A systematic review of the aetiology and management of post cholecystectomy syndrome.

BACKGROUND: 10% of patients who undergo a cholecystectomy go on to develop post-cholecystectomy syndrome (PCS). The majority of these patients may suffer from extra-biliary or unrelated organic disorders that may have been present before cholecystectomy. The numerous aetiological causes of PCS result in a wide spectrum of management options, each with varying success in abating symptoms. This systematic review aims to provide a summary of the causative aetiologies of post cholecystectomy syndrome, their incidences and efficacy of available management options. METHODS: The Medline, Embase and Cochrane databases were searched for studies patients who developed PCS symptoms following laparoscopic cholecystectomy, published between 1990 and 2016. The aetiology, incidence and management options were extracted, with separate collation of randomised control trials and non-randomised studies that reported intervention. Outcomes included recurrent symptoms following intervention, unscheduled primary and secondary care attendances and complications. RESULTS: Twenty-one studies were included (15 case series, 2 cohort studies, 1 case control, 3 RCTs). Five studies described medical treatment (nifedipine, cisapride, opiates); seven studies described endoscopic or surgical intervention. Early presentation of PCS (<3 years post-cholecystectomy) was more likely to be gastric in origin, and later presentations were found to be more likely due to retained stones. Sphincter of Oddi dysfunction (SOD) accounted for a third of cases in an unselected population with PCS. CONCLUSIONS: Causes of post cholecystectomy syndrome are varied and many can be attributed to extra-biliary causes, which may be present prior to surgery. Early symptoms may warrant early upper gastrointestinal endoscopy. Delayed presentations are more likely to be associated with retained biliary stones. A large proportion of patients will have no cause identified. Treatment options for this latter group are limited.

Sustainability in quality improvement: redefining value.

Sustainability can be considered a domain of quality in -healthcare, extending the responsibility of health services to patients not just of today but of the future. The longer term -perspective highlights the impacts of our healthcare system on our environment and communities and in turn back onto population health. A sustainable approach will therefore expand the healthcare definition of value to measure health outcomes against environmental and social impacts alongside financial costs. We set out a practical framework for including these new dimensions in an already well-defined model of quality improvement. This has the potential to harness the growing quality improvement movement to shape a more sustainable health service, while improving patient outcomes. Early experience suggests that the new model may also provide immediate -benefits, including additional motivation for clinicians to engage in quality improvement, directing their efforts towards high value interventions and enabling capture and communication of a wider range of impacts on patients, staff and communities.

Sustainability in quality improvement: measuring impact.

'Sustainable value' considers patient and population outcomes against environmental, social and economic costs or impacts, providing a framework for driving sustainable improvements in healthcare for current and future generations. Measuring the impact of a quality improvement initiative on sustainable value is a new endeavour. For this to be both meaningful and useful, we must balance academic rigour (using a reproducible methodology to capture the most relevant and important impacts) against pragmatism (working within the constraints of available time and data). Using case studies, we discuss how the different variables of sustainable value may be measured in practice.

Changing the face of STEM with stormwater research.

BACKGROUND: The University of Maine Stormwater Management and Research Team (SMART) program began in 2014 with the goal of creating a diverse science-technology-engineering-math (STEM) pathway with community water research. The program engages female and underrepresented minority high school students in locally relevant STEM research. It focuses on creating educational experiences that are active and relevant to students that build confidence, connect knowledge and skills directly to solving problems in local communities, and support student cultural identities. The core tools of the SMART program are resources and relationships: university-designed or commercial water data collection equipment, data loggers and chemistry supplies, on-campus science and engineering training for teacher-mentors and students, and a community mentor network. The program supports an annual summer institute that trains both students and teacher-mentors and academic-year student research projects. SMART groups are formed at local schools or community centers. Activities revolve around engaging students in citizen-science to expand their understanding of the environment, developing community strategies to address the complex problem of stormwater pollution, and using the tools of science, engineering, and technology effectively. In addition, the program supports teachers and students in reaching out to local science and engineering professionals to form a mentor network for student research. RESULTS: Over 3 years, 220 students and 25 teachers have been trained in the science and engineering of stormwater, having taken and recorded over 4000 local water measurements (i.e., temperature, conductivity, pH). In all cohorts to date, over 75% of student participants have self-identified as either female or a racial minority. Of approximately 125 currently college-eligible former and current SMART students, more than 41% have been accepted or are enrolled in a secondary STEM degree program. In pre- and post-program surveys, female and underrepresented minority students reported that SMART activities and their relationship with mentors have increased their awareness of how stormwater affects the community and increased their interest in pursuing a STEM career. CONCLUSION: With its focus on problem-solving at the community level, SMART supports students in active, local, and culturally relevant science and engineering experiences that contribute to building their confidence and affirming their decision to pursue post-secondary STEM careers.

Diagnostic and therapeutic treatment modalities for acute lower gastrointestinal bleeding: a systematic review.

BACKGROUND AND STUDY AIMS: Investigations for lower gastrointestinal bleeding (LGIB) include flexible sigmoidoscopy, colonoscopy, computed tomographic angiography (CTA), and angiography. All may be used to direct endoscopic, radiological or surgical treatment, although their optimal use is unknown. The aims of this study were to determine the diagnostic and therapeutic yields of endoscopy, CTA, and angiography for managing LGIB, and their influence on rebleeding, transfusion, and hospital stay. PATIENTS AND METHODS: A systematic search of MEDLINE, PubMed, EMBASE, and CENTRAL was undertaken to identify randomized controlled trials (RCTs) and nonrandomized studies of intervention (NRSIs) published between 2000 and 12 November 2015 in patients hospitalized with LGIB. Separate meta-analyses were conducted, presented as pooled odds (ORs) or risk ratios (RR) with 95 % confidence intervals (CIs). RESULTS: Two RCTs and 13 NRSIs were included, none of which examined flexible sigmoidoscopy, or compared endotherapy with embolization, or investigated the timing of CTA or angiography. Two NRSIs (57 - 223 participants) comparing colonoscopy and CTA were of insufficient quality for synthesis but showed no difference in diagnostic yields between the two interventions. One RCT and 4 NRSIs (779 participants) compared early colonoscopy (< 24 hours) with colonoscopy performed later; meta-analysis of the NRSIs demonstrated higher diagnostic and therapeutic yields with early colonoscopy (OR 1.86, 95 %CI 1.12 to 2.86, P  = 0.004 and OR 3.08, 95 %CI 1.93 to 4.90, P  < 0.001, respectively) and reduced length of stay (mean difference 2.64 days, 95 %CI 1.54 to 3.73), but no difference in transfusion or rebleeding. CONCLUSIONS: In LGIB there is a paucity of high-quality evidence, although the limited studies on the timing of colonoscopy suggest increased rates of diagnosis and therapy with early colonoscopy.

Cognitive and Interpersonal Features of Intellectual Humility.

Four studies examined intellectual humility-the degree to which people recognize that their beliefs might be wrong. Using a new Intellectual Humility (IH) Scale, Study 1 showed that intellectual humility was associated with variables related to openness, curiosity, tolerance of ambiguity, and low dogmatism. Study 2 revealed that participants high in intellectual humility were less certain that their beliefs about religion were correct and judged people less on the basis of their religious opinions. In Study 3, participants high in intellectual humility were less inclined to think that politicians who changed their attitudes were "flip-flopping," and Study 4 showed that people high in intellectual humility were more attuned to the strength of persuasive arguments than those who were low. In addition to extending our understanding of intellectual humility, this research demonstrates that the IH Scale is a valid measure of the degree to which people recognize that their beliefs are fallible.

How do people define moderation?

Eating in moderation is considered to be sound and practical advice for weight maintenance or prevention of weight gain. However, the concept of moderation is ambiguous, and the effect of moderation messages on consumption has yet to be empirically examined. The present manuscript examines how people define moderate consumption. We expected that people would define moderate consumption in ways that justified their current or desired consumption rather than view moderation as an objective standard. In Studies 1 and 2, moderate consumption was perceived to involve greater quantities of an unhealthy food (chocolate chip cookies, gummy candies) than perceptions of how much one should consume. In Study 3, participants generally perceived themselves to eat in moderation and defined moderate consumption as greater than their personal consumption. Furthermore, definitions of moderate consumption were related to personal consumption behaviors. Results suggest that the endorsement of moderation messages allows for a wide range of interpretations of moderate consumption. Thus, we conclude that moderation messages are unlikely to be effective messages for helping people maintain or lose weight.

Reporting Results from Structural Equation Modeling Analyses in Archives of Scientific Psychology.

Psychological research typically involves the analysis of data (e.g., questionnaire responses, records of behavior) using statistical methods. The description of how those methods are used and the results they produce is a key component of scholarly publications. Despite their importance, these descriptions are not always complete and clear. In order to ensure the completeness and clarity of these descriptions, the Archives of Scientific Psychology requires that authors of manuscripts to be considered for publication adhere to a set of publication standards. Although the current standards cover most of the statistical methods commonly used in psychological research, they do not cover them all. In this manuscript, we propose adjustments to the current standards and the addition of additional standards for a statistical method not adequately covered in the current standards-structural equation modeling (SEM). Adherence to the standards we propose would ensure that scholarly publications that report results of data analyzed using SEM are complete and clear. SCIENTIFIC ABSTRACT: We recommend reporting standards consistent with the Journal Article Reporting Standards (JARS) of the American Psychological Association for manuscripts in which results from structural equation modeling (SEM) analyses are presented. For all sections of the general JARS except the results section, we recommend minor adjustments. For the results section of the JARS, we provide a supplemental module specific to reports of research that use SEM. The result is a questionnaire that ensures thorough and detailed reports of SEM analyses in the Archives.

Documenting informed consent in elective hip replacement surgery: a simple change in practice.

Adequate documentation of informed consent is an important aspect of many doctors' work and failings in this area may result in patient dissatisfaction or litigation. In 2009 the documentation of risks and complications on the consent forms of patients undergoing primary hip replacement was audited at a specialist centre. Following this audit procedure-specific complication stickers were introduced in an attempt to improve the documentation of the consent process. This article discusses the results of a re-audit and aims to determine if this change in practice had resulted in any significant improvement in documentation. The consent forms of 100 consecutive patients undergoing primary total hip replacement were re-audited using a standardized data collection sheet in order to close the audit loop. The re-audit found that 86 consent forms used the procedure-specific complication sticker to list the potential complications associated with a total hip replacement. Statistically significant improvements in the documentation of fracture, neurovascular damage, leg length discrepancy, failure, premature loosening, death, medical complications, ongoing pain, stiffness, wound healing problems and other were all seen in the 2012 re-audit in comparison to the 2009 audit (P<0.0001). The cheap and simple introduction of procedure-specific complication stickers in order to help surgeons document the process of informed consent has resulted in significant improvements in practice. In the context of patient-focused care and satisfaction in the NHS, it is vital that simple measures such as the introduction of procedure-specific complication stickers are embraced.