RESUMO
INTRODUCTION: Humanitarian surgery is essential to surgical care in limited resource settings. The difficulties associated with resource constraints necessitate special training for civilian surgeons to provide care in these situations. Specific training or curricula for humanitarian surgeons are not well described in the literature. This scoping review summarizes the existing literature and identifies areas for potential improvement. METHODS: A review of articles describing established courses for civilian surgeons interested in humanitarian surgery, as well as those describing training of civilian surgeons in conflict zones, was performed. A total of 4808 abstracts were screened by two independent reviewers, and 257 abstracts were selected for full-text review. Articles describing prehospital care and military experience were excluded from the full-text review. RESULTS: Of the eight relevant full texts, 10 established courses for civilian surgeons were identified. Cadaver-based teaching combined with didactics were the most common course themes. Courses provided technical education focused on the management of trauma and burns as well as emergencies in orthopedics, neurosurgery, obstetrics, and gynecology. Other courses were in specialty surgery, mainly orthopedics. Two fellowship programs were identified, and these provide a different model for training humanitarian surgeons. CONCLUSIONS: Humanitarian surgery is often practiced in austere environments, and civilian surgeons must be adequately trained to first do no harm. Current programs include cadaver-based courses focused on enhancing trauma surgery and surgical subspecialty skills, with adjunctive didactics covering resource allocation in austere environments. Fellowships programs may serve as an avenue to provide a more standardized education and a reliable pipeline of global surgeons.
Assuntos
Missões Médicas , Obstetrícia , Ortopedia , Cirurgiões , Humanos , Ortopedia/educação , CadáverRESUMO
CONTEXT: Concomitant obesity is common among patients with type 1 diabetes mellitus (T1DM), yet adjunctive therapy options are scarce. OBJECTIVE: We assess the efficacy and adverse outcomes of glucagon-like peptide 1 (GLP-1) analogues when used as adjunctive therapy for T1DM. METHOD: PubMed, EMBASE, Cochrane Central, and Scopus databases were searched for randomized controlled trials up to December 2022. Efficacy outcomes were A1c level, body weight, and total daily insulin (TDI) after ≥12 weeks of GLP-1 therapy. We also assessed 12 different adverse outcomes. Subgroup analysis was done for newly diagnosed or C-peptide positive (C-pos) patients. We report the certainty of evidence based on the GRADE assessment tool. RESULTS: A total of 24 studies using 4 different GLP-1 analogues with a total of 3377 patients were included. Liraglutide had the most substantial evidence with effect sizes on A1c (-0.09%/mg), weight (-2.2 kg/mg), and TDI (-4.32 IU/mg). Liraglutide dose was the greatest predictor of greater average weight loss and TDI decrease but was associated with higher odds of nausea (OR 6.5; 95% CI, 5.0-8.4) and ketosis (OR 1.8; 95% CI, 1.1-2.8). Odds of severe (OR 0.67; 95% CI, 0.43-1.04) or symptomatic hypoglycemia (OR 0.89; 95% CI, 0.53-1.51) were not significantly elevated. Among C-pos patients, greater A1c decrease (-0.51% vs -0.28%) but similar weight loss and TDI were seen. Effect sizes for exenatide were similar, but studies had higher risk of bias and safety data were sparse. CONCLUSION: Our meta-analysis supports therapeutic benefits of liraglutide for patients with T1DM mainly for weight loss and insulin dose reduction. Newly diagnosed or C-pos patients do not appear to experience greater weight loss benefits.
Assuntos
Diabetes Mellitus Tipo 1 , Diabetes Mellitus Tipo 2 , Humanos , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/tratamento farmacológico , Diabetes Mellitus Tipo 2/complicações , Peptídeo 1 Semelhante ao Glucagon , Receptor do Peptídeo Semelhante ao Glucagon 1 , Hemoglobinas Glicadas , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Liraglutida/uso terapêutico , Peçonhas , Redução de PesoRESUMO
Children exposed to intimate partner violence (IPV) can experience negative social, emotional, behavioral, and academic outcomes. A growing body of research has examined the relationship between intellectual and developmental disabilities (IDD) and IPV exposure. We systematically reviewed the literature for research exploring this relationship and found a limited number of studies meeting inclusion criteria ( N = 11). Over half (64%) identified a significant relationship between IPV and IDD, although the cross-sectional methodologies of the majority of studies (82%) prevented the ability to ascertain directionality. Further, the studies defined and measured IPV and IDD in various ways. Some studies were limited by poor external validity and small sample sizes. More research is needed to understand the intersection between IPV exposure and IDD.
Assuntos
Deficiências do Desenvolvimento/epidemiologia , Exposição à Violência/estatística & dados numéricos , Deficiência Intelectual/epidemiologia , Violência por Parceiro Íntimo/estatística & dados numéricos , Criança , HumanosRESUMO
Our objective was to describe the racial and ethnic differences in experimental pain sensitivity. Four databases (PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and PsycINFO) were searched for studies examining racial/ethnic differences in experimental pain sensitivity. Thermal-heat, cold-pressor, pressure, ischemic, mechanical cutaneous, electrical, and chemical experimental pain modalities were assessed. Risk of bias was assessed using the Agency for Healthcare Research and Quality guideline. Meta-analysis was used to calculate standardized mean differences (SMDs) by pain sensitivity measures. Studies comparing African Americans (AAs) and non-Hispanic whites (NHWs) were included for meta-analyses because of high heterogeneity in other racial/ethnic group comparisons. Statistical heterogeneity was assessed by subgroup analyses by sex, sample size, sample characteristics, and pain modalities. A total of 41 studies met the review criteria. Overall, AAs, Asians, and Hispanics had higher pain sensitivity compared with NHWs, particularly lower pain tolerance, higher pain ratings, and greater temporal summation of pain. Meta-analyses revealed that AAs had lower pain tolerance (SMD: -0.90, 95% confidence intervals [CIs]: -1.10 to -0.70) and higher pain ratings (SMD: 0.50, 95% CI: 0.30-0.69) but no significant differences in pain threshold (SMD: -0.06, 95% CI: -0.23 to 0.10) compared with NHWs. Estimates did not vary by pain modalities, nor by other demographic factors; however, SMDs were significantly different based on the sample size. Racial/ethnic differences in experimental pain sensitivity were more pronounced with suprathreshold than with threshold stimuli, which is important in clinical pain treatment. Additional studies examining mechanisms to explain such differences in pain tolerance and pain ratings are needed.
Assuntos
Limiar da Dor/etnologia , Limiar da Dor/psicologia , Dor/etnologia , Dor/fisiopatologia , Bases de Dados Bibliográficas/estatística & dados numéricos , Etnicidade , Humanos , Dor/epidemiologia , Estados Unidos/epidemiologia , Estados Unidos/etnologiaRESUMO
BACKGROUND: Youth violence affects thousands annually, with homicide being the third leading cause of death for those aged 10 to 24 years. This systematic review aims to evaluate the published evidence for the effects of health care-based violence intervention programs (VIPs), which focus on reducing recurrent presentations for injury due to youth violence ("recidivism"). METHODS: Health literature databases were searched. Studies were retained if peer reviewed and if programs were health care based, focused on intentional injury, addressed secondary or tertiary prevention (i.e., preventing recidivism and reducing complications), included participants aged 14 to 25 years, had greater than 1-month follow-up, and evaluated outcomes. Studies of child and sexual abuse and workplace, intimate partner, and self-inflicted violence were excluded. Extracted data subject to qualitative analysis included enrollment and retention, duration of follow-up, services provided, statistical analysis, and primary and intermediate outcomes. RESULTS: Of the 2,144 citations identified, 22 studies were included in the final sample. Twelve studies were randomized controlled trials representing eight VIPs. Injury recidivism was assessed in six (75%) of eight programs with a significant reduction in one (17%) of six programs. Of the randomized controlled trials showing no difference in recidivism, all were either underpowered or did not include a power analysis. Two observational studies also showed significant reduction in recidivism. Significant intermediate outcomes included increased service use, attitude change, and decreases in violence-related behavior. Reductions in injury recidivism led to reductions in health care and criminal justice system costs. CONCLUSIONS: Three studies showing reduced injury recidivism and several studies showing positive intermediate outcomes identify VIPs as a promising practice. Many studies were limited by poor methodological quality, including high losses to follow-up. LEVEL OF EVIDENCE: Systematic review, level III.
Assuntos
Atenção à Saúde , Violência/prevenção & controle , Adolescente , Custos e Análise de Custo , Educação em Saúde , Humanos , Prevenção Secundária/educação , Ferimentos e Lesões/prevenção & controle , Adulto JovemRESUMO
Cognitive behavioral therapy for insomnia (CBT-I) is effective for treatment of primary insomnia. There has been no synthesis of studies quantifying this effect on insomnia comorbid with medical and psychiatric disorders using rigorous selection criteria. The objective of this study was to quantify the effect of CBT-I in studies including patients with medical or psychiatric disorders. Studies were identified from 1985 through February 2014 using multiple databases and bibliography searches. Inclusion was limited to randomized controlled trials of CBT-I in adult patients with insomnia diagnosed using standardized criteria, who additionally had a comorbid medical or psychiatric condition. Twenty-three studies including 1379 patients met inclusion criteria. Based on weighted mean differences, CBT-I improved subjective sleep quality post-treatment, with large treatment effects for the insomnia severity index and Pittsburgh sleep quality index. Sleep diaries showed a 20 min reduction in sleep onset latency and wake after sleep onset, 17 min improvement in total sleep time, and 9% improvement in sleep efficiency post-treatment, similar to findings of meta-analyses of CBT-I in older adults. Treatment effects were durable up to 18 mo. Results of actigraphy were similar to but of smaller magnitude than subjective measures. CBT-I is an effective, durable treatment for comorbid insomnia.