.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Valid estimates of health-related quality-of-life (HRQoL) are often difficult to obtain from persons with Alzheimer's disease (AD) and family caregiver proxies. To help assess whether the general public can serve as an alternate source of proxy HRQoL estimates in AD, we examined whether the general public can use vignettes to discriminate between AD health states. METHODS:We administered a telephone survey to randomly recruited participants from the general public who were aged 18 years or older. Interviewers read vignettes describing the mild, moderate, and severe AD health states to the participants, who answered the EQ-5D-5L and Quality of Life-Alzheimer's Disease (QoL-AD) scales as if they had AD based on the vignette descriptions. Participants also answered the EQ-5D-5L for their current health states. We converted EQ-5D-5L responses into health utility scores using Canadian preference weights. We employed the Wilcoxon signed rank test to examine whether mean health utility scores and mean QoL-AD scores differed between health states. We used Pearson's r to assess correlations between health utility and QoL-AD scores. RESULTS:Forty-eight participants (median age = 53 years; 25 female) completed the telephone interview; health utility and QoL-AD scores decreased as AD severity increased (p <0.0001). Mean health utility scores were 0.65 (mild), 0.51 (moderate), and 0.25 (severe). Mean QoL-AD scores were 26.7 (mild), 23.0 (moderate), and 17.4 (severe). The correlations between health utility and QoL-AD scores were moderate to strong (r ≥ 0.62). CONCLUSIONS:Using the vignettes, the general public provided HRQoL estimates that discriminated between the three AD health states. This finding suggests the general public may be a promising source of proxy HRQoL estimates in place of persons with AD.

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