Home Birth in the United States: An Evidence-Based Ethical Analysis.

AbstractThe assumption in current U.S. mainstream medicine is that birthing requires hospitalization. In fact, while the American College of Obstetricians and Gynecologists supports the right of every birthing person to make a medically informed decision about their delivery, they do not recommend home birth owing to data indicating greater neonatal morbidity and mortality. In this article, we examine the evidence surrounding home birth in the United States and its current limitations, as well as the ethical considerations around birth setting.

Opioid receptor system contributes to the acute and sustained antidepressant-like effects, but not the hyperactivity motor effects of ketamine in mice.

In 2000, a subanesthetic dose (0.5 mg/kg i.v.) of the dissociative anesthetic ketamine was reported to have both rapid and robust antidepressant effects in patients diagnosed with major depressive disorder and later, ketamine also was shown to be effective in treatment-resistant depressed patients. However, the mechanisms responsible for ketamine's antidepressant effects remain unclear. In 2018, a clinical study reported that pretreatment with the nonselective opioid antagonist naltrexone attenuated the rapid antidepressant effect of ketamine in depressed patients. The current study investigated the potential role of the opioid receptor system in the acute and sustained antidepressant-like and hyperactive effects of ketamine. Mice were tested in the tail suspension test (TST) and differential-reinforcement-of-low-rate responding (DRL) 72 s task which are behavioral screens for antidepressant-like properties. Additionally, open field locomotor activity also was measured. In all behavioral assays, mice were pretreated with the nonselective opioid receptor antagonist naltrexone or saline prior to ketamine administration. The current study found that ketamine (10 mg/kg) produced acute (30 min) and sustained (24 h) antidepressant-like effects in TST, which were attenuated by pretreatment of 2 mg/kg naltrexone. Ketamine (32 mg/kg) also produced an acute antidepressant-like effect in the DRL 72 s task that was attenuated by pretreatment of 2 mg/kg naltrexone. Finally, ketamine (10 and 32 mg/kg) produced hyperactivity in the open field; however, pretreatment with 2 mg/kg naltrexone failed to block the hyperactivity effects ketamine. These results, along with recent clinical findings, suggest that ketamine's antidepressant effects, but not its hyperactive effects, involve activation of the opioid system.

The Relationship Between Patient Satisfaction With Hospitalization and Outcomes Up to 6 Months Post-Discharge in Cardiac Patients.

Little is known about the relationship between patient satisfaction with inpatient care and post-discharge outcomes. This study examined inpatient hospital satisfaction after a cardiac event and outcomes through 6 months post-discharge. We examined 327 cardiac patients from the Bridging the Discharge Gap Effectively database who completed a patient satisfaction survey about their hospital admission and had post-discharge outcomes data. Higher patient satisfaction with the discharge process correlated with fewer readmissions at 90 days post-discharge. Higher patient satisfaction with hospital staff management of personal issues correlated with fewer emergency department visits at 6 months post-discharge. Higher patient satisfaction with overall assessment of care and hospitalization correlated with lower mortality rate at 6 months post-discharge. Being nonwhite correlated with lower nursing care satisfaction. Associations between cardiac patient satisfaction and outcomes exist. In this population, higher patient satisfaction correlated with better outcomes. Patient satisfaction data may be able to inform areas for health system improvement.

Mindfulness for Healthcare Providers: The Role of Non-Reactivity in Reducing Stress.

CONTEXT: There is strong evidence in the literature that the cultivation of mindfulness through programs such as Mindfulness-Based Stress Reduction (MBSR) has a profound impact on perceived stress for healthcare providers. The mechanism of the latter association is still being studied. However, it has been hypothesized that in particular, the cultivation of non-reactivity as a mindfulness skill may be particularly associated with the salutary effect of MBSR to reduce stress in health care providers even if adjusted for the benefit on quality of life gained after MBSR. The latter may represent important mechanistic information to build customized mindfulness interventions for health care providers. OBJECTIVE: Determine whether the change in non-reactivity to inner experience after MBSR is associated with the adjusted changes in perceived stress after MBSR. DESIGN: a Cross-sectional study. SETTING: A large, Midwestern teaching hospital. PARTICIPANTS: 100 health care providers. INTERVENTION: 8-week standard MBSR course. MAIN OUTCOME MEASURES: Perceived Stress Scale-10, Linear Analog Scale Assessment to measure Quality of life, and the mindfulness domain non-reactivity to inner experience was assessed by the non-reactivity subscale of the Five Facet Mindfulness Questionnaire. All measures were administered at baseline and completion of the intervention. RESULTS: The change from baseline to completion of MBSR was significant for all variables, with moderate-to-robust effect sizes. There was a significant negative correlation between non-reactivity and perceived stress both at baseline (p < 0.0001) and when comparing changes in scores from baseline to post-intervention (p < 0.0001). Change in non-reactivity to inner experience was robustly associated with the change in perceived stress (p < 0.0001) after MBSR (97% in 5000 bootstrapped models). CONCLUSION: Non-reactivity to inner experience is a key aspect of MBSR that is independently associated with a change in perceived stress in health care providers.

Bridging the gap between physician and medical student education: using the Train the Trainer model to improve cultural competence training in the clerkship years of medical school.

Cultural competence (CC) training has become a required part of medical education to create future physicians dedicated to decreasing health disparities. However, current training seems to be inadequate as research has demonstrated gaps between CC training and clinical behaviors of students. One aspect that is potentially contributing to this gap is the lack of physician education of CC. Without it being something not only taught in the classroom, but also modeled and taught in the clinical setting, CC will continue to be a theoretical concept instead of a skill set that changes the way that future physicians interact with patients and make decisions about patient care. To change this, we propose the implementation of a Train the Trainer model in which the preclinical professor in charge of CC education trains Clerkship and Residency Directors who then can train and supervise the physicians and residents in their departments on CC to better implement it into the formal and informal curriculum of clerkships.

Development and Feasibility of a Home Pulmonary Rehabilitation Program With Health Coaching.

BACKGROUND: Pulmonary rehabilitation (PR) is an effective intervention for COPD. However, traditional center-based PR programs suffer from low uptake. Home-based PR is a viable solution, but few studies have shown the effectiveness of remote PR, as there is a scarcity of systems that can be easily adopted in clinical practice. The aim of this report is to communicate the development and feasibility of a home PR program that includes commercially available technology that allows the PR health coach to follow the patient through his or her PR process and to present the design of a prospective clinical trial. METHODS: We developed a home PR system that includes a computer tablet, an activity monitor, and an oximeter connected to a cloud server. The home PR consists of 12 min of walking and 6 full-body exercises, to be completed 6 d/week, plus weekly telephone calls with the PR health coach. Two pilot studies were conducted in subjects with moderate-to-severe COPD. The first aimed to fine-tune the system development (N = 3), and the second tested the program feasibility of the 8-week program (N = 12). RESULTS: In pilot study 1, PR monitoring data from the subjects' home PR sessions were transmitted to the health coach application successfully. On a 10-point scale, participants rated the system as helpful (median = 8, interquartile range 8-9) and simple to use (median = 10, interquartile range 9-10). In pilot study 2, adherence ± SD for prescribed use was 87 ± 0.24%. Overall, participants gave the home PR system a rating of 6.2 ± 0.94 on a 7-point scale. CONCLUSIONS: A home PR program was developed that integrated health coaching and a home PR system that facilitated remote monitoring. Pilot testing indicated that the program is well-developed and feasible in a population of individuals with COPD. (ClinicalTrials.gov registration NCT02999685.).