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Journal of Gastrointestinal and Liver... Jun 2024There has been a growing emphasis on dietary therapies for irritable bowel syndrome (IBS). Furthermore, there has been an evolving evidence base for the low fermentable...
BACKGROUND AND AIMS
There has been a growing emphasis on dietary therapies for irritable bowel syndrome (IBS). Furthermore, there has been an evolving evidence base for the low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet, gluten-free diet (GFD), and lactose-free diet. This study examines the dietary approaches employed and the factors influencing dietetic decision-making for IBS interventions.
METHODS
Participants, including registered dietitians and nutritionists, were recruited from diverse healthcare settings at the point of registration for the 4th Sheffield National Dietetic Gastroenterology Symposium, 2023. A 15-question online survey investigated the practices of dietitians and nutritionists in managing IBS patients, covering dietary approaches, decision-making factors, and patient education. The evidence base for different dietary interventions was provided and a follow-up survey assessed symposium attendees, views on current IBS dietary practices.
RESULTS
Out of 731 respondents, primarily registered dietitians (93%) and females (93%), 54% spent 10-50% of clinic time on IBS. Respondents noted that a GFD (34%), low lactose (32%), and traditional dietary advice (TDA) (18%) were the most frequently used dietary interventions that patients try before seeking professional advice. Delegates were asked to rank their dietary intervention preferences pre- and post-meeting (after the evidence base had been presented): TDA pre-meeting 75% versus post-meeting 87% (p=0.04), fibre modification 59% versus 6% (p<0.0001), low FODMAP 25% versus 10% (p=0.0001), low lactose 12% versus 62% (p<0.0001) and GFD 6% to 23% (p<0.0001).
CONCLUSIONS
TDA remains the choice of diet for dietitians. After our educational event, the use of low-lactose and gluten-free diet significantly increased. Factors influencing the decision-making process were based on patient acceptability, counselling time, supporting evidence base and dietary triggers.
Topics: Humans; Irritable Bowel Syndrome; Female; Male; Nutritionists; Patient Education as Topic; Diet, Gluten-Free; Diet, Carbohydrate-Restricted; Surveys and Questionnaires; Health Care Surveys; Adult; Middle Aged; Clinical Decision-Making
PubMed: 38944865
DOI: 10.15403/jgld-5466 -
International Journal of Gynaecology... Jun 2024An arbitrary gestational age limit of viability cannot be set, and in clinical practice the focus should be on a periviability interval-the so-called "gray zone" of...
An arbitrary gestational age limit of viability cannot be set, and in clinical practice the focus should be on a periviability interval-the so-called "gray zone" of prognostic uncertainty. For cases within this interval, the most appropriate decision-making process remains debatable and periviability has emerged as one of the greatest challenges in bioethics. Universally recognized ethical principles may be interpreted differently due to socioeconomic, cultural, and religious aspects. In the case of periviability, there is considerable uncertainty over whether interventions result in a greater balance of clinical good over harm. Furthermore, the fetus or neonate is unable to exercise autonomy and the physicians and parents will act as patient surrogates. When parents and physicians disagree about the infant's best interest, a dialogue without paternalistic attitudes is essential, whereby physicians should only offer, but not recommend, perinatal interventions. Parental choice, based on thorough information, should be respected within the limits of what is medically feasible and appropriate. When disagreements between parents and physicians occur, how is consensus to be achieved? Professional guidelines can be helpful as a framework and starting point for discussion. In reality, however, guidelines only rarely draw categorical lines and in many cases remain vague and ambiguously worded. Local ethics committees can provide counseling and function as moderators during discussions, but ethics committees do not have decision precedence. Counseling assumes the most significant role in periviability discussions, taking into consideration the particular fetal and maternal characteristics, as well as parental values. Several caveats should be observed relative to counseling: message fragmentation or inconsistence should be minimized, prognosis should preferably be presented in a positive framing, and overreliance on statistics should be avoided. It is recommended that decisions regarding neonatal resuscitation in the periviability interval be made before birth and not conditional on the newborn's appearance at birth. Regardless of decision, it is important to assure pre- and postnatal coherence. The present article describes how individual physicians, centers, and countries differ in the approach to the decision to initiate or forgo intensive care in the periviability interval. It is impossible to provide a global consensus view and there can be no unifying ethical, moral, or practical strategy. Nevertheless, ethically justified, quality care comprises early involvement of the obstetric and neonatal team to enable a coherent, comprehensible, nonpaternalistic, and balanced plan of care. Ultimately, physicians will need to adjust the expectations to the local standards, local outcome data, and local neonatal support availability.
PubMed: 38944691
DOI: 10.1002/ijgo.15744 -
Nature Communications Jun 2024Real-time genomics through nanopore sequencing holds the promise of fast antibiotic resistance prediction directly in the clinical setting. However, concerns about the...
Real-time genomics through nanopore sequencing holds the promise of fast antibiotic resistance prediction directly in the clinical setting. However, concerns about the accuracy of genomics-based resistance predictions persist, particularly when compared to traditional, clinically established diagnostic methods. Here, we leverage the case of a multi-drug resistant Klebsiella pneumoniae infection to demonstrate how real-time genomics can enhance the accuracy of antibiotic resistance profiling in complex infection scenarios. Our results show that unlike established diagnostics, nanopore sequencing data analysis can accurately detect low-abundance plasmid-mediated resistance, which often remains undetected by conventional methods. This capability has direct implications for clinical practice, where such "hidden" resistance profiles can critically influence treatment decisions. Consequently, the rapid, in situ application of real-time genomics holds significant promise for improving clinical decision-making and patient outcomes.
Topics: Klebsiella pneumoniae; Genomics; Humans; Anti-Bacterial Agents; Klebsiella Infections; Drug Resistance, Multiple, Bacterial; Plasmids; Nanopore Sequencing; Genome, Bacterial; Microbial Sensitivity Tests
PubMed: 38944650
DOI: 10.1038/s41467-024-49851-4 -
Risk Analysis : An Official Publication... Jun 2024As countries and communities grapple with climate change, they seek to rapidly decarbonize their economies and cultures. A low-carbon future will likely depend on more...
As countries and communities grapple with climate change, they seek to rapidly decarbonize their economies and cultures. A low-carbon future will likely depend on more distributed solar energy, the electrification of mobility, and more efficient homes and buildings. But what emergent risks are evident within this low-carbon society? This exploratory study first reviews the existing literature to identify 75 risk-risk tradeoffs by their category, medium of distribution, and type. It builds on these 75 examples to apply a typology of Risk Offsets, Risk Substitution, Risk Transfer, and Risk Transformation. Based on extensive document analysis, it applies that typology to three low-carbon innovations: solar energy, battery electric vehicles, and building energy efficiency retrofits, identifying 36 distinct risk-risk tradeoffs in total. As such, the paper moves to discuss complexities and challenges in risk management. In doing so, it calls for a more refined risk assessment that better accounts for decision-making considerations such as the magnitude or probability of risk, size of population exposed, certainty in risk estimation, severity of adverse outcome, distributional considerations, and the timing of risk impacts. It also summarizes emergent research gaps. Risk management in the context of climate action becomes a three-dimensional chess game of weighing risk transmission, risk mediums, and risk categories.
PubMed: 38944643
DOI: 10.1111/risa.14667 -
Joint Commission Journal on Quality and... May 2024Inpatient suicides have devastating and long-lasting consequences for patients, families, and health care organizations, posing a major challenge for hospitals. Although...
A Review of Modifiable Health Care Factors Contributing to Inpatient Suicide: An Analysis of Coroners' Reports Using the Human Factors Analysis and Classification System for Healthcare.
BACKGROUND
Inpatient suicides have devastating and long-lasting consequences for patients, families, and health care organizations, posing a major challenge for hospitals. Although many studies have identified patient risk factors for inpatient suicide, the modifiable health care factors are less understood. Failure to understand these modifiable factors weakens organizations' ability to design and implement effective prevention strategies.
METHODS
The Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare) was used to classify and analyze modifiable health care factors that contributed directly or indirectly to inpatient suicides in Australian hospitals between 2009 and 2018. Comparisons were made between general and psychiatric hospital units to identify context-specific recommendations.
RESULTS
Of the 367 cases, 216 (58.9%) had enough information to analyze the contributing factors, and 214 (58.3%) included unit location information. Multiple modifiable health care factors were identified in the cases as contributing to the patients' suicides. Commonly, cases reported decision errors made by individuals (57.4%), problems with the physical environment (56.0%), and unit-level operational decision-making errors (that is, planned inappropriate operations) (48.6%). An association was found between unit type and problems with coordination, mental state, tasks, physical environment, planned inappropriate operations, and organizational culture (p < 0.05).
CONCLUSION
General prevention initiatives may not be effective in addressing inpatient suicides across specialty units. HFACS-Healthcare enabled a deeper understanding of inpatient suicide and the identification of priority areas that, if addressed, could help reduce the number of preventable suicides in hospitals. Hospital suicide prevention initiatives need to be tailored to specific units and target individual and system vulnerabilities to improve safety and reduce inpatient suicide rates.
PubMed: 38944573
DOI: 10.1016/j.jcjq.2024.05.008 -
The Surgical Clinics of North America Aug 2024Secondary hyperparathyroidism (SHPT) often arises from kidney disease and is characterized by elevated parathyroid hormone (PTH) levels. The reported optimal PTH level... (Review)
Review
Secondary hyperparathyroidism (SHPT) often arises from kidney disease and is characterized by elevated parathyroid hormone (PTH) levels. The reported optimal PTH level to balance the compensatory physiologic response in SHPT with the pathologic morbidity and mortality has changed over time with our evolving understanding. Parathyroidectomy for kidney-related hyperparathyroidism requires consideration of the patient's dialysis status, potential for kidney transplantation, and medical history. Extent of parathyroidectomy and intraoperative decision-making requires consideration to maximize cure with the risk of permanent hypoparathyroidism. Parathyroidectomy for kidney-related hyperparathyroidism can provide a reduction in morbidity, mortality, and improved kidney allograft function and survival.
Topics: Humans; Parathyroidectomy; Hyperparathyroidism, Secondary; Renal Dialysis; Kidney Transplantation; Parathyroid Hormone; Kidney Failure, Chronic
PubMed: 38944502
DOI: 10.1016/j.suc.2024.02.011 -
Advances in Pediatrics Aug 2024Patients with differences of sex development (DSDs) have complex anatomy and surgical needs related to both Mullerian and non-Mullerian structures. Approaches to vaginal... (Review)
Review
Patients with differences of sex development (DSDs) have complex anatomy and surgical needs related to both Mullerian and non-Mullerian structures. Approaches to vaginal reconstruction for these conditions are guided by individual anatomy, with the goal of establishing unobstructed outflow for the reproductive, urinary, and gastrointestinal tracts. Patients may have anatomy requiring vaginoplasty for either outflow tract obstruction or chosen sexual function. In this article, the authors focus on management of differences in vaginal anatomy with delayed vaginoplasty for the newborn with DSD.
Topics: Humans; Female; Disorders of Sex Development; Vagina; Infant, Newborn; Plastic Surgery Procedures; Male
PubMed: 38944480
DOI: 10.1016/j.yapd.2024.04.002 -
Thoracic Surgery Clinics Aug 2024Transitions during a career in cardiothoracic surgery include transition to practice following residency, multiple transitions over the course of the career, and... (Review)
Review
Transitions during a career in cardiothoracic surgery include transition to practice following residency, multiple transitions over the course of the career, and transition to retirement. Each carries some degree of uncertainty and stress, and early preparation for each transition is key to success. A clear understanding of both professional and personal goals drives decisions and choices along the course of a career. It is crucial to seek legal counsel with expertise in physician employment contracts. Developing collegial and collaborative relationships should be a focus throughout one's career. This article outlines the key elements to successful career progression.
Topics: Humans; Thoracic Surgery; Career Choice; Career Mobility; Internship and Residency; Retirement
PubMed: 38944456
DOI: 10.1016/j.thorsurg.2024.04.012 -
Journal of Shoulder and Elbow Surgery Jun 2024Patient expectations for orthopedic surgeries, and elective shoulder surgery in particular, have been shown to be important for patient outcomes and satisfaction....
BACKGROUND
Patient expectations for orthopedic surgeries, and elective shoulder surgery in particular, have been shown to be important for patient outcomes and satisfaction. Current surveys assessing patient expectations lack clinical applicability and allow patients to list multiple expectations at the highest level of importance. The purpose of this study was to develop and evaluate the use of a novel, rank-based survey assessing the relative importance of patient expectations for shoulder surgery.
METHODS
The Preoperative Rank of Expectations for Shoulder Surgery (PRESS) survey was developed by polling 100 patients regarding their expectations for surgery. The PRESS survey consisted of eight common expectations for elective shoulder surgery by importance and a 0-100% scale of expected pain relief and range of motion improvement. After initial development of the PRESS survey, it was administered preoperatively to 316 patients undergoing surgery for shoulder arthritis, rotator cuff tear, subacromial pain syndrome, or glenohumeral instability between August 2020 and April 2021. Patients also completed preoperative outcome measures such as ASES, PROMIS PF, and PROMIS PI surveys. PROM surveys were administered six months postoperatively.
RESULTS
Improvement in range of motion was the expectation most often ranked first for the entire study group (18%), arthritis subgroup (23%), and rotator cuff tear subgroup (19%). Subacromial pain syndrome patients most often ranked improving ability to complete ADL's and relieving daytime pain first (19%). Shoulder instability patients most often ranked improving ability to participate in sports first (31%). Patients that ranked improving range of motion or sports highly had better PROMs. Those who ranked relieving pain highly had worse PROMs. Patients with high (>90%) expectations of pain relief had better PROMIS PI scores. Patients with high pain relief expectations in the arthritis and subacromial pain syndrome groups had better PROMs, while patients with instability were less satisfied.
CONCLUSION
The novel PRESS survey assesses patient expectations for shoulder surgery in a new, more clinically applicable rank-based format. The responses provided by patients provide actionable information to clinicians and are related to postoperative outcomes. Therefore the PRESS survey represents a useful tool for guiding discussions between patients and surgeons, as well as aiding in overall patient-centered clinical decision making.
PubMed: 38944374
DOI: 10.1016/j.jse.2024.05.015 -
Journal of Shoulder and Elbow Surgery Jun 2024The degree of atrophy and fatty infiltration of rotator cuff muscle belly is a key predictor for cuff repairability. Traditionally, Goutallier grading of fatty...
Medial Scapular Body (MSB) Goutallier Classification - MRI based reliability and validity of evaluation of the Goutallier classification for grading fatty infiltration of the rotator cuff.
INTRODUCTION
The degree of atrophy and fatty infiltration of rotator cuff muscle belly is a key predictor for cuff repairability. Traditionally, Goutallier grading of fatty infiltration is assessed at sagittal scapular Y-view. Massive rotator cuff tears are associated with tendon retraction and medial retraction of cuff musculature, resulting in medialization of the muscle bulk. Thus, standard Y-view can misrepresent the region of interest and may misguide clinicians when assessing repairability. It is hypothesized that by assessing the muscle belly with multiple medial sagittal MRI sections at medial scapular body, the Medial Scapular Body - Goutallier Classification (MSB-GC) will improve reliability and repeatability giving a more representative approximation to the degree of fatty infiltration, as compared with original Y-view.
METHODS
Fatty infiltration of the rotator cuff muscles were classified based on the Goutallier grade (0 to 4) at three defined sections section 1: original Y-view; section 2: level of suprascapular notch; section 3: three cm medial to suprascapular notch on MRI scans. Six sub-specialist fellowship trained shoulder surgeons, and three musculoskeletal radiologists independently evaluated deidentified MRI scans of included patients.
RESULTS
Out of 80 scans, 78% (n=62) were massive cuff tears involving supraspinatus, infraspinatus and subscapularis tendon. Inter-observer reliability (consistency between observers) for Goutallier grade was excellent for all three predefined sections (range:0.87-0.95). Intra-observer reliability (repeatability) for Goutallier grade was excellent for all three sections and four rotator cuff muscles (range:0.83-0.97). There was a moderate to strong positive correlation of Goutallier grades between sections 1 and 3 and between sections 2 and 3 and these were statistically significant (p<0.001). There was a reduction in the severity of fatty infiltration on the Goutallier classification from sections 1 to 3 across all muscles. 42.5% of both supraspinatus and infraspinatus were downgraded by one, 20% of supraspinatus and 3.8% of infraspinatus were downgraded by 2 and 2.5% of supraspinatus were downgraded by 3.
CONCLUSION
This study found that applying the Goutallier classification to more medial MRI sections (MSB-GC) resulted in assignment of lower grades for all rotator cuff muscles. Additionally, this method demonstrated excellent test-retest reliability and repeatability. Inclusion of a more medial view or whole scapula on MRI, especially in advanced levels of tear retraction, could be more reliable and representative for assessment of the degree of fatty infiltration within the muscle bulk that could help predict tear repairability and therefore improve clinical decision-making which should be studied further in clinical studies.
PubMed: 38944373
DOI: 10.1016/j.jse.2024.05.013