Oral-motor function in older people: Exploring new dimensions of frailty.

BACKGROUND: Oral-motor performance for speech and swallowing, and verbal fluency represent important domains that can determine frailty thresholds in older people. OBJECTIVES: The study aims to explore the association between oral-motor performance and verbal fluency to achieve a comprehensive measurement of the frailty phenotype. METHODS AND PROCEDURES: An exploratory and inferential cross-sectional study was carried out in two nursing homes and 2 day care centres. The study comprised a sample of 95 individuals with a mean age of 83 years. The oral-diadochokinesis test (ODDK), water swallow test (WST), time of mastication and swallowing (TOMASS), maximum tongue pressure, verbal fluency, physical phenotype and Mini-Mental State Examination (MMSE) were used as measurements variables. RESULTS: The comparison of mean values between the performance of observed and normative values for the target population was shown to be statistically significant for all the measurements and between the pre-frail and frail. CONCLUSIONS: The results of this study add to the growing body of evidence that oral-motor function for speech and swallowing and verbal fluency are relevant to the diagnosis and management of the frailty condition in older people. The frailty syndrome is more than just the traditionally observed physical function, rather it is a multidimensional construct, where additional dimensions should be considered when evaluating frailty in clinical practice.

Prescribing the Binary for Intersex (and Transgender) Children.

Robert Perske argued in 1972 that "there can be such a thing as human dignity in risk, and there can be a dehumanizing indignity in safety." Though Perske was referring to paternalistic care for the intellectually disabled, we can extend his counsel to the persistent attempts to impose a different kind of "safety," including efforts to enforce the gender and sex binary, as intersex surgeries were (and still are) meant to do. This article argues that when physicians surgically and hormonally alter the genitals and gonads of intersex infants, shaping their bodies to safely align with typical male and female bodies and gender roles, they unwittingly subject them to a dehumanizing indignity. Imposing the binary legislatively with anti-transgender bills is similarly harmful and can inadvertently undermine intersex care. Conservative lawmakers' tacit dismissal of young people's transgender identities parallels physicians' paternalistic, even if well-intentioned, efforts to make intersex bodies fit neatly into prescribed categories. Whether legislative or medical, these interventions promote the traditional gender and sex binary and undermine the dignity of such persons' eventual self-authorship.

The need for a unified ethical stance on child genital cutting.

The American College of Nurse-Midwives, American Society for Pain Management Nursing, American Academy of Pediatrics, and other largely US-based medical organizations have argued that at least some forms of non-therapeutic child genital cutting, including routine penile circumcision, are ethically permissible even when performed on non-consenting minors. In support of this view, these organizations have at times appealed to potential health benefits that may follow from removing sexually sensitive, non-diseased tissue from the genitals of such minors. We argue that these appeals to "health benefits" as a way of justifying medically unnecessary child genital cutting practices may have unintended consequences. For example, it may create a "loophole" through which certain forms of female genital cutting-or female genital "mutilation" as it is defined by the World Health Organization-could potentially be legitimized. Moreover, by comparing current dominant Western attitudes toward female genital "mutilation" and so-called intersex genital "normalization" surgeries (i.e. surgeries on children with certain differences of sex development), we show that the concept of health invoked in each case is inconsistent and culturally biased. It is time for Western healthcare organizations-including the American College of Nurse-Midwives, American Society for Pain Management Nursing, American Academy of Pediatrics, and World Health Organization-to adopt a more consistent concept of health and a unified ethical stance when it comes to child genital cutting practices.

Measuring Quality of Life in the Speaker with Dysarthria: Reliability and Validity of the European Portuguese Version of the QoL-DyS.

BACKGROUND: The impact of acquired dysarthria on the person's life and social participation is well recognized and is the key to the process of rehabilitation. Evaluation of the effectiveness of an intervention that addresses this impact is a challenge for clinicians and researchers. OBJECTIVES: The purpose of this study was to evaluate the validity and reliability of the European Portuguese version of the Quality of Life in the Speaker with Dysarthria (QoL-DyS). METHODS: This research was conducted in three phases: (i) cultural and linguistic adaptation; (ii) feasibility and reliability; and (iii) validity. The sample was composed of 105 subjects with dysarthria and 103 healthy subjects. The QAD (Quick Assessment for Dysarthria), PEAT10 (Portuguese Eating Assessment Tool), and EQ-5D (EuroQol five-dimension scale) were used for validity and reliability. RESULTS AND CONCLUSION: The QoL-DyS correlated positively with the QAD, PEAT-10, and EQ5D. Cronbach's α was 0.973, and it remained excellent when any item was deleted. The QoL-DyS score mean difference between the non-dysarthric cohort and the dysarthric cohort was also significant. Confirmatory factor analysis did not validate the original 40-item scale but a 33-item scale maintaining the four domains of the original version. A significantly higher perception of QoL was found in the non-dysarthric group. The results indicate that the European Portuguese version of the QoL-DyS is a reliable and valid tool to assess QoL in patients with dysarthria and may be used for screening in clinical practice and in research.

Did Bioethics Matter? A History of Autonomy, Consent, and Intersex Genital Surgery.

This article argues that the rise of bioethics in the post-WWII era and the emergence of the legal doctrine of informed consent in the late 1950s should have had a greater impact on patients with intersex traits (atypical sex development) than they did, given their emphasis on respect for autonomy and beneficence toward patients. Instead, these progressive trends collided with a turn in intersex management toward infants, who were unable to provide autonomous consent about their medical care. Patient autonomy took a back seat as parents heeded physicians' advice in an environment even more hierarchical than we know today. Intersex care of both infants and adults continues to need improvement. It remains an open question whether the abstract ideals of bioethics-respect, patient autonomy, and the requirement of informed consent-are alone adequate to secure that improvement, or whether legal actions (or the threat of litigation) or some other reforms will be required to effect such change.

A Multicenter Performance Improvement Program Uses Rural Trauma Filters for Benchmarking: An Evaluation of the Findings.

Colorado requires Level III and IV trauma centers to conduct a formal performance improvement program (PI), but provides limited support for program development. Trauma program managers and coordinators in rural facilities rarely have experience in the development or management of a PI program. As a result, rural trauma centers often face challenges in evaluating trauma outcomes adequately. Through a multidisciplinary outreach program, our Trauma System worked with a group of rural trauma centers to identify and define seven specific PI filters based on key program elements of rural trauma centers. This retrospective observational project sought to develop and examine these PI filters so as to enhance the review and evaluation of patient care. The project included 924 trauma patients from eight Level IV and one Level III trauma centers. Seven PI filters were retrospectively collected and analyzed by quarter in 2016: prehospital managed airway for patients with a Glasgow Coma Scale (GCS) score of less than 9; adherence to trauma team activation criteria; evidence of physician team leader presence within 20 min of activation; patient with a GCS score less than 9 in the emergency department (ED): intubated in less than 20 min; ED length of stay (LOS) less than 4 hr from patient arrival to transfer; adherence to admission criteria; documentation of GCS on arrival, discharge, or with change of status. There was a significantly increasing compliance trend toward appropriate documentation of GCS (p trend < .001) and a significantly decreasing compliance trend for ED LOS of less than 4 hr (p trend = .04). Moving forward, these data will be used to develop compliance thresholds, to identify areas for improvement, and create corrective action plans as necessary.

What Hospitalists Should Know About Intersex Adults.

An intersex condition is one in which an individual is born with atypical male or female external genitalia, gonads, hormones, or chromosomes. Older terms, such as pseudohermaphroditism and hermaphroditism, are controversial, leading the Lawson Wilkins Pediatric Endocrine Society (LWPES) and the European Society for Paediatric Endocrinology (ESPE) to propose in 2006 the expression "disorders of sex development" (DSD), a contentious term in its own right, to define congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical. The birth of a child with DSD often prompts a long-term, multidisciplinary strategy, involving an array of health-care professionals. While much has been written about these potentially challenging management decisions, particularly those regarding infant genital surgery, very little has been written on the health management of intersex adults, and no literature exists regarding the role of the hospitalists-specialists in inpatient medicine-in the care of patients with DSD. With more than 50,000 members, Hospital Medicine represents the fast-growing subspecialty in the history of medicine. We believe hospitalists are uniquely positioned to provide high-quality care while educating trainees about issues pertinent to this often marginalized patient population. This essay poses a case study to explore some of the medical issues that intersex patients face as adults and that hospitalists will likely encounter.

Transgender Patients, Hospitalists, and Ethical Care.

Meeting the needs of current and future transgender individuals is a pressing medical concern. The transgender community faces unique health issues, including an elevated risk of HIV infection in male-to-female transgender people and high rates of violence, suicide, and substance abuse. Unfortunately, many trans people avoid seeking treatment because they have experienced discrimination, hostility, and refusal of medical care because of their status. Health-care workers who are not transphobic simply may not understand enough about the medical process of transitioning to adequately care for these patients. Hospitalists-specialists in inpatient medicine-are uniquely positioned to change this trajectory. We believe that as this burgeoning cohort of doctors takes on an expanded role in medicine, they should take the lead in the care of hospitalized transgender patients and in providing education to trainees about medical issues pertinent to this group of underserved and marginalized patients.

Verbal Fluency Tasks: Effects of Age, Gender, and Education.

OBJECTIVES: This study presents data for semantic fluency, phonemic fluency, action fluency, and alternate fluency. The aim is to provide normative data by age, gender, and education for European Portuguese in each fluency category. METHODS: Norms for the verbal fluency task were collected from a volunteer population of 444 healthy Portuguese participants. Multiple regression analysis with age, gender, and education as independent variables was performed for the semantic fluency global score, and these variables were considered separately for each phonemic category. RESULTS: Age, education, and gender significantly affected the semantic global score, as well as scores of names, supermarket, kitchen objects, food, and clothes. No gender effect was observed in the categories "p-words," animals, transports, verbs, and alternating fluency. This last category was only influenced by years of education. CONCLUSIONS: Equivalent scores of verbal fluency tasks are useful in clinical practice, allowing the comparison between the normal and the abnormal performance of language disorders.

Measuring Outcomes for Dysphagia: Validity and Reliability of the European Portuguese Eating Assessment Tool (P-EAT-10).

The purpose of this study was to evaluate the validity and the reliability of the European Portuguese version of the EAT-10 (P-EAT-10). This research was conducted in three phases: (i) cultural and linguistic adaptation; (ii) feasibility and reliability test; and (iii) validity tests. The final sample was formed by a cohort of 520 subjects. The P-EAT-10 index was compared for socio-demographic and clinic variables. It was also compared for both dysphagic and non-dysphagic groups as well as for the results of the 3Oz wst. Lastly, the P-EAT-10 scores were correlated with the EuroQol Group Portuguese EQ-5D index. The Cronbach's α obtained for the P-EAT-10 scale was 0.952 and it remained excellent even if any item was deleted. The item-total and the intraclass correlation coefficients were very good. The P-EAT-10 mean of the non-dysphagic cohort was 0.56 and that of the dysphagic cohort was 14.26, the mean comparison between the 3Oz wst groups and the P-EAT-10 scores were significant. A significant higher perception of QoL was also found among the non-dysphagic subjects. P-EAT-10 is a valid and reliable measure that may be used to document dysphagia which makes it useful both for screening in clinical practice and in research.

Hope Less: How a Healthy Dose of Realism Can Help in the ICU.

The author's father died recently after a sudden heart attack. This essay discusses how the family's experiences in the cardiac intensive care unit surprised her, even though she is a member of the Ethics Committee and the Ethics Consult Team at her local hospital, and how this led her to reconsider the ways in which families and hospital physicians communicate about the process of dying. How should doctors balance their messages of hope and realism when the situation is grim? Important judgment calls needed to be made, yet the family did not fully understand what they needed to know to make good decisions, especially the importance of the timing of their decisions. A conversation early on about what would happen if the patient became physically stable--no matter how impaired--while all options remained on the table might usefully (and mercifully) transform hope at the end.

Gene amplification mutations originate prior to selective stress in Acinetobacter baylyi.

The controversial theory of adaptive amplification states gene amplification mutations are induced by selective environments where they are enriched due to the stress caused by growth restriction on unadapted cells. We tested this theory with three independent assays using an Acinetobacter baylyi model system that exclusively selects for cat gene amplification mutants. Our results demonstrate all cat gene amplification mutant colonies arise through a multistep process. While the late steps occur during selection exposure, these mutants derive from low-level amplification mutant cells that form before growth-inhibiting selection is imposed. During selection, these partial mutants undergo multiple secondary steps generating higher amplification over several days to multiple weeks to eventually form visible high-copy amplification colonies. Based on these findings, amplification in this Acinetobacter system can be explained by a natural selection process that does not require a stress response. These findings have fundamental implications to understanding the role of growth-limiting selective environments on cancer development. We suggest duplication mutations encompassing growth factor genes may serve as new genomic biomarkers to facilitate early cancer detection and treatment, before high-copy amplification is attained.

Protective factors in the lives of bisexual adolescents in North America.

OBJECTIVES: We compared protective factors among bisexual adolescents with those of heterosexual, mostly heterosexual, and gay or lesbian adolescents. METHODS: We analyzed 6 school-based surveys in Minnesota and British Columbia. Sexual orientation was measured by gender of sexual partners, attraction, or self-labeling. Protective factors included family connectedness, school connectedness, and religious involvement. General linear models, conducted separately by gender and adjusted for age, tested differences between orientation groups. RESULTS: Bisexual adolescents reported significantly less family and school connectedness than did heterosexual and mostly heterosexual adolescents and higher or similar levels of religious involvement. In surveys that measured orientation by self-labeling or attraction, levels of protective factors were generally higher among bisexual than among gay and lesbian respondents. Adolescents with sexual partners of both genders reported levels of protective factors lower than or similar to those of adolescents with same-gender partners. CONCLUSIONS: Bisexual adolescents had lower levels of most protective factors than did heterosexual adolescents, which may help explain their higher prevalence of risky behavior. Social connectedness should be monitored by including questions about protective factors in youth health surveys.

Are Physicians Blameworthy for Iatrogenic Harm Resulting from Unnecessary Genital Surgeries?

We argue that physicians should, in certain cases, be held accountable by patients and their families for harm caused by "successful" genital surgeries performed for social and aesthetic reasons. We explore the question of physicians' blameworthiness for three types of genital surgeries common in the United States. First, we consider surgeries performed on newborns and toddlers with atypical sex development, or intersex. Second, we discuss routine neonatal male circumcision. Finally, we consider cosmetic vaginal surgery. It is important for physicians not just to know when and why to perform genital surgery, but also to understand how their patients might react to wrongful performance of these procedures. Equally, physicians should know how to respond to their own blameworthiness in socially productive and morally restorative ways.

Freezing Eggs and Creating Patients: Moral Risks of Commercialized Fertility.

There's no doubt that reproductive technologies can transform lives for the better. Infertile couples and single, lesbian, gay, intersex, and transgender people have the potential to form families in ways that would have been inconceivable years ago. Yet we are concerned about the widespread commercialization of certain egg-freezing programs, the messages they propagate about motherhood, the way they blur the line between care and experimentation, and the manipulative and exaggerated marketing that stretches the truth and inspires false hope in women of various ages. We argue that although reproductive technology, and egg freezing in particular, promise to improve women's care by offering more choices to achieve pregnancy and childbearing, they actually have the potential to be disempowering. First, commercial motives in the fertility industry distort women's medical deliberations, thereby restricting their autonomy; second, having the option to freeze their eggs can change the meaning of women's reproductive choices in a way that is limiting rather than liberating.