Advice for dementia carers: A critique of the literature.

Although hundreds of advice manuals for dementia carers have been published, most have serious limitations. They emphasize the various problems family members experience without noting the social and political context within which caring unfolds. As a result, they eschew structural reforms in favor of individual solutions, including self-care. The manuals also encourage carers to detach emotionally from people with dementia by viewing them in terms of their disease. In addition, the books hew so closely to the medical model of dementia that they ignore newer perspectives. Narratives by people with dementia provide a critical corrective. Those works argue that the disproportionate attention directed toward carers has eclipsed the perspective of people with dementia, that people remain individuals despite a dementia diagnosis, that issues of stigma and discrimination shape the experience of living with dementia, that more emphasis should be placed on promoting the autonomy of people with dementia, that they are entitled to reasonable accommodations, and that they should have more opportunities for growth. I have reviewed the policies detailed in the guide and have no competing interests.

Understanding the disconnect between lifestyle advice and patient engagement: a discourse analysis of how expert knowledge is constructed by patients with CHD.

OBJECTIVE: Adherence to healthy lifestyle advice is effective in prevention of non-communicable diseases like coronary heart disease (CHD). Yet patient disengagement is the norm. We take a novel discursive approach to explore patients' negotiation of lifestyle advice and behaviour change. METHOD: A discourse analysis was performed on 35 longitudinal interviews with 22 heterosexual British people in a long-term relationship, where one had a diagnosis of CHD. The analysis examined the relationships between patients' constructions of expert knowledge and the implications of these accounts for patients' dis/engagement with lifestyle advice. RESULTS: Expert knowledge was constructed in four ways: (1) Expert advice was valued, but adherence created new risks that undermined it; (2) expert knowledge was problematised as multiple, contradictory, and contested and therefore difficult to follow; (3) expert advice was problematised as too generalised to meet patients' specific needs; and (4) expert advice was understood as limited and only one form of valued knowledge. CONCLUSION: Patients and partners simultaneously valued and problematised expert knowledge, drawing on elaborate lay epistemologies relating to their illness which produced complex patterns of (dis)engagement with expert lifestyle advice. Recognition of the multiple and fluid forms of knowledge mobilised by CHD patients could inform more effective interventions.

Advice to future family physicians: findings from qualitative interviews with family medicine residents and early-career family physicians.

BACKGROUND: Canadians continue to report challenges accessing primary care. Practice choices made by primary care providers shape services available to Canadians. Although there is literature observing family medicine practice trends, there is less clarity on the reasoning underlying primary care providers' practice intentions. Advice offered by residents and early-career family physicians may reveal challenges they have experienced, how they have adapted to them, and strategies for new residents. In this paper, we examine advice family medicine residents and early-career family physicians would give to new family medicine residents. METHODS: Sixty early-career family physicians and thirty residents were interviewed as part of a mixed-methods study of practice patterns of family medicine providers in Canada. During qualitative interviews, participants were asked, "what advice would you give [a new family medicine resident] about planning their career as a family physician?" We inductively analyzed responses to this question. RESULTS: Advice consisted of understanding the current climate of family medicine (need for specialization, business management burden, physician burnout) and revealed reasons behind said challenges (lack of support for comprehensive clinic care, practical limitations of different practice models, and how payment models influence work-life balance). Subtheme analyses showed early-career family physicians being more vocal on understanding practical aspects of the field including practice logistics and achieving job security. CONCLUSION: Most advice mirrored current changes and challenges as well as revealing strategies on how primary care providers are handling the realities of practicing family medicine. Multi-modal systemic interventions may be needed to support family physicians throughout the changing reality of family medicine and ensure family medicine is an appealing specialty.

Enhancing the design of voting advice applications with BERT language model.

The relevance and importance of voting advice applications (VAAs) are demonstrated by their popularity among potential voters. On average, around 30% of voters take into account the recommendations of these applications during elections. The comparison between potential voters' and parties' positions is made on the basis of VAA policy statements on which users are asked to express opinions. VAA designers devote substantial time and effort to analyzing domestic and international politics to formulate policy statements and select those to be included in the application. This procedure involves manually reading and evaluating a large volume of publicly available data, primarily party manifestos. A problematic part of the work is the limited time frame. This study proposes a system to assist VAA designers in formulating, revising, and selecting policy statements. Using pre-trained language models and machine learning methods to process politics-related textual data, the system produces a set of suggestions corresponding to relevant VAA statements. Experiments were conducted using party manifestos and YouTube comments from Japan, combined with VAA policy statements from six Japanese and two European VAAs. The technical approaches used in the system are based on the BERT language model, which is known for its capability to capture the context of words in the documents. Although the output of the system does not completely eliminate the need for manual human assessment, it provides valuable suggestions for updating VAA policy statements on an objective, i.e., bias-free, basis.

[Analysis and Optimization Suggestions on Allowance Allocation Methods of the Power Industry in the Carbon Market].

The initial allocation of carbon emission allowances is an important component of the carbon market. An equitable, scientific, and operational quota allocation method and quota management system are the cornerstones for ensuring the healthy operation of the carbon market. Owing to the high emissions, simple process, and good data foundation, the pilot and national carbon market in China have initially included the power industry in allowance management and introduced a common and differentiated quota allocation method. In this study, we compared the allowance allocation methods for the power industry and summarized the methods for key issues such as unit classification, correction factor, product measurement, and quota carry-over. We observed that there were concerns, such as lagging issuance time, lack of carry-over provisions, lack of regulatory mechanisms, and imperfect methods, in the first performance cycle of the national carbon market quota allocation. We improved the allowance allocation system for the power industry in the carbon market from the methodological and management perspectives, including establishing a total allowance constraint, clarifying quota carry-over provisions, improving the quota verification method for co-firing units, optimizing correction factors' selection, and introducing a compensatory distribution system in a timely manner.

Discharge Against Medical Advice: The Causes, Consequences and Possible Corrective Measures.

Patients who discharge themselves against medical advice comprise 1%-2% of hospital admissions. Discharge against medical advice (DAMA) is defined as when a hospitalised patient chooses to leave the hospital before the treating medical team recommends discharge. The act of DAMA impacts on both the patient, the staff and their ongoing care. Specifically, this means that the patient's medical problems maybe inadequately assessed or treated. Patients who decide to DAMA tend to be young males, from a lower socioeconomic background and with a history of mental health or substance misuse disorder. DAMA has an associated increased risk of morbidity and mortality. In this review of studies across Western healthcare settings, specifically adult medical inpatients, we will review the evidence and seek to address the causes, consequences and possible corrective measures in this common scenario.

What nutrition advice is freely available for gymnasts, coaches and parents on their member National Governing Body webpages?

The purpose of this content analysis was to ascertain what nutrition advice or information is freely available on a global scale through each National Governing Body (NGB) webpage. In total, 52 NGBs and the International Federation of Gymnastics (FIG) were identified based on the FIG November 2022 world rankings for both male and female athletes in all disciplines. Concluding observations were that publicly available nutrition advice is limited across the global gymnastics platforms. Conflicting advice was also identified within some organisations surrounding the weighing of gymnasts for hydration purposes and some macronutrient discrepancies thus, potentially impacting the clarity of the message for the reader. Based on this content analysis recommendations for future practice include providing clarity and provision of tools to measure hydration, dietary recommendations should be clear and specific, and a more centralised approach to standardise advice and publicly available information.

A study of "left against medical advice" emergency department patients: an optimized explainable artificial intelligence framework.

The issue of left against medical advice (LAMA) patients is common in today's emergency departments (EDs). This issue represents a medico-legal risk and may result in potential readmission, mortality, or revenue loss. Thus, understanding the factors that cause patients to "leave against medical advice" is vital to mitigate and potentially eliminate these adverse outcomes. This paper proposes a framework for studying the factors that affect LAMA in EDs. The framework integrates machine learning, metaheuristic optimization, and model interpretation techniques. Metaheuristic optimization is used for hyperparameter optimization-one of the main challenges of machine learning model development. Adaptive tabu simulated annealing (ATSA) metaheuristic algorithm is utilized for optimizing the parameters of extreme gradient boosting (XGB). The optimized XGB models are used to predict the LAMA outcomes for patients under treatment in ED. The designed algorithms are trained and tested using four data groups which are created using feature selection. The model with the best predictive performance is then interpreted using the SHaply Additive exPlanations (SHAP) method. The results show that best model has an area under the curve (AUC) and sensitivity of 76% and 82%, respectively. The best model was explained using SHAP method.

Leaving Against Medical Advice: Current Problems and Plausible Solutions.

Leave against medical advice (LAMA) is defined as 'a decision to leave the hospital before the treating physician recommends discharge', and is associated with higher rates of readmission, longer subsequent hospitalization, and worse health outcomes. In addition to this, they also contribute to poor healthcare resource utilization. We conducted a single-center audit to establish patient demographics and contributing factors of patients leaving against medical advice from our emergency department (ED). We benchmarked our data against locally available clinical policy guidelines. We interrogated our electronic health record system (known as Salamtak®), which is a Cerner-based platform (Cerner Corporation, Kansas City, MO 64138) for patients who signed LAMA from ED from 2018 to 2023. We selected a convenience pilot sample of 120 subjects. Based on a literature review, we identified patient demographics (age, gender, nationality, socioeconomic status, marital status, religion), possible contributing factors (time of attendance, insurance status, length of ED stay), and patient outcomes (reattendances within 1 week and mortality) to evaluate. Based on locally available guidance, we formulated six criteria to audit with a standard set at 100% for each. A team of emergency medicine residents collected data that was anonymized on an Excel spreadsheet (Microsoft Excel, Microsoft Corporation. (2018). Basic descriptive statistics were used to collate results. About 93 patients (77.5%) were 16 years and above, and 27 patients (22.5%) were below 16 years. There was a slight preponderance of males (64 patients, 53.3%) than females (56 patients, 46.6%). The majority of LAMA cases presented in the evening and night (97 patients, 80.8%). About 57 (47.5%) patients had an ED length of stay of 3 hours or more. The average ED length of stay for these patients was 3.4 hours. About 73 patients (60.3%) were insured. Out of 120 patients, only 12 (10%) had a mental capacity assessment documented. The commonest reason for signing LAMA was a social reason in 45 (37.5%) cases. In the remaining cases, the causes were a combination of family, financial, waiting, or other/undocumented reasons). When faced with a decision to LAMA, the involvement of a Public Relationship Officer (PRO) was only documented to be consulted in seven (5.8%) cases. About 14 cases were re-attended within 1 week (11.6%) and no mortalities were reported in any of the reattendances. LAMA is a not-so-rare phenomenon often occurring in EDs, and often a cause of trepidation for healthcare workers. Treating this as an aberrant behavior on the part of the patient, or laying the responsibility for this action on the healthcare provider is primitive, counter-productive, and not patient-centric. Familiarity with local guidelines around this contentious area is essential. Revised nomenclature like 'premature discharge' may be less stigmatizing for the patient. Where possible, a harm reduction approach should be used and frontline healthcare workers must be prepared with an escalation plan. In the United Arab Emirates, familiarity with Wadeema's Law as a child protection measure is essential.

The process of developing and implementing health and nursing policy: Implications of research and opportunities to influence.

AIM: To provide insight into the process of developing health and nursing policy and how that process can be influenced by both researchers and nursing leaders. BACKGROUND: Nurses care for people across the life course from birth to death, in our communities, hospitals, care homes and schools. They have unique insight into how people live their lives and how this affects their health. Despite being well placed to influence health policy, nurses often fail to capitalise on this. At the same time, academics often struggle to identify the policy implications of their research resulting in further missed opportunities to use policy influence. SOURCES OF EVIDENCE: Classical policy theory, which is predominantly drawn from economics and public administration together with a range of contemporary nursing and health policy studies, is used in this paper to discuss the policy process and opportunities to influence. DISCUSSION: Researchers need to focus on realistic policy suggestions that aim to raise awareness, highlight policy problems or set the agenda. In turn, nursing leaders, from National Nursing Associations, need to harness evidence to support their efforts to influence policy. In terms of influence, a range of approaches exist, and each lends itself to different parts of the policy cycle. CONCLUSION: The role nurses can play in health policy is not well developed in many countries. Nursing researchers and leaders are well placed to influence policy but must do so in a clear and pragmatic way recognising that policymakers make decisions despite being faced with conflicting evidence, competing demands and economic imperatives. IMPLICATIONS FOR NURSING PRACTICE: Recognising that nurses can offer much in terms of policy development, the paper argues that a pragmatic approach based on different forms of influence at different stages is likely to be most successful. IMPLICATIONS FOR NURSING AND HEALTH POLICY: The evidence reviewed in this paper suggests that nursing academics and leaders need to identify realistic policy interventions when examining their own empirical work or identifying ways to individually or collectively influence policymakers.

Prompt engineering on leveraging large language models in generating response to InBasket messages.

OBJECTIVES: Large Language Models (LLMs) have been proposed as a solution to address high volumes of Patient Medical Advice Requests (PMARs). This study addresses whether LLMs can generate high quality draft responses to PMARs that satisfies both patients and clinicians with prompt engineering. MATERIALS AND METHODS: We designed a novel human-involved iterative processes to train and validate prompts to LLM in creating appropriate responses to PMARs. GPT-4 was used to generate response to the messages. We updated the prompts, and evaluated both clinician and patient acceptance of LLM-generated draft responses at each iteration, and tested the optimized prompt on independent validation data sets. The optimized prompt was implemented in the electronic health record production environment and tested by 69 primary care clinicians. RESULTS: After 3 iterations of prompt engineering, physician acceptance of draft suitability increased from 62% to 84% (P <.001) in the validation dataset (N = 200), and 74% of drafts in the test dataset were rated as "helpful." Patients also noted significantly increased favorability of message tone (78%) and overall quality (80%) for the optimized prompt compared to the original prompt in the training dataset, patients were unable to differentiate human and LLM-generated draft PMAR responses for 76% of the messages, in contrast to the earlier preference for human-generated responses. Majority (72%) of clinicians believed it can reduce cognitive load in dealing with InBasket messages. DISCUSSION AND CONCLUSION: Informed by clinician and patient feedback synergistically, tuning in LLM prompt alone can be effective in creating clinically relevant and useful draft responses to PMARs.

Does "Dr. Google" improve discussion and decisions in small animal practice? Dog and cat owners use of internet resources to find medical information about their pets in three European countries.

Modern dog and cat owners increasingly use internet resources to obtain information on pet health issues. While access to online information can improve owners' knowledge of patient care and inform conversations with their veterinarian during consultations, there is also a risk that owners will misinterpret online information or gain a false impression of current standards in veterinary medicine. This in turn can cause problems or tensions, for example if the owner delays consulting their veterinarian about necessary treatment, or questions the veterinarian's medical advice. Based on an online questionnaire aimed at dog and cat owners in Austria, Denmark and the United Kingdom (N = 2117) we investigated the use of internet resources to find veterinary medical information, the type of internet resources that were used, and whether owner beliefs explain how often they used the internet to find medical information about their pet. Approximately one in three owners reported that they never used internet resources prior to (31.7%) or after (37.0%) a consultation with their veterinarian. However, when owners do make use of the internet, our results show that they were more likely to use it before than after the consultation. The most common internet resources used by owners were practice websites (35.0%), veterinary association websites (24.0%), or 'other' websites providing veterinary information (55.2%). Owners who believe that the use of internet resources enables them to have a more informed discussion with their veterinarians more often use internet resources prior to a consultation, whereas owners who believed that internet resources help them to make the right decision for their animal more often use internet resources after a consultation. The results suggest that veterinarians should actively ask pet owners if they use internet resources, and what resources they use, in order to facilitate open discussion about information obtained from the internet. Given that more than a third of pet owners use practice websites, the findings also suggest that veterinarians should actively curate their own websites where they can post information that they consider accurate and trustworthy.

The Unhoused Burn Population: An Alarming Increase of Leaving Against Medical Advice.

Unhoused burn patients (UBP) have historically been more likely to leave against medical advice (AMA) and suffer worse health outcomes than the general population. The coronavirus disease 2019 (COVID-19) pandemic created a major strain on the healthcare system, resulting in worse overall health outcomes for burn patients. We sought to investigate how COVID-19 impacted treatment for UBP, specifically the rate of leaving AMA. We conducted a retrospective chart analysis of patients admitted to a regional burn center between June 2015 and January 2023. March 1, 2020, was used as a cut point to separate the cohorts into patients seen pre-COVID-19 (p-CV) and during COVID-19 (CV). Outcomes included leaving treatment AMA and readmission within 30 days. 385 patients met criteria for being unhoused and were included in our analytic sample, of which 199 were in the p-CV cohort and 186 in the CV cohort. UBP were significantly more likely to leave AMA during CV compared to p-CV (22.6% vs. 7.5%, p<0.001). Housed burn patients did not experience an increase in discharges AMA during this time period. The COVID-19 pandemic resulted in an increase in discharges AMA among unhoused patients only. While the etiology is unclear, our findings suggest that this vulnerable patient population is receiving inadequate care post-COVID. Future research should determine the driving force behind these increases and identify early interventions to mitigate them.

Updated review on contaminant communication experiences in the circumpolar Arctic.

Arctic populations are amongst the highest exposed populations to long-range transported contaminants globally, with the main exposure pathway being through the diet. Dietary advice is an important immediate means to address potential exposure and help minimize adverse health effects. The objective of this work is to enable easier access to dietary advice and communication guidance on contaminants with a focus on the Arctic. This manuscript is part of a special issue summarizing the Arctic Monitoring and Assessment Programme's Assessment 2021: Human Health in the Arctic. The information was derived with internet searches, and by contacting relevant experts directly. Results include risk communication efforts in European Arctic countries, effectiveness evaluation studies for several Arctic countries, experience of social media use, and the advantages and challenges of using social media in risk communication. We found that current risk communication activities in most Arctic countries emphasize the importance of a nutritious diet. Contaminant-related restrictions are mostly based on mercury; a limited amount of dietary advice is based on other contaminants. While more information on effectiveness evaluation was available, specific information, particularly from Arctic countries other than Canada, is still very limited.

Assessing GPT-4's Performance in Delivering Medical Advice: Comparative Analysis With Human Experts.

Background: Accurate medical advice is paramount in ensuring optimal patient care, and misinformation can lead to misguided decisions with potentially detrimental health outcomes. The emergence of large language models (LLMs) such as OpenAI's GPT-4 has spurred interest in their potential health care applications, particularly in automated medical consultation. Yet, rigorous investigations comparing their performance to human experts remain sparse. Objective: This study aims to compare the medical accuracy of GPT-4 with human experts in providing medical advice using real-world user-generated queries, with a specific focus on cardiology. It also sought to analyze the performance of GPT-4 and human experts in specific question categories, including drug or medication information and preliminary diagnoses. Methods: We collected 251 pairs of cardiology-specific questions from general users and answers from human experts via an internet portal. GPT-4 was tasked with generating responses to the same questions. Three independent cardiologists (SL, JHK, and JJC) evaluated the answers provided by both human experts and GPT-4. Using a computer interface, each evaluator compared the pairs and determined which answer was superior, and they quantitatively measured the clarity and complexity of the questions as well as the accuracy and appropriateness of the responses, applying a 3-tiered grading scale (low, medium, and high). Furthermore, a linguistic analysis was conducted to compare the length and vocabulary diversity of the responses using word count and type-token ratio. Results: GPT-4 and human experts displayed comparable efficacy in medical accuracy ("GPT-4 is better" at 132/251, 52.6% vs "Human expert is better" at 119/251, 47.4%). In accuracy level categorization, humans had more high-accuracy responses than GPT-4 (50/237, 21.1% vs 30/238, 12.6%) but also a greater proportion of low-accuracy responses (11/237, 4.6% vs 1/238, 0.4%; P=.001). GPT-4 responses were generally longer and used a less diverse vocabulary than those of human experts, potentially enhancing their comprehensibility for general users (sentence count: mean 10.9, SD 4.2 vs mean 5.9, SD 3.7; P<.001; type-token ratio: mean 0.69, SD 0.07 vs mean 0.79, SD 0.09; P<.001). Nevertheless, human experts outperformed GPT-4 in specific question categories, notably those related to drug or medication information and preliminary diagnoses. These findings highlight the limitations of GPT-4 in providing advice based on clinical experience. Conclusions: GPT-4 has shown promising potential in automated medical consultation, with comparable medical accuracy to human experts. However, challenges remain particularly in the realm of nuanced clinical judgment. Future improvements in LLMs may require the integration of specific clinical reasoning pathways and regulatory oversight for safe use. Further research is needed to understand the full potential of LLMs across various medical specialties and conditions.

A national survey of rheumatology telephone advice line support in the United Kingdom: frontline perspectives.

Objectives: Telephone advice lines are a key component of rheumatology services. A national survey of telephone advice line providers was undertaken to explore how this service is currently delivered and the impact on those delivering it to inform providers, policymakers and patients. Methods: We conducted an online survey between March and September 2023 collecting data on demographics, how advice lines function, governance and the impact on nurses' well-being. Data were analysed using descriptive statistics. Results: A total of 123 health professionals completed the survey. The majority were rheumatology nurses [n = 118 (96%)], >45 years of age [n = 112 (91%)], band ≥7 [n = 92 (76%)], with 77 (65%) reporting >10 years of experience within rheumatology. Most advice lines operated weekdays only [n = 93 (79%)], with most calls returned within 2 days [n = 81 (66%)], although some callers waited >7 days [n = 19 (15%)]. The number of calls received monthly ranged from 100 to >800, with 46 (37%) responders reporting >500 calls/month. The most common reasons for contacting advice lines were disease activity, pain and medication concerns. For most responders, governance arrangements were unclear [n = 72 (61%)]. Providing advice lines impacted on the well-being of nurses providing the service: 89 (72%) felt anxious 'sometimes to mostly' and 79 (64%) found it 'mostly-always' stressful. A total of 85 (69%) nurses had not received any training to manage advice lines. Conclusion: Although telephone advice lines are provided by experienced rheumatology nurses, high demand is impacting on well-being. Having designated training could equip nurses with additional skills to manage increased capacity and monitor their own well-being.

In their own words: advice from parents of children with cancer.

BACKGROUND: Approximately 770 children are diagnosed with cancer in Australia every year. Research has explored their experiences and developed recommendations for improving support provided to families. These have included the provision of psychology services, improved communication between healthcare professionals and parents, and increased information for families. METHODOLOGY: In our hermeneutic phenomenological study, 44 participants (21 fathers and 23 mothers), with ages ranging from 28 to 51 years (M = 37 years, SD = 5.6 years) were interviewed. Interviews ranged from 45 to 150 min (M = 65 min, SD = 18 min) duration. FINDINGS: Thematic analysis of the data generated seven themes. Take it second by second; Find some normality; Take care of yourself; You need to talk to someone; Just take all the help; Speaking up for your child; and Take care of the siblings. CONCLUSION: The results of our study provide firsthand advice from parents. The overwhelming theme that emerged is that while many parents revealed that they had not asked for or received support, in hindsight they unanimously reflected that they wished they had sought out services. The strength of this study is that parents are more likely to accept the advice of other parents with a shared lived experience. The results of our study can be used to develop resources that could be provided to parents. These resources would emphasize that the recommendations come from parents who have traveled the same path and have learnt from hindsight and experience.

Implementing Individually Tailored Prescription of Physical Activity in Routine Clinical Care: A Process Evaluation of the Physicians Implement Exercise = Medicine Project.

BACKGROUND: Although the prescription of physical activity in clinical care has been advocated worldwide, in the Netherlands, "Exercise is Medicine" (E = M) is not yet routinely implemented in clinical care. METHODS: A set of implementation strategies was pilot implemented to test its feasibility for use in routine care by clinicians in 2 departments of a university medical center. An extensive learning process evaluation was performed, using structured mixed methods methodology, in accordance with the Reach, Effect, Adoption, Implementation, and Maintenance framework. RESULTS: From 5 implementation strategies employed (education, E = M tool embedded in the electronic medical records, lifestyle coach situated within the department, overviews of referral options, and project support), the presence of adequate project support was a strong facilitator of the implementation of E = M. Also, the presence of the lifestyle coach within the department seemed essential for referral rate. Although clinicians appreciated the E = M tool, barriers hampered its use in practice. CONCLUSIONS: Specific implementation strategies, tailored to the setting, are effective in facilitating the implementation of E = M with specific regard to education for clinicians on E = M, deployment of a lifestyle coach within a department, and project coordination. Care providers do see a future for lifestyle coaches who are structurally embedded in the hospital, to whom they can easily refer.