From a Single Voice to Diversity: Reframing 'Representation' in Patient Engagement.

There has been a growing emphasis on consumer representation in the development of health policy, services, research, and education. Existing literature has critiqued how discourses of representativeness can disempower consumers working in health systems. The context of the current study is consumer engagement in the development of COVID-19 triage policy and practice in a local health service. Consumer engagement has often been an afterthought in the COVID response, with few examples of consumers in agenda-setting or decision-making roles. In the Australian Capital Territory, 26 consumer, carer, and community groups worked together with academics and clinicians to develop these principles. Interviews were conducted with stakeholders (including consumers, clinicians, and other health professionals) to evaluate the development of triage principles. A discursive psychological approach to analysis was used to explore participants' understandings about and constructions of consumers being representative (or not) and how this may reproduce power imbalances against consumers. The results explore two distinct ways in which participants talked about consumer representativeness: the first drawing on rhetoric about consumers as lay members of the public (as distinct from being professionally engaged in the health sector), and the second in terms of consumer representatives being diverse and having intersectional identities and experiences. Expectations about consumers to be representative of the general population may reproduce traditional power imbalances and silence lived experience expertise. These power imbalances may be challenged by a shift in the way representativeness is conceptualised to requiring health services to seek out diverse and intersectionally marginalised consumers.

Evaluation of Artificial Intelligence-generated Responses to Common Plastic Surgery Questions.

Background: Artificial intelligence (AI) is increasingly used to answer questions, yet the accuracy and validity of current tools are uncertain. In contrast to internet queries, AI generates summary responses as definitive. The internet is rife with inaccuracies, and plastic surgery management guidelines evolve, making verifiable information important. Methods: We posed 10 questions about breast implant-associated illness, anaplastic large lymphoma, and squamous carcinoma to Bing, using the "more balanced" option, and to ChatGPT. Answers were reviewed by two plastic surgeons for accuracy and fidelity to information on the Food and Drug Administration (FDA) and American Society of Plastic Surgeons (ASPS) websites. We also presented 10 multiple-choice questions from the 2022 plastic surgery in-service examination to Bing, using the "more precise" option, and ChatGPT. Questions were repeated three times over consecutive weeks, and answers were evaluated for accuracy and stability. Results: Compared with answers from the FDA and ASPS, Bing and ChatGPT were accurate. Bing answered 10 of the 30 multiple-choice questions correctly, nine incorrectly, and did not answer 11. ChatGPT correctly answered 16 and incorrectly answered 14. In both parts, responses from Bing were shorter, less detailed, and referred to verified and unverified sources; ChatGPT did not provide citations. Conclusions: These AI tools provided accurate information from the FDA and ASPS websites, but neither consistently answered questions requiring nuanced decision-making correctly. Advances in applications to plastic surgery will require algorithms that selectively identify, evaluate, and exclude information to enhance the accuracy, precision, validity, reliability, and utility of AI-generated responses.

Tributary Inflows to a Regulated River Influence Bacterial Communities and Increase Bacterial Carbon Assimilation.

Inflows from unregulated tributaries change the physical, chemical, and biotic conditions in receiving regulated rivers, impacting microbial community structure and metabolic function. Understanding how tributary inflows affect bacterial carbon production (BCP) is integral to understanding energy transfer in riverine ecosystems. To investigate the role of tributary inflows on bacterial community composition and BCP, a ~90th percentile natural flow event was sampled over 5 days along the Lachlan River and its tributaries within the Murray-Darling Basin of eastern Australia. Increased tributary inflows after rainfall corresponded with a significantly different and more diverse bacterial community in the regulated mainstem. The major contributor to this difference was an increase in relative abundance of bacterial groups with a potential metabolic preference for humic substances (Burkholderiaceae Polynucleobacter, Alcaligenaceae GKS98 freshwater group, Saccharimonadia) and a significant decrease in Spirosomaceae Pseudarcicella, known to metabolise algal exudates. Increases in orthophosphate and river discharge explained 31% of community change, suggesting a combination of resource delivery and microbial community coalescence as major drivers. BCP initially decreased significantly with tributary inflows, but the total load of carbon assimilated by bacteria increased by up to 20 times with flow due to increased water volume. The significant drivers of BCP were dissolved organic carbon, water temperature, and conductivity. Notably, BCP was not correlated with bacterial diversity or community composition. Tributary inflows were shown to alter mainstem bacterial community structure and metabolic function to take advantage of fresh terrestrial dissolved organic material, resulting in substantial changes to riverine carbon assimilation over small times scales.

A Standardized Protocol for Measuring Bioelectrical Impedance in Green Turtles (Chelonia mydas).

AbstractBioelectrical impedance analysis (BIA) is gaining popularity in wildlife studies as a portable technology for immediate and nondestructive predictions of body composition components, such as fat-free and fat masses. Successful application of BIA for field-based research requires the identification and control of potential sources of error, as well as the creation of and adherence to a standardized protocol for measurement. The aim of our study was to determine sources of error and to provide a standardization protocol to improve measurement precision of BIA on juvenile green turtles (Chelonia mydas; n=35). We assessed the effects of altered environmental temperature (20°C-30°C), postprandial state (2-72 h), and time out of the water (2 h) on five impedance parameters (resistance at infinite frequency [Rinf], resistance at zero frequency [R0], resistance at 50 kHz [R50], phase angle at 50 kHz [PhA50], and intracellular resistance [Ri]) using a bioimpedance spectroscopy device. Technical reproducibility of measurements and interanimal variability were also assessed. We found an inverse exponential relationship between change in environmental temperature and impedance parameters Rinf, R0, and R50. Postprandial state significantly increased Rinf and Ri 72 h after feeding. BIA measurements were reproducible within individual juvenile green turtles at temperatures from 20°C to 30°C. Significant variation in impedance values was found between animals at all temperatures, sampling times, and postprandial states, but the relative differences (%) were small in magnitude. Our study suggests that measurement precision is improved by measuring animals at consistent environmental temperatures close to their preferred thermal range. We propose a standardized protocol of measurement conditions to facilitate laboratory and field use of BIA for body composition assessment studies in turtles.

Liver Transplantation in Patients with Sickle Cell Disease in the United States.

BACKGROUND: Up to 30% of patients with sickle cell disease (SCD) develop chronic liver disease via etiologies including sickle cell hepatopathy, acquired viral hepatitis, or secondary hemochromatosis. It is unclear how many patients with SCD ultimately undergo liver transplantation (LT) and what factors are associated with survival after LT. In this study, we examined LT outcomes in these patients by reviewing the Scientific Registry of Transplant Recipients (SRTR) and our institutional experience. METHODS: Analysis of the SRTR identified 23 LT recipients and five simultaneous liver and kidney transplantation (SLKT) recipients with SCD. Patient demographics and graft and patient survival were analyzed. Two patients with SCD at our institution underwent SLKT. RESULTS: Review of the SRTR revealed that recipients with SCD had significantly higher model for end-stage liver disease scores (33 versus 21, P = 0.004), preoperative intensive care unit admission (43.5% versus 19.1%, P = 0.007), preoperative dialysis (17.4% versus 4.9%, P = 0.009), and were more likely to be status 1 (26.1% versus 12.1%, P = 0.041) when compared with the reference population of African American LT recipients. Despite being higher risk at the time of LT, patients with SCD had equivalent posttransplant graft and patient survival when compared with the reference population (P = 0.5 and P = 0.2, respectively) and a 2:1 propensity score-matched group (P = 0.5 and P = 0.2, respectively). Two recent SLKT recipients with SCD from our institution have performed well with stable allograft function. CONCLUSIONS: Data from the SRTR demonstrate that patients with SCD can expect equivalent graft and patient survival after LT despite exhibiting more comorbidities at the time of LT. The low number of patients with SCD who underwent LT in the SRTR in comparison with the rate of chronic liver disease in this population raises the question as to whether a disparity in access to LT exists for this complex population.

Management of Hypertension on the Labor and Delivery Unit: Delivering Care in the Era of Protocols and Algorithms.

INTRODUCTION: Preeclampsia with severe hypertension, which occurs in 5% to 8% of pregnancies, is a leading cause of maternal and perinatal morbidity and mortality in the US. Early recognition and treatment of hypertensive crises can significantly reduce poor outcomes. A protocol to ensure prompt treatment with antihypertensive medication (intravenous labetalol) was implemented at our institution. OBJECTIVE: To determine adherence to this protocol on the Labor and Delivery Unit. DESIGN: Retrospective chart review was performed for patients admitted to the Labor and Delivery Unit between April 2015 and June 2015. Charts were reviewed if the patient had a diagnosis of chronic hypertension, gestational hypertension, superimposed preeclampsia, preeclampsia with severe features, eclampsia, or stroke in pregnancy. Only patients with confirmed severe blood pressures, in which the protocol would be initiated, were included in the final analysis. MAIN OUTCOME MEASURE: Overall compliance with the entire protocol. RESULTS: Of 178 cases reviewed, 58 (32.6%) had confirmed severe blood pressures. Most patients (n = 46, 79.3%) received a diagnosis of preeclampsia with severe features, and most delivered via cesarean delivery (n = 38, 65.5%). No cases were compliant with the entire labetalol protocol. Of 58 patients, 2 (3.5) adequately repeated a confirmation blood pressure within 5 minutes, and 34 (58.6%) were adequately treated with intravenous labetalol according to protocol requirements. CONCLUSION: Labetalol treatment was appropriately initiated in many cases; however, protocol adherence could greatly improve. Potential factors affecting protocol compliance include shift changes, communication issues, and conflicting protocols. Institutions should review protocol compliance to improve care.

Efficacy of a brief web-based intervention with and without SMS to enhance healthy eating behaviors among university students.

BACKGROUND: Healthy eating, such as the regular inclusion of fruits and vegetables in one's diet, is essential for maintaining optimal weight, maximizing brain and immune system functioning, and reducing the risk for disease. Despite its importance, few students meet recommended guidelines for healthy dietary behavior. The current study was designed to test the efficacy of two ehealth intervention approaches for increasing healthy eating behaviors among university students. METHODS: Student volunteers from an introductory psychology class at a northeastern US university participated for class credit (n=154). Students were randomized to either an assessment only (AO), web-based nutrition intervention only (WBO), or web-intervention with daily text-messaging condition (WB+M). Participants completed measures of vegetable and fruit consumption and frequency of meals with designated healthy food selections at baseline and one-month follow-up. RESULTS: Only the WB+M intervention significantly increased the likelihood of attaining vegetable consumption standards and increased the frequency of designated healthy food choice options guidelines at follow-up compared to the AO condition. CONCLUSIONS: Findings suggest that delivering a brief web-based intervention with daily text messages about personal nutrition and fitness goals may support healthier eating patterns among students.

One-Legged Cycle Training for Chronic Obstructive Pulmonary Disease. A Pragmatic Study of Implementation to Pulmonary Rehabilitation.

RATIONALE: In patients with chronic obstructive pulmonary disease (COPD), partitioned exercise training using one-legged cycling leads to greater improvements in peak oxygen uptake than conventional two-legged cycling. OBJECTIVES: We evaluated the feasibility of incorporating one-legged cycling as the principal aerobic training modality for pulmonary rehabilitation in COPD. METHODS: Physiotherapists underwent four teaching sessions about the principles and practical implementation of one-legged cycling training. Patients enrolled in a pulmonary rehabilitation program underwent 6-8 weeks of training in which one-legged cycling three times per week was the principal aerobic exercise activity. Participants cycled for 15 minutes with each leg, in each session. An incremental cardiopulmonary exercise test was completed before and after pulmonary rehabilitation along with standard pulmonary rehabilitation outcome measures. Participants and physiotherapists completed a satisfaction survey at the end of the program. MEASUREMENTS AND MAIN RESULTS: A total of 22 out of 32 participants (14 male; mean [SD] age, 66 [7] years; FEV1% predicted, 32 [17]%; median [interquartile range] Medical Research Council dyspnea scale, 3.5 [3.0-4.3]) completed pulmonary rehabilitation. Peak oxygen uptake increased 1.1 (0.4-1.7) ml·min(-1)·kg(-1) (8%) from baseline (P<0.01). The mean (95% confidence interval) 6-minute-walk test distance improved by 72 (45-98) m (P=0.001). The change in the Chronic Respiratory Questionnaire total score of 1.6 (1.1-2.1; P<0.001) was achieved by improvement in all four domains above the clinically important difference. All the physiotherapists considered one-legged cycling safe and would continue to prescribe it; 75% of participants would recommend it to other patients. CONCLUSIONS: One-legged cycling was successfully implemented into a "real-life" pulmonary rehabilitation program, demonstrating improvements in cardiorespiratory fitness with associated improvement in function for patients with moderate/severe COPD. One-legged cycling should be recommended in professional pulmonary rehabilitation guidelines as an option for exercise training and be available in other pulmonary rehabilitation programs. Clinical trial registered with www.clinicaltrials.gov (NCT01930526).

Weight management-related assessment and counseling by primary care providers in an area of high childhood obesity prevalence: current practices and areas of opportunity.

BACKGROUND: Childhood obesity in Georgia exceeds the national rate. The state's pediatric primary care providers (PCPs) are well positioned to support behavior change, but little is known about provider perceptions and practices regarding this role. PURPOSE: The aim of this study was to assess and compare weight-management-related counseling perceptions and practices among Georgia's PCPs. METHODS: In 2012-2013, 656 PCPs (265 pediatricians, 143 family practice physicians [FPs], and 248 nurse practitioners/physician assistants [NP/PAs]) completed a survey regarding weight-management-related practices at well-child visits before their voluntary participation in a free training on patient-centered counseling and child weight management. Data were analyzed in 2014. Likert scales were used to quantify responses from 1 (strongly disagree or never) to 5 (strongly agree or always). Responses of 4 and 5 responses were combined to denote agreement or usual practice. Chi-squared analyses tested for independent associations between pediatricians and others. Statistical significance was determined using two-sided tests and p value <0.05. RESULTS: The majority of PCPs assessed fruit and vegetable intake (83%) and physical activity (78%), but pediatricians were more likely than FPs and NP/PAs to assess beverage intake (96% vs. 82-87%; p≤0.002) and screen time (86% vs. 74-75%; p≤0.003). Pediatricians were also more likely to counsel patients on lifestyle changes (88% vs. 71%; p<0.001) and to track progress (50% vs. 35-39%; p<0.05). Though all PCPs agreed that goal setting is an effective motivator (88%) and that behavior change increases with provider encouragement (85%), fewer were confident in their ability to counsel (72%). CONCLUSIONS: Our results show that many PCPS in Georgia, particularly pediatricians, have incorporated weight management counseling into their practice; however, important opportunities to strengthen these efforts by targeting known high-risk behaviors remain.

Impact of a rapid respiratory panel test on patient outcomes.

CONTEXT: Evolution of polymerase chain reaction testing for infectious pathogens has occurred concurrent with a focus on value-based medicine. OBJECTIVE: To determine if implementation of the FilmArray rapid respiratory panel (BioFire Diagnostics, Salt Lake City, Utah) (hereafter RRP), with a shorter time to the test result and expanded panel, results in different outcomes for children admitted to the hospital with an acute respiratory tract illness. DESIGN: Patient outcomes were compared before implementation of the RRP (November 1, 2011, to January 31, 2012) versus after implementation of the RRP (November 1, 2012, to January 31, 2013). The study included inpatients 3 months or older with an acute respiratory tract illness, most admitted through the emergency department. Testing before RRP implementation used batched polymerase chain reaction analysis for respiratory syncytial virus and influenza A and B, with additional testing for parainfluenza 1 through 3 in approximately 11% of patients and for human metapneumovirus in less than 1% of patients. The RRP tested for respiratory syncytial virus, influenza A and B, parainfluenza 1 through 4, human metapneumovirus, adenovirus, rhinovirus/enterovirus, and coronavirus NL62. RESULTS: The pre-RRP group had 365 patients, and the post-RRP group had 771 patients. After RRP implementation, the mean time to the test result was shorter (383 minutes versus 1119 minutes, P < .001), and the percentage of patients with a result in the emergency department was greater (51.6% versus 13.4%, P < .001). There was no difference in whether antibiotics were prescribed, but the duration of antibiotic use was shorter after RRP implementation (P = .003) and was dependent on receiving test results within 4 hours. If the test result was positive, the inpatient length of stay (P = .03) and the time in isolation (P = .03) were decreased after RRP implementation compared with before RRP implementation. CONCLUSIONS: The RRP decreases the duration of antibiotic use, the length of inpatient stay, and the time in isolation.

Retained Foreign Body: "Needle in a Haystack".

Retained foreign bodies remain an area of potential patient harm. This case describes a retained needle from distant surgery discovered at the time of the needle count after myomectomy.

Web-based screening and brief intervention for student marijuana use in a university health center: pilot study to examine the implementation of eCHECKUP TO GO in different contexts.

This pilot study sought to test the feasibility of procedures to screen students for marijuana use in Student Health Services (SHS) and test the efficacy of a web-based intervention designed to reduce marijuana use and consequences. Students were asked to participate in voluntary screening of health behaviors upon arrival at SHS. One hundred and twenty-three students who used marijuana at least monthly completed assessments and were randomized to one of four intervention conditions in a 2 (intervention: Marijuana eCHECKUP TO GO vs. control)×2 (site of intervention: on-site vs. off-site) between-groups design. Follow-up assessments were conducted online at 3 and 6 months. Latent growth modeling was used to provide effect size estimates for the influence of intervention on outcomes. One thousand and eighty undergraduate students completed screening. The intervention did not influence marijuana use frequency. However, there was evidence of a small overall intervention effect on marijuana-related consequences and a medium effect in stratified analyses in the on-site condition. Analyses of psychological variables showed that the intervention significantly reduced perceived norms regarding peer marijuana use. These findings demonstrate that it is feasible to identify marijuana users in SHS and deliver an automated web-based intervention to these students in different contexts. Effect size estimates suggest that the intervention has some promise as a means of correcting misperceptions of marijuana use norms and reducing marijuana-related consequences. Future work should test the efficacy of this intervention in a full scale randomized controlled trial.

Cardiac management of ventilator-assisted individuals with Duchenne muscular dystrophy.

As life expectancy of patients with Duchenne muscular dystrophy (DMD) has increased to the 5th decade, in part due to improved ventilatory support, cardiomyopathy is projected to increase as a cause of death. International guidelines recommend an annual assessment of cardiac function and initiation of appropriate pharmacological treatment. We conducted an audit of the cardiac management in patients with DMD requiring ventilatory support and reported a case series of the collated cardiac investigations. Patients with DMD requiring ventilatory support were included in the study. The date of the last electrocardiogram (ECG), echocardiogram (ECHO), cardiology review and pharmacological management were retrieved from the medical records. If an annual cardiac assessment had not been performed this was requested and the latest ECGs and ECHO reports were collated. A total of 30 patients with DMD (29 males, mean (SD) age of 30 (7) years) met the inclusion criteria. Although there was ECG and ECHO documentation in 24 and 21 individuals, respectively, it was only recent in 10 and 6 individuals. In all, 60% of patients had been assessed by a cardiologist, but only 10% within the last year. Over half of the patients failed to attend their new appointments. From the available results, 18 of the 19 patients had an abnormal ECG, 11 of the 16 patients had left ventricular (LV) impairment and 55% of patients had a change in prescription following cardiac investigations. There is a need for a coordinated cardiorespiratory approach towards adult patients with DMD. Over a third of patients had normal LV function suggesting that cardiomyopathy is not inevitable in this group.

Patient characteristics and availability of onsite non-rapid and rapid HIV testing in US substance use disorder treatment programs.

Racial and ethnic minorities and injection drug users (IDUs) are at increased risk of HIV infection. However, the associations between these caseload characteristics and the availability of onsite HIV testing in substance use disorder treatment programs are unknown. This study uses data collected in 2008-2009 from 198 program administrators of treatment programs participating in the National Institute on Drug Abuse's Clinical Trials Network to address this gap in the literature. Results show positive associations between the percentages of African American, Hispanic, and IDU patients and the odds of offering non-rapid onsite HIV testing versus no onsite testing. The associations between racial/ethnic composition and the availability of rapid HIV testing were more complicated. These findings suggest that many programs are responding to the needs of at-risk populations. However, programs and their patients may benefit from greater adoption of rapid testing which is less costly and better ensures that patients receive their results.

HIV/AIDS services in private substance abuse treatment programs.

BACKGROUND: HIV infection among substance abusers is a growing concern in the United States. Little research, however, has examined the provision of HIV/AIDS services in substance abuse treatment programs. METHODS: This study examines the provision of onsite HIV/AIDS services in a nationally representative sample of 345 privately funded substance abuse treatment programs. Data were collected via face-to-face interviews with administrators and/or clinical directors of treatment programs in 2007-2008. RESULTS: Results show that larger programs and programs with a higher percentage of both African American and injection drug using (IDU) patients were more likely to offer onsite HIV/AIDS support groups and a dedicated HIV/AIDS treatment track. Multinomial logistic regression reveals that the odds of offering onsite HIV testing services were higher for hospital based programs, programs providing medical services onsite, and programs with higher percentages of African American patients, relative to the odds of offering no HIV testing or referring patients to an external provider for HIV testing services. The odds of providing onsite testing were lower for outpatient-only treatment programs, relative to the odds of offering no HIV testing or referring patients to an external provider for HIV testing services. CONCLUSIONS: Our findings highlight critical barriers to the adoption of onsite HIV/AIDS services and suggest treatment programs are missing the opportunity to significantly impact HIV-related health outcomes.