Pediatric Irritable Bowel Syndrome: Perspectives on Pain and Adolescent Social Functioning.

OBJECTIVE: The goal of the study was to describe the experiences of adolescents with irritable bowel syndrome (IBS) from the perspective of adolescents, their parents, and health care providers who treat adolescents who have IBS. DESIGN: The study consisted of semistructured interviews. SETTING: Participants were recruited from multidisciplinary pain clinics. SUBJECTS: Thirty-six people participated in the study: 12 adolescents, 12 parents, and 12 health care providers. RESULTS: Two main themes associated with the impact of IBS on adolescents' social functioning emerged from the qualitative interview data: 1) disconnection from peers and 2) strain on family relationships, with subthemes reflecting the perspectives of adolescents, parents, and health care providers. CONCLUSIONS: Participants in our study described that adolescents with IBS encounter significant peer- and family-related social stress. Helpful interventions may be those that focus on social support from other adolescents with similar conditions, as well as family-based therapeutic interventions.

Formulating evidence-based guidelines for certified nurse-midwives and certified midwives attending home births.

INTRODUCTION: Implementing national home birth guidelines for certified nurse-midwives (CNMs) and certified midwives (CMs) in the United States may facilitate a common approach to safe home birth practices. Guidelines are evidence-based care recommendations for specified clinical situations that can be modified by individual providers to meet specific client needs. METHODS: Following a review of home birth guidelines from multiple countries, a set of home birth practices guidelines for US CNMs/CMs was drafted. Fifteen American Midwifery Certification Board, Inc. (AMCB)-certified home birth midwives who participate in the American College of Nurse-Midwives (ACNM) home birth electronic mailing list considered the use of such a document in their practices and reviewed and commented on the guidelines. RESULTS: The proposed guidelines addressed client screening, informed consent, antepartum care, routine intrapartum care, obstetric complications and hospital transports, postpartum care, neonatal care, gynecologic care, primary care, peer reviews, recordkeeping, and physician collaboration. The reviewers had varying assessments as to whether the guidelines reflected international standards and current best evidence. The primary concern expressed was that an adoption of national guidelines could compromise provider autonomy. DISCUSSION: Incorporation of evidence-based guidelines is an ACNM standard and was recommended by the Home Birth Consensus Summit. Clinical practice guidelines are informed by current evidence and supported by experts in a given discipline. Implementation of guidelines ensures optimal patient care and is becoming increasingly central to reimbursement and to medicolegal support. A set of practice guidelines based on current best evidence and internationally accepted standards was developed and reviewed by an interested group of US CNMs/CMs. Further discussion with home birth midwives and other stakeholders about the development and implementation of home birth guidelines is needed, especially in light of this project's finding of less support for national home birth guidelines among the reviewers subsequent to versus prior to their review of the draft guidelines.

Phosphorus in Phoenix: a budget and spatial representation of phosphorus in an urban ecosystem.

As urban environments dominate the landscape, we need to examine how limiting nutrients such as phosphorus (P) cycle in these novel ecosystems. Sustainable management of P resources is necessary to ensure global food security and to minimize freshwater pollution. We used a spatially explicit budget to quantify the pools and fluxes of P in the Greater Phoenix Area in Arizona, USA, using the boundaries of the Central Arizona-Phoenix Long-Term Ecological Research site. Inputs were dominated by direct imports of food and fertilizer for local agriculture, while most outputs were small, including water, crops, and material destined for recycling. Internally, fluxes were dominated by transfers of food and feed from local agriculture and the recycling of human and animal excretion. Spatial correction of P dynamics across the city showed that human density and associated infrastructure, especially asphalt, dominated the distribution of P pools across the landscape. Phosphorus fluxes were dominated by agricultural production, with agricultural soils accumulating P. Human features (infrastructure, technology, and waste management decisions) and biophysical characteristics (soil properties, water fluxes, and storage) mediated P dynamics in Phoenix. P cycling was most notably affected by water management practices that conserve and recycle water, preventing the loss of waterborne P from the ecosystem. P is not intentionally managed, and as a result, changes in land use and demographics, particularly increased urbanization and declining agriculture, may lead to increased losses of P from this system. We suggest that city managers should minimize cross-boundary fluxes of P to the city. Reduced P fluxes may be accomplished through more efficient recycling of waste, therefore decreasing dependence on external nonrenewable P resources and minimizing aquatic pollution. Our spatial approach and consideration of both pools and fluxes across a heterogeneous urban ecosystem increases the utility of nutrient budgets for city managers. Our budget explicitly links processes that affect P cycling across space with the management of other resources (e.g., water). A holistic management strategy that deliberately couples the management of P and other resources should be a priority for cities in achieving urban sustainability.