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The principles of shared decision making are well documented but there is a lack of guidance about how to accomplish the approach in routine clinical practice. Our aim here is to translate existing conceptual descriptions into a three-step model that is practical, easy to remember, and can act as a guide to skill development. Achieving shared decision making depends on building a good relationship in the clinical encounter so that information is shared and patients are supported to deliberate and express their preferences and views during the decision making process. To accomplish these tasks, we propose a model of how to do shared decision making that is based on choice, option and decision talk . The model has three steps: a) introducing choice, b) describing options, often by integrating the use of patient decision support, and c) helping patients explore preferences and make decisions. This model rests on supporting a process of deliberation, and on understanding that decisions should be influenced by exploring and respecting “what matters most” to patients as individuals, and that this exploration in turn depends on them developing informed preferences.

Decorin is a ubiquitous extracellular matrix proteoglycan with a variety of important biological functions that are mediated by its interactions with extracellular matrix proteins, cytokines, and cell surface receptors. Decorin is the prototype of the family of small leucine-rich repeat proteoglycans and proteins (SLRPs), characterized by a protein core composed of leucine-rich repeats (LRRs), flanked by two cysteine-rich regions. We report here the crystal structure of the dimeric protein core of decorin, the best characterized member of the SLRP family. Each monomer adopts the curved solenoid fold characteristic of LRR domains, with a parallel β-sheet on the inside interwoven with loops containing short segments of β-strands, 310 helices, and polyproline II helices on the outside. Two main features are unique to this structure. First, decorin dimerizes through the concave surfaces of the LRR domains, which have been implicated previously in protein-ligand interactions. The amount of surface buried in this dimer rivals the buried surfaces of some of the highest-affinity macromolecular complexes reported to date. Second, the C-terminal region adopts an unusual capping motif that involves a laterally extended LRR and a disulfide bond. This motif seems to be unique to SLRPs and has not been observed in any other LRR protein structure to date. Possible implications of these features for decorin ligand binding and SLRP function are discussed.

Shared decision making requires a shift in attitudes at all levels but can become part of routine practice with the right support, say Natalie Joseph-Williams and colleagues

Neonatal human dermal fibroblasts cultured in vitro synthesize an organized and physically substantial three-dimensional extracellular matrix, without the addition of exogenous matrix components or synthetic scaffolds. De novo matrix synthesis proceeds in an orderly manner over a 21-d culture period and beyond. Analysis of the fibroblast phenotype, i.e., matrix synthesis by the fibroblasts, suggests that both serum and serum-free conditions are conducive to the production of a human tissue-engineered \"dermal equivalent\". We report that given the appropriate permissive environment, the fibroblasts establish and grow a tissue in vitro, which bears striking biochemical and physical resemblance to normal human dermis.

Medial and lateral knee menisci were obtained from 20‐week‐old pigs, dissected into three zones of equal width, and analyzed for collagen and glycosaminoglycan content and for types of glycosaminoglycan and proteoglycan. The thin inner zones contained about 76% collagen and 8% glycosaminoglycan (by dry weight) and the ouer zones. 93% collagen and 2% glycosaminoglycan. The most abundant glycosaminoglycan in all zones was chondroitin sulphate, accounting for about 80% of total glycosaminoglycan in the inner zones and 50–56% in the outer zones, Dermatan sulphate was the second most abundant glycosaminoglycan, present relative to chondroitin sulphate in a ratio of about 1:5–6 in the inner zones and 1:1.5 in the outer zones. Hyaluronic acid accounted for 4–5% of total glycosaminoglycan content in the inner zones and 10% in the outer zones. All compositional parameters for the middle zones were between those for the inner and outer zones. There were no statistically significant differences in composition between medial and lateral menisci. Proteoglycans were extracted and separated into two groups (large and small proteoglycans) by gel chromatography and were further characterized by gel electrophoresis. The large proteoglycans stained with use of monoclonal antibodies to chondroitin sulphate and keratan sulphate. Biglycan and decorin, two related dermatan sulphate proteoglycans, were identified in the small proteoglycan pool by their behaviour on gel electrophoresis and by immunostaining with specific antibodies. In the middle and inner zones, biglycan predominated. The observed lower dectrophoretic mobilities of dermatan sulphate proteoglycans from the inner zone compared with those from the outer zone were explained by the discovery of longer dermatan sulphate chains on the former. Collectively, these results show that the extracellular matrix of knee meniscus varies continuously across its width in a manner consistent with increased compressive loading on the thinner, inside aspect of the structure.

Hypertrophic scar (HTS) following thermal injury is a dermal fibroproliferative disorder that leads to considerable morbidity. The development of HTS involves numerous cell types and cytokines with dermal fibroblasts being a key cell. We have previously reported that the phenotype of fibroblasts isolated from HTS was altered compared to fibroblasts from normal skin. In this study, normal skin was horizontally sectioned into five layers using a dermatome from which fibroblasts were isolated and cultured. Cells from the deeper layers were observed to proliferate at a slow rate, but were morphologically larger. In ELISA and FACS assays, cells from the deeper layers produced more TGF- β 1 and TGF- β 1 producing cells were higher. In quantitative RT-PCR, the cells from the deeper layers had higher CTGF and HSP47 mRNA levels compared to those from superficial layers. In western blot, FACS and collagen gel assays, fibroblasts from the deeper layers produced more α -smooth muscle actin ( α -SMA), had higher α -SMA positive cells and contracted collagen gels more. Fibroblasts from the deeper layers were also found to produce more collagen, but less collagenase by mass spectrometry and collagenase assay. Interestingly, cells from the deeper layers also produced more of the proteoglycan, versican, but less decorin. Taken together, these data strongly demonstrate that fibroblasts from the deeper layers of the dermis resemble HTS fibroblasts, suggesting that the deeper layer fibroblasts may be critical in the formation of HTS.

Neonatal human dermal fibroblasts cultured in vitro synthesize an organized and physically substantial three-dimensional extracellular matrix, without the addition of exogenous matrix components or synthetic scaffolds. De novo matrix synthesis proceeds in an orderly manner over a 21-d culture period and beyond. Analysis of the fibroblast phenotype, i.e., matrix synthesis by the fibroblasts, suggests that both serum and serum-free conditions are conducive to the production of a human tissue-engineered “dermal equivalent”. We report that given the appropriate permissive environment, the fibroblasts establish and grow a tissue in vitro, which bears striking biochemical and physical resemblance to normal human dermis.

Hip protectors are used in the preventive management of older people who are at risk of fracturing their hip after a fall. However, nurses have little guidance about which type is the most appropriate for particular patients. This article highlights the different designs available and their mechanical performance was assessed by the authors using a purpose-built impact rig. Problems with compliance and issues about tissue viability are discussed and the article also contains a risk assessment tool to help nurses decide on which is the most suitable type of hip protector to use.

The participating parents of 1st, 3 rd, and 5th grade students in Arkansas schools within the Benton, Fort Smith, and Hot Springs school districts completed a 12 item Likert-scale questionnaire. The questionnaire also contained a brief demographic form inquiring about the parents' household income, marital status, race, gender, and highest level of education as well as the students' grade in school, race, gender, and BMI category. One hundred one of the surveys were included in the final analysis upon completion of the data screening process. The 12 survey questions were broken into two constructs. The final analysis included 3 items in the Attitude construct (questions seeking parents' attitude toward the Child Health Report) and 7 items in the Implementation construct (items seeking to determine parents' acting to make healthy changes in their child's eating habits and activity levels). Preliminary descriptive and correlational analyses were completed. A structural equation model was utilized to determine if Attitude predicts Implementation of the information in the Child Health Report. Examination of the individual path coefficients for each item on Attitude indicated that all of the items included in the SEM were statistically significant. Similar to the Attitude measurement model, each of the path coefficients for the Implementation items was statistically significant. The path coefficient between Attitude (predictor) and Implementation (outcome) was statistically significant ( b = .89; 47% explained variance). The moderately high strength of this relationship suggests that a positive attitude toward the Child Health Report was followed by some kind of parental action to help children implement strategies to reduce excessive weight.

A modified bilingual class (like Laura's) has both English and Spanish speakers--they try to achieve a balance of about half and half. But in this particular class, there's very little Spanish speaking going on. These are Spanish speakers who are ready to move into a full English curriculum. Since then, the principal has met with Mrs. [Linda] Jones and her husband twice. I've been in continual contact with her and I've even talked to a therapist she referred me to who had seen Laura. We continue to feel it's much more of a concern to Mrs. Jones than it is to Laura.