Lesions of the posterior insular cortex impair water maze performance in the rat

This special issue of Patient Education and Counseling on genetic education and counseling provides an overview of studies and findings in this field. It features a mixture of papers dealing with five different topics related to several psychosocial aspects of genetic education and counseling. Attention is paid to new issues in counseling for hereditary cancer and Huntington Disease. Articles are presented on information recall of counseled individuals, the use and impact of genetic services on counselees (acceptance of testing; knowledge of inherited cancer susceptibility; risks of genetically testing children). Also topics are addressed with respect to the counselor (neutral attitude; understandable language; information recall; satisfaction with the services provided by the genetic counselor). Furthermore, recommendations are discussed for screening practices for women with a family history of breast cancer, and in addition, the effectiveness of genetic counseling is addressed. In conclusion several suggestions for future research are given.     

Genetic counseling. An evaluation of public health genetic clinics

The geographic distribution of County Health Department clinic facilities in the state of California has made it readily possible to establish a regionalized program for genetic counseling services, using public health nurses as a major source of case-finding. From both consumer and health professional standpoints, regionalized satellite genetic counseling clinics have been successful, and in particular, the effectiveness of public health nurses in identifying clinical genetic problems is readily apparent.Long-term follow-up reinforcement of genetic counseling appears to be an important conclusion from these studies. It is our suggestion that reinforcement of counseling would best be accomplished through the health team member (physician, nurse and so forth) following the patient or family rather than through the consulting geneticist.     

Men at family planning clinics: the new patients?

Using a survey of family planning clinics in the continental United States that received Title X funding conducted by The Urban Institute in 1993, those clinics were identified that had made substantial efforts to serve male clients. The final sample size was 567 clinics. 10% of their clients were men and 31% reported that their male clientele had increased in the previous 5 years. During January through March 1995 follow-up telephone interviews were conducted with 25 selected clinics that reported a 10% male share of clients. The clinics were classified into 5 types: 1) 7 clinics with a family planning focus beginning to provide primary care to attract more men; 2) 7 clinics with a family planning focus using community outreach and the partners of female clients to recruit men for clinic services; 3) 6 primary health care clinics beginning to place more emphasis on male reproductive health; 4) 3 hospital-based clinics providing comprehensive and reproductive health care for young men; and 5) 2 school-based clinics providing sports physicals, primary health care, and reproductive health services. In Type 1 clinics males made up 10-40% of clients. They also screened for testicular cancer, and provided infertility, mental health, and nutrition counseling services. Type 2 clinics had an average of 10% male clients and offered male infertility services, nutrition counseling, and specific STD and HIV services for males in the Hispanic and immigrant communities. Type 3 clinics promoted the male role in family planning decision making and STD prevention. A substantial proportion of the clientele was low-income males, but men who came for vasectomies tended to have higher incomes. Type 4 clinics catered to 20-40% male clients with outreach programs for gay minority men, and sessions on stopping domestic violence, male role in family planning, and responsible parenthood. Type 5 clinics had 40-45% males and provided mental health counseling, HIV risk assessment, and screening for testicular cancer.     

Electron microscopy study of explanted intraocular lenses from clinically noninfected eyes

Five to ten percent of cases of breast cancer and colorectal cancer are familial. These families can be divided into high-risk families and moderate-risk families. Cancer in high-risk families can often be explained by dominant inheritance of a gene causing increased susceptibility to cancer. There is a great demand for genetic counseling in these families, and the structure of and experiences from a familial cancer clinic at Odense University Hospital is described. The establishment of a familial cancer clinic involves three steps: 1) Identification of families with increased cancer susceptibility; 2) Molecular tests to identify gene carriers; 3) Clinical examinations for early detection of tumors. Achievement of these three steps requires the involvement of several medical specialties to ensure patient care. Experience with familial cancer clinics is still limited and the involvement of genetic testing and clinical examination programs at risk individuals are insufficiently examined. The rapidly improving techniques for genetic testing make it urgent that it is implemented as part of already established clinical programs.     

Family history of breast cancer: what do women understand and recall about their genetic risk?

The current study has two aims: (1) to look at people's recall of risk information after genetic counselling and (2) to determine the impact of receiving an audiotape of the genetic consultation on level of recall, cancer related worry, and women's uptake of risk management methods. Using a prospective randomised controlled design, subjects receiving an audiotape were compared with a standard consultation group. Participants were drawn from attenders at the genetic clinics of two London hospitals and included 115 women with a family history of breast cancer. Assessment of perceived genetic risk, mental health, cancer worry, and health behaviour was made before counselling at the clinic (baseline) and by postal follow up. Usefulness of audiotapes and satisfaction with the clinical service was assessed by study specific measures. The data indicate that cancer worry is reduced by provision of an audiotape of the genetic consultation. Recall of the genetic risk figure, however, is not affected by provision of an audiotape and neither is it related to women's overall perception of being more or less at risk of breast cancer than the average woman. Forty-one percent of women accurately recalled their personal risk of breast cancer at one month follow up; however, 25% overestimated, 11% underestimated, and 23% could not remember or did not know their breast cancer risk. Recall of the risk figure is more accurate when the clinical geneticist has given this to the woman as an odds ratio rather than in other formats. Subsequent health behaviour is unaffected by whether women have an audiotape record of their genetic consultation. Results suggest that having a precise risk figure may be less important than women taking away from the consultation an impression that something can be offered to help them manage that risk. Provision of an audiotape of the consultation is of limited usefulness. The need for psychological care to be better integrated into genetic counselling at cancer family clinics was highlighted by the study. The results are discussed in terms of future service development.     

Genetic predisposition testing for cancer: effects on families' lives

Genetic testing to identify a predisposition to the development of cancer affects not only the person undergoing DNA analysis but also his or her entire family. Multiple complex issues arise in conjunction with the clinical application of this new tool for assessing cancer risk. Counseling families regarding genetic risk is multifaceted and requires genetic knowledge that may go beyond the expertise of the health care provider. The article describes the psychosocial effects of cancer predisposition testing on families, ethical and social concerns of cancer risk testing, and implications for nurses in counseling individuals and families considering predisposition testing.     

Trauma healing in refugee camps in guinea: A psychosocial program for Liberian and Sierra Leonean survivors of torture and war.

From 1999 to 2005, the Minneapolis-based Center for Victims of Torture (CVT) served Liberian and Sierra Leonean survivors of torture and war living in the refugee camps of Guinea. A psychosocial program was developed with 3 main goals: (a) to provide mental health care, (b) to train local refugee counselors, and (c) to raise community awareness about war trauma and mental health. Utilizing paraprofessional counselors under the close, on-site supervision of expatriate clinicians, the treatment model blended elements of Western and indigenous healing. The core component consisted of relationship-based supportive group counseling. Clinical interventions were guided by a 3-stage model of trauma recovery (safety, mourning, reconnection), which was adapted to the realities of the refugee camp setting. Over 4,000 clients were provided with counseling, and an additional 15,000 were provided with other supportive services. Results from follow-up assessments indicated significant reductions in trauma symptoms and increases in measures of daily functioning and social support during and after participation in groups. The treatment model developed in Guinea served as the basis for CVT's ongoing work with survivors in Sierra Leone and Liberia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Need for psycho-oncologic management in Germany--a comparison of present status and future needs

A comparison of acute care, inpatient rehabilitation and outpatient aftercare in Germany reveals significant differences in the quality and spreading of psychosocial services for cancer patients. Planning psychosocial care for cancer patients, we have to consider patients' need for psychosocial care as well as the health professionals' estimation of patients' needs and the demand for health care services. Analyses of patients' requirements have shown that the needs which patients defined themselves differ from the needs estimated by experts. Therefore, decisions made in health care must be based on systematic data acquired by various approaches. Within the frame of evaluation performed in the research program "Rehabilitation of Cancer Patients" funded by the German Ministry of Research (the former BMFT), data from two studies are presented investigating the need for psychosocial care in oncology using two different approaches. In one study we investigated the status quo of psychosocial care for cancer patients in acute hospitals (n = 585) and rehabilitation centers (n = 42). By use of the Delphi technique, the second study focuses on an analysis of patients' need estimated by health professionals (n = 34). Comparing both studies, deficits in psychosocial care for cancer patients were found especially in acute hospitals and outpatient aftercare services. Methodological problems of the two approaches are discussed and further research strategies are suggested.     

Changes in social support as mediators of the impact of a psychosocial intervention for spouse caregivers of persons with Alzheimer's disease.

The spouse caregivers of 406 patients with Alzheimer's disease were randomly assigned to an enhanced counseling and support intervention or to a usual care control condition. Structured interviews were conducted to assess changes in social support and psychosocial outcomes for the 312 caregivers who provided care in the home for at least 1 year. The number of support persons, satisfaction with the support network, and support persons' assistance with caregiving all increased significantly as a function of the intervention. Structural equation models indicated increased satisfaction with the social support network mediated a significant proportion of the intervention's impact on caregiver depression. A portion of this mediated effect was further mediated by changes in caregiver stress appraisals. Implications for strengthening intervention programs for spouse caregivers of individuals with Alzheimer's disease are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Physician practice styles and patient outcomes: differences between family practice and general internal medicine

OBJECTIVES: This study compared patient health status, patient satisfaction, and physician practice style between family practice and internal medicine. METHODS: New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care. Practice styles were characterized by the Davis Observation Code. Self-reported health status (Medical Outcomes Study, Short Form-36) and patient satisfaction also were measured. RESULTS: There were no significantly different changes in self-reported health status or patient satisfaction between family practice and internal medicine physicians during the course of the study. Family practice initial encounters, however, were characterized by a style placing greater relative emphasis on health behavior and counseling, whereas internists used a more technical style. Improved health status scores after treatment were predicted by a practice style emphasis on counseling, whereas improvements in patient satisfaction scores were predicted by a style of care stressing patient activation. Although this is the first known randomized trial studying this issue, the conclusions are limited by a 38% loss of patients from enrollment to care and a loss of 18% at the 1-year follow-up evaluation. CONCLUSIONS: There were significant differences in practice styles between family physicians and internists; however, it was the physician's behavior, not specialty per se, that affected patient outcomes. A practice style emphasizing psychosocial aspects of care was predictive of improvements in patient health status, whereas a practice style emphasizing patient activation was predictive of improvements in patient satisfaction.     

Genetic counseling and interdisciplinary management of retinoblastoma

The rare childhood malignancy retinoblastoma (Rb) serves as one of the most important models in modern cancer genetics, since the study of its familial and sporadic occurrence has lead to the identification of the first so-called tumor suppressor gene. The nature of the Rb-predisposition and its mode of transmission could also hold true for many other familial cancers. An important goal of medical care is prevention, either by preventing the manifestation of retinoblastoma and of secondary malignancies related to the same predisposition or of their reaching an advanced stage of exacerbation. This can only be achieved by the close collaboration of several medical specialists. The human geneticist can contribute by offering genetic counselling, including risk estimates for offsprings of affected individuals, and by the molecular estimation of the Rb-trait.     

Update on contraception

Genitourinary medicine (GUM) clinics are likely to play an expanded role in the provision of family planning services. A recent survey of GUM clinics in the UK indicated that 71.4% provided emergency contraception and 48.1% provided routine contraception services. To facilitate the ability of GUM practitioners to provide contraceptive counseling and supplies to both men and women, this article reviews the current state of emergency contraception, combined oral contraceptives (OCs), modern IUDs, the levonorgestrel-releasing intrauterine system, female condoms, and the personalized computerized contraceptive system Persona. Also reviewed are current issues regarding the possible impact of combined OCs on an increased risk of venous thromboembolism and breast cancer.     

Epidemiology of drug use during the first three months of life in a urban area of southern Brazil

Evidence-based evaluations of clinical preventive services help define priorities for research in prevention as part of primary health care. In this article, we draw on our experiences with the U.S. Preventive Services Task Force (USPSTF) to outline some major areas where research is needed to define the appropriate use of specific screening tests, counseling interventions, immunizations, and chemoprophylaxis. Areas of particular importance included research to: (1) Identify effective and practical primary care interventions for modifying personal health practices of patients, especially around issues such as diet, exercise, alcohol and drug use, and risky sexual behavior; (2) Clarify the optimal periodicity for certain screening tests and counseling interventions; (3) Identify practical ways to allow patients to share decision-making about preventive care, especially for services of possible but uncertain benefit; (4) Examine the most sensitive and efficient ways to identify high-risk groups who may need different services than the average population; and (5) Expand the use of decision-analysis and cost-effectiveness analysis to help identify optimal use of clinical preventive services. Given the difficulty of large, prospective trials, we discuss the use of alternative research designs to fill in critical gaps in the evidence for the effectiveness of specific services. Finally, we note several issues of increasing importance that may need to be addressed by future work of the USPSTF: what are the most reliable and effective ways to (1) measure and (2) improve the delivery and quality of preventive care provided in the primary care setting.     

Pregnancy in HIV-infected women. Counseling and care--12 years' experiences and results

BACKGROUND: A specialized antenatal care unit was set up for counseling and care of HIV-infected pregnant women. The team consisted of gynecologists, a midwife, a social worker and pediatricians. METHODS: The women were referred from departments of infectious diseases, venereology or institutions for drug addicts, antenatal care units and abortion clinics, or applied themselves. Women identified in the pregnancy HIV screening program were informed primarily by the team. The women were counseled along with their partners and cared for during abortion or the antenatal period, delivery and post partum. Contraceptive services were offered and psychosocial support was given. RESULTS: Between April 1985 and March 1997, 95 HIV-infected women with 122 pregnancies attended. Twenty-one per cent were or had been drug users, 2% had been infected by transfused blood and 77% were classified as having been sexually infected, two thirds of whom were Africans. The mean age was 27.8 years. In 54 of 93 pregnancies (58%) in which the woman could make an informed decision, she elected abortion -- in 37 cases for HIV related reasons. Significantly more women with an uninfected steady partner, compared to women without a steady partner, chose to continue the pregnancy, as did women in a relatively stable social situation. Of the partners, 68 were HIV-negative, 36 HIV-positive and 18 not tested. No severe HIV-related complications occurred during pregnancy. Seven of 40 (18%) children with a known infection status were infected. During the course of follow-up, nine mothers, two fathers and three children have died. Seventeen children were at risk of being orphaned, and another five were placed in foster care. CONCLUSION: Although it is possible to reduce mother-to-infant transmission by zidovudine therapy, the negative consequences of HIV and childbearing are still substantial. Therefore HIV screening during pregnancy and pre-pregnancy counseling are important issues for the health care system.     

Rural telepsychiatry

Telepsychiatry is the use of telecommunications technology to connect patients and health care providers, permitting effective diagnosis, education, treatment, consultation, transfer of medical data, research, and other health care activities. Telepsychiatry has been used as a partial solution to the problem of limited psychiatric services for clinics and hospitals in remote areas of areas underserved by psychiatrists and other mental health care specialists. In the United States, eastern Oregon's RodeoNet telepsychiatry program and the telemedicine program of the Kansas University Medical Center, which has a psychiatric component, are excellent models. Telepsychiatric applications can be cost-effective, but careful evaluation is needed.     

Medical clinics in junior high school: changing the model to meet demands

PURPOSE: To document the development of an initiative undertaken by the Columbia University School of Public Health to provide medical, mental health, and social services in inner city junior high school-based clinics. METHODS: Review of records, reports, and foundation proposals from 1984-1993. Site visits, interviews with clinic staff, school personnel, and students. RESULTS: Years of planning and community development produced four clinics in the Washington Heights area of New York City, the first school-based clinics located in junior high schools in the country. After seven years, the program has the capacity to serve over 4,000 students who present an overwhelming array of physical, psychological, social, and family problems. Almost 23,000 visits were made to the clinics this year: 49% for medical services, 38% for social services, and 13% for health education. As the demand multiplied, a form of triage was implemented that tracked the highest risk students into intensive individual and group interventions. Primary health screening, mental health services, and pregnancy prevention were identified among the critical needs in this deprived community. CONCLUSIONS: Over the years, the clinics have become integrated into the fabric of the schools. Strategies for working in urban junior high schools must be broad, encompassing medical and mental health services, group counseling, life planning and career orientation, along with enhancement of the total school and learning environment.     

Patterns of general health care and STD services use among high-risk youth in Denver participating in community-based urine chlamydia screening

BACKGROUND: In the United States, youth are at highest risk for STDs, and innovative programs have been called for to increase their access to essential STD-related services. To guide the development of such programs, locally relevant information is needed on current use of general health care and STD services in this population. GOAL: To study access to and use of general health care and STD services in a purposive sample of high-risk youth in inner-city Denver. STUDY DESIGN: An interview-based survey conducted as part of a community program for urine chlamydia screening targeting black and Hispanic youth 13 years to 25 years. RESULTS: Of 221 sexually experienced youth in the survey, 72% had accessed general health services in the past year and 39% reported an STD evaluation at any time in the past. Community and school clinics were reported by 50% as a source for general health care and by 62% as a source for STD services. STD clinics were reported by only 14% as a source for STD services. Routine checkups were the most important reasons to seek general health care, yet of those who went for a routine checkup, only 34% reported an STD evaluation. Although few barriers appeared to exist in accessing general health care, anticipated anxiety about procedures and results formed the major barrier to accessing STD services. CONCLUSIONS: Use of general health services was common in this population of high-risk adolescents; however, the provision of STD services as part of general health care visits appeared to be low. On the basis of these findings, a comprehensive STD prevention strategy may be envisioned, which would include provider interventions to increase the provision of STD prevention services in general health care settings; community interventions to enhance access to general health care and STD services; and community-based screening programs for those not able or willing to seek clinic-based services.     

Clinical genetics in The Netherlands. I. Organization, activities and laboratory diagnosis]

The main feature of clinical genetics is the involvement of close relatives in the diagnostics of a hereditary disorder, and the possible consequences of the findings for future generations. Complex genetic counseling is required in cases with different, possibly hereditary disorders or congenital anomalies in the family or by a syndrome with variable risks of recurrence, depending on the exact nature of the disorder; also the difficult, often emotionally charged choices with which counselees are faced demands the expertise of a clinical genetic centre. Results of follow-up studies after genetic counseling show that experience with a handicap or disease in the own environment and the presence of healthy issue are the main determinants for the decision about reproduction of persons with an enhanced genetic risk who request counseling. Because of the great variety in perception of risks and of the severity of a disorder, and because of the marked clinical heterogeneity, rigid legislation should be avoided in the field of prenatal diagnosis. In the future, the training of the clinical geneticist has to be adapted to the rapid progress in human genetics. Increasingly, the clinical geneticist will function in collaboration with other disciplines such as oncology, obstetrics and gynaecology, paediatrics and neurology; in connection with family testing and counseling, there will also be more collaboration with primary health care.     

Counseling and therapy on the Internet.

Rapid development of Internet technology has allowed a growing number of individuals and corporations to offer consumers, health care services, or "eHealth," including counseling and therapy. Almost no information exists about such individuals, due in part to difficulties in conducting research over the Internet. An Internet survey solicited backgrounds, communication technologies, and clinical interventions from individual behavioral eHealth care practitioners. Results are discussed regarding legal, ethical, and professional issues related to use of different Internet technologies. Psychologists are urged to give proper attention to empirical research, language, and current standards of practice before attempting to deliver counseling or psychotherapy over the Internet. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cooperative health care clinics: a group approach to individual care

In cooperative health care clinics (CHCC), health care is provided to older patients in a group setting. The CHCC concept, which was developed under a research grant by Kaiser Permanente in Colorado in 1991, showed improvement in patient and provider satisfaction, as well as improved quality of care and cost effectiveness. CHCC are being replicated in other sites under a research grant from the Robert Wood Johnson Foundation. In addition to formal findings from research studies, much has been learned about factors that have promoted the success of the program.