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Background and Aims To investigate the superiority of individualized dietary advice based on dietary assessment for patients with type 2 diabetes. Methods and Results A total of 136 Japanese adults with type 2 diabetes were randomized into either individualized or conventional dietary advice groups after dietary assessment using a self-administered brief-type diet history questionnaire. All participants received three 30-minute face-to-face dietary advice sessions by dietitians at 1, 3, 5 months from study entry. The individualized group received dietary advice based on individual dietary intakes. The conventional group received dietary advice using generalized pamphlets. The primary outcome was the change in HbA1c over 6 months, and secondary outcomes were changes in weight, serum triglyceride, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), and dietary intakes. In total, 126 participants were included in the analysis. After adjustment for age, sex, and baseline measurements, HbA1c significantly decreased larger in the individualized group [−1.1%, 95% CI: −1.3 to −0.8)] than the conventional group [−0.7% (95% CI: −1.0 to −0.4)] (P=0.0495). Weight, serum triglyceride, and LDL-C significantly lowered, and HDL-C significantly increased only in the individualized group, without a significant difference to the conventional group. In dietary changes, the individualized group decreased intakes of energy, confectioneries, meats, oil and fats, and sugar-sweetened beverages. The conventional group decreased alcohol intake, and increased total fat and saturated fatty acid intakes. Conclusions Individualized dietary advice among patients with type 2 diabetes was superior to conventional dietary advice in lowering HbA1c. Trial Registration UMIN000037268 ( https://www.umin.ac.jp/ctr/index.htm ) in July 4, 2019.

We investigate competition between experts with different motives. A policy-maker has to implement a policy and can either acquire information herself or hire a biased but well-informed expert. We show that the expert charges a fee if interests between the agents are roughly aligned, and pays contributions in order to get the decision delegated—and thus acts as a lobbyist instead of as an advisor—if the conflict of interest is substantial and the policy is important to her. We then introduce an unbiased career-concerned expert and show that lobbying may occur because of competition. Finally, the effect of competition on societal welfare may be negative if policy is (not) important to society but the unbiased expert provides bad (good) advice.

Background Urinary incontinence (UI) in women is a common problem worldwide. It has a major impact on the physical and social activities and interpersonal relationships. The societies in the Gulf countries are conservative and favours large families, high parity and short inter-pregnancy intervals. Moreover, there is a high prevalence of gestational diabetes with many macrosomic babies. This study aimed to review the published literature on UI among women in this region. Methods All published literature which investigated the prevalence, social impact and help-seeking behavior in women with UI in the Gulf countries was reviewed. Results Nine studies met the criteria and were very heterogeneous. None of them was a true population-based study and all except one, investigated subjects from healthcare facilities. The prevalence of UI ranged from 20.3% to 54.5%. Stress UI was the main type reported. The main predisposing factors were chronic respiratory diseases and constipation. There was a large impact on the quality of life with major interference with prayers (34-90%) and sexual relationships (18-57%). The main reasons for not seeking medical advice were embarrassment to see doctors especially male doctors and the belief that UI is common, normal or incurable disease. Conclusions There is a need for true whole population-based studies of UI in this region with the use of validated international questionnaires. UI was shown to have a major impact on the act of prayers and sexual relationships. A large proportion of women are still embarrassed to discuss the issue with doctors especially male doctors.

Objective To investigate how doctors deliver lifestyle advice to patients in ordinary general practice consultations. Method A secondary analysis of audio/video recorded primary care consultations between doctors and patients. Instances of lifestyle related talk were identified and analysed according to the methods of Conversation Analysis. Results The most frequently used format for delivering advice was found to be if-conditional forms. Conditional forms work to convey how advice is relevant to the individual’s health circumstances 1) topicalising the problematic risk to the patient, 2) informing and warning the patient of reoccurring or future health risks, and 3) offering changes in lifestyle in addition to or as a replacement for medication. Conclusion The results show that doctors use if-conditional constructions to navigate anticipated or actual difficulties evidenced through misalignment in delivering lifestyle advice, by conveying the importance of the advice to the individual patient. Practice Implications Using if-conditional constructions when talking with patients regarding their problematic risk factors provides a technique enabling doctors to navigate the sensitivities associated with giving advice, whilst delivering personalised and preventative medicine.

Objective To assess primiparous and multiparous women, and singleton and multiple pregnancies in a recently published randomized trial. Study design Secondary analysis of a randomized clinical trial was performed. In total, 500 women with sacroiliac dysfunction diagnosed in pregnancy were randomized into a study group (who received expert advice about therapeutic exercise) and a control group (who continued with their normal lifestyle habits). The outcome measures assessed were: pain intensity [visual analogue scale (VAS)] and degree of functional disability (Quebec scale) at enrolment and after 3 and 6 weeks. Primiparous and multiparous women, and singleton and multiple pregnancies in the study and control groups were analysed separately. Results Sacroiliac dysfunction was more common in primiparous women compared with multiparous women (84.70% vs 77.16%), and in multiple pregnancies compared with singleton pregnancies (86.53% vs 80.07%). For all four subgroups analysed in this secondary analysis, the reduction in pain intensity (p = 0.001) and the degree of functional disability (p = 0.001) were better in the study group compared with the control group. Better results for the two outcome measures were found when comparing primiparous and multiparous women in the study group at follow-up, but the difference in functional disability disappeared 6 weeks after enrolment (p = 0.383). There was no difference in the two outcome measures between singleton and multiple pregnancies 3 and 6 weeks after enrolment (p = 0.061, p = 0.489 and p = 0.741, p = 0.353, respectively). Conclusion Expert advice about therapeutic exercise is effective for the reduction of symptoms of sacroiliac dysfunction in all four subgroups (primiparous and multiparous women, singleton and multiple pregnancies). Earlier reduction of pain intensity and degree of functional disability were obtained in primiparous women compared with multiparous women in the study group.

Zusammenfassung Hintergrund In der SARS-CoV-2-Pandemie muss die Politik weitreichende Entscheidungen treffen, die von wissenschaftlichen Erkenntnissen gestutzt sein sollten. Angesichts der zumeist limitierten Evidenz in Krisensituationen stellt dies eine grose Herausforderung dar, insbesondere in fruhen Phasen der Pandemie. Entscheidungstrager*innen haben daher wissenschaftliche Expert*innen einbezogen, welche die Evidenzlage vermitteln und kontextualisieren sollten. Die Formen dieser Konsultationen variierten stark. Zum Teil wurden sogenannte Expert*innenrate mit Vertreter*innen verschiedenster Disziplinen einberufen. Die Zusammensetzung dieser Expert*innenrate hat jedoch Fragen der Reprasentation und Transparenz aufgeworfen. Unser Forschungsvorhaben untersucht, ob und wie Expert*innenrate in Deutschland auf Bundes- und Landesebene einberufen wurden, um die Regierungen und Ministerien in der SARS-CoV-2-Pandemie zu beraten. Es wurden die disziplinare Zusammensetzung, die Geschlechterverteilung und die Transparenz der Arbeitsablaufe analysiert. Methoden Wir fuhrten eine mehrstufige Dokumentenanalyse durch. Zwischen Mai und Juli 2020 wurden Anfragen an die Regierungseinrichtungen der Lander und die Bundesministerien nach dem Informationsfreiheitsgesetz gestellt. Erganzend zur Analyse der Antwortschreiben wurde eine Sichtung und Analyse der i) Pandemieplane, ii) der offiziellen Pressemitteilungen und iii) der kleinen Anfragen auf Bundes- und auf Landesebene zu Expert*innenraten im SARS-CoV-2-Kontext fur den Zeitraum von Januar bis Anfang Dezember 2020 durchgefuhrt. Die Auswertung erfolgte mittels qualitativer Inhaltsanalyse. Ergebnisse Zehn Bundeslander und vier Bundesministerien etablierten insgesamt 21 Expert*innenrate. Fur elf Gremien waren Namen und disziplinarer Hintergrund der Mitglieder bekannt. In diesen Gremien betrug der Frauenanteil 26%. Am haufigsten waren biomedizinische Fachbereiche wie Virologie, Krankenhaushygiene, Medizin, und Biologie vertreten. Weitere Disziplinen (Wirtschafts-, Rechts- und Sozialwissenschaften) und nichtwissenschaftliche Expert*innen waren in sieben Bundeslandern vertreten. Die zehn Rate ohne namentliche Nennung der Mitglieder waren verschiedenen Themenbereichen (Schule und Kita, Burgerbeteiligung, Medizin und Pflege, Wirtschaft) zuzuordnen, ihre Mitglieder waren haufig Akteur*innen aus der Praxis und Betroffene. Diskussion Die SARS-CoV-2-Pandemie hat zu einer verstarkten Konsultation von Expert*innen durch die Politik gefuhrt. Die entsprechenden Gremien in Deutschland sind jedoch nicht ausreichend reprasentativ, trans- und interdisziplinar zusammengesetzt, um die Politik in komplexen Pandemielagen zu beraten und unterschiedliche Perspektiven zu berucksichtigen. Die Arbeitsweise der Gremien ist unter anderem durch einen erschwerten Zugang zu Informationen nicht ausreichend transparent. Schlussfolgerung Aufgrund fehlender Transparenz ist unklar, ob und wie die identifizierten Expert*innenrate Einfluss auf die Politik genommen haben. Transparenz politischer Entscheidungsprozesse und die Berucksichtigung pluralistischer Perspektiven gelten jedoch als wesentlich fur die Legitimation und Gute politischer Entscheidungen in einer Pandemie und sollten in Deutschland im Pandemiemanagement gestarkt werden.

Objective To characterize the general health status of infertile men in the United States using a nationally representative sample of men. Methods Using the National Survey for Family Growth from 2011 to 2017, infertile subgroups were created using a range of inclusion criteria. Univariate and multivariate analyses were conducted comparing these men to fertile men. Results Using population estimates, 6.5 million men with reduced fertility potential were compared to 26 million fertile men. After controlling for demographic and healthcare utilization factors, these groups did not have significantly different rates of key medical co-morbidities, including cancer, obesity, and overall disability. Looking at the subset of men who had received a specific infertility diagnosis, estimated as a population of nearly 600,000 men, this pattern held, in that there were no significant differences in the rates of medical co-morbidities. Notably, the rate of male infertility evaluation among potentially infertile men was only 50%. These findings also persisted after a propensity-matched analysis. Conclusion In this cohort, there was no significant relationship between infertility and specific medical co-morbidities. We must consider the influence of sample selection as we continue to investigate the relationship between medical co-morbidities and reduced fertility potential. Given the persistent low rates of infertility evaluation, even among men who seek medical advice to conceive, we must continue to search for ways to characterize the infertile male population while simultaneously working to improve access.

Study Objective To explore key aspects of menstrual health literacy and menstrual management in young women at school or in tertiary education. Design Cross-sectional online survey. Setting Australia-wide. Participants A total of 4202 adolescent and young women (13-25 years of age; median age 17 years), having reached menarche, living in Australia and currently attending school (n = 2421) or tertiary education (n = 1781). Interventions Online survey hosted by Qualtrics between November 2017 and January 2018. Data were collected on contraceptive use, management strategies, sources of information, and knowledge of menstruation. Main Outcome Measures Information on prevalence and effectiveness of different management strategies, health-seeking behavior, knowledge about menstruation, and common menstrual disorders such as endometriosis. Results The majority of young women did not seek medical advice for their menstrual symptoms, but used information from the Internet (50%) and engaged in self-management, most commonly with over-the-counter medications such as paracetamol (51%) or ibuprofen (52%). Oral contraceptive use was relatively common (35%), and mostly for reduction of menstrual pain (58%). Despite having significant dysmenorrhea, approximately one-half of the participants (51%) thought that their period was normal. Women with higher pain scores were more likely to rate their period as “abnormal” (P Conclusion Self-management of menstrual symptoms is common, but a significant minority of women are underdosing or choosing ineffective methods. Most women do not seek medical advice even when symptoms are severe, and cannot identify symptoms suggestive of secondary dysmenorrhea. Improved education on menstruation is vital.

But de l’étude Plusieurs études ont confirmé l’impact du confinement sur la population, entraînant une rupture de soins, des effets somatiques et psychologiques. Notre étude s’intéresse aux effets indésirables et aux problèmes d’observance au cours d’immunothérapie orale (ITO) alimentaires pendant le confinement. Patients et méthodes Au total, 132 patients, majoritairement des enfants (95 %), avec un antécédent atopique (60 %) suivis pour une ITO ont été inclus dans 3 centres d’allergologie en Île-de-France, pendant le confinement lié à la pandémie SARS-Cov-2 du 16/03 au 11/05/20. Les aliments des ITO étaient principalement l’arachide (38 %), le lait de vache (24 %), la noisette (14 %), l’œuf (9 %), la noix de cajou et la pistache (8 %). Résultats Des effets indésirables ont été retrouvés chez 13 patients soit 10 % des cas. Ces réactions étaient principalement de grade 1 et 2 selon la classification de Ring et Messmer. Trois patients ont présenté des réactions de grade 3 et six patients ont utilisé l’adrénaline au domicile. L’observance était correcte dans 81 % des cas sans aucun oubli. Trois patients ont augmenté leur dose quotidienne sans avis médical. Nous n’avons pas retrouvé de différence significative dans l’analyse en sous-groupe comparant des enfants appariés en âge suivis en ITO en 2019 et en 2020 sur la même période dans le même hôpital. Conclusion Il n’y a pas eu d’augmentation des effets indésirables au cours d’ITO pendant la période du confinement. L’éducation thérapeutique au cours de l’ITO est primordiale et participe à réduire la survenue d’effets indésirables.

Objective To examine the psychosocial factors that influence Australian women’s intentions to freeze their eggs. Design Initially, a qualitative elicitation study followed by a larger-scale quantitative study. Setting Both studies were conducted online. Patients A total of 234 Australian women 25−43 years of age, who identifed as heterosexual, had no children, were open to the idea of having children, were currently not pregnant, and did not have a diagnosis of medical infertility. Intervention None. Main Outcome Measure(s) Intentions and willingness of women to freeze their eggs. Result(s) Hierarchical multiple regression analyses showed that after accounting for demographic variables, there was strong support for the psychosocial predictors of attitude, pressure from others, and control perceptions as predictors of women’s intentions to freeze their eggs. Of the additional variables, cognitive bias (influence of the media) was significant, and the final model accounted for 52.7% of variance in women’s intentions to freeze their eggs. Conclusion(s) This study was the first to predict women’s intentions to freeze their eggs using a well-established decision-making model, the theory of planned behavior. Messages designed to develop a positive attitude toward egg freezing, and to encourage an increased perception of personal control of the egg freezing process, as well as approval from others, could support women to investigate egg freezing, in consultation with appropriate medical advice, as an option when faced with possible future infertility. Effective strategies broaden fertility options for women faced with age-related fertility decline, maximize women’s chances of a successful pregnancy, and, critically, prevent the often substantial psychological distress associated with involuntary childlessness.

Emergency department (ED) patients may elect to refuse any aspect of medical care. They may leave prior to physician evaluation, elope during treatment, or leave against medical advice during treatment. This study was undertaken to identify patient perspectives and reasons for refusal of care.This prospective study was conducted at an urban Level 1 Trauma Center. This study examined ED patients who left without being seen (LWBS), eloped during treatment, or left against medical advice during September to December 2018. This project included both chart review and a prospective patient survey.Among 298 participants, the majority were female (54%). Most participants were White (61%) or African American (36%). Thirty-eight percent of participants left against medical advice, 23% eloped, and 39% left without being seen by a provider. When compared to the general ED population, patients who refused care were significantly younger (p 0.001). When comparing by groups, patients who left AMA were significantly older than those who eloped or left without being seen (p 0.001). Among 68 patients interviewed by telephone, the most common stated reasons for refusal of care included wait time (23%), unmet expectations (23%), and negative interactions with ED staff (15%).ED patients who refused care were significantly younger than the general ED population. Common reasons cited by patients for refusal of care included wait time, unmet expectations, and negative interactions with ED staff.

The Legal Clinics (LC) are no-profit programs aimed to provide legal assistance to low-income citizens. Given the large number of consultations requested by the LC, the processes usually are delayed. This delay entails higher costs for the institutions that offer this legal advice. This paper explores the low-cost automation of legal problem identification in LC through the use of Natural Language Processing (NLP) techniques. We propose a methodology of text processing for the legal issue identification in the legal complaint assistance in LC. The method is based on preprocessing of the text, word to vector transformation, text identification models, and model evaluation for final classification. This methodology looks to accelerate the first step of the legal consultation process identifying the legal issue described by the LC user. The method is evaluated using real cases from the LC of the Santo Tomas University of Colombia. The results provided by the methodology depict a performance of around 95% for the legal issue identification. It is expected that this system will contribute to the delay decrease in the legal advice from LC, and it will help increase the number of advised users through virtual legal assistance.

The elemental composition and bioaccessibility of the wild holothuroids Holothuria arguinensis, Holothuria forskali, and Holothuria mammata was studied. Nutritional and toxicological aspects were evaluated. H. mammata was the richest in Mn, Ni, As, Cd, Pb, and Hg; H. forskali had the highest Cu and I contents, 4.12–4.93 mg/kg dw and 28.02–28.26 mg/kg dw, respectively; and Summer H. arguinensis had high Se content, 4.26 ± 0.08 mg/kg dw. Holothuroids as food may be a dietary Se and I source, with Pb as main hazard. In order to meet the Se Recommended Daily Allowance (RDA), 15–18 g of dried H. arguinensis and 18–33 g of dried H. mammata would have to be consumed everyday. For I, 10 g of dried H. arguinensis, 6–11 g of dried H. forskali, and 20–21 g of dried H. mammata everyday would be required to achieve the I Dietary Recommended Intake (DRI). For meeting Cu dietary requirements, consumption frequencies would have to exceed 330 g dw/day in the most favourable case (Winter H. forskali). Regarding other essential elements, quantities would be much higher. Regarding contaminants, a consumption above 20–21 g/day of dried H. mammata would constitute a Pb risk. Overall, holothuroids can substantially contribute to elemental nutritional requirements. Highlights: Holothuria forskali was rich in I, ∼28 mg/kg dw, and Cu, up to 5 mg/kg dw; H. mammata was the richest sea cucumber in Mn, Ni, As, Cd, Pb, and Hg; Sea cucumbers may be a significant dietary source of Se and I, with Pb as main hazard; For I, 6–11 g of dried H. forskali everyday meet the I Dietary Recommended Intake. Sabrina Sales acknowledges the Doctoral Grant (Ref. SFRH/BD/128813/2017) funded by the “Fundação para a Ciência e a Tecnologia” (FCT). Experimental work was funded by the projects AQUAMAX (Ref.: 16-02-01-FMP-0047) and NEWCUMBER (Ref.: MAR-02.01.01-FEAMP 0052) as well as FCT-funded through CIIMAR (UIDB/04423/2020 and UIDP/04423/2020) and the strategic projects (UID/MAR/04292/2020, LA/P/0069/2020) granted to MARE and ARNET). info:eu-repo/semantics/publishedVersion

Background and aims Alcohol consumption is an important risk factor for cardiovascular morbidity and mortality worldwide. The highest levels of alcohol consumption are observed in Europe, where alcohol as contributing cause of coronary heart disease (CHD) is also most significant. We aimed to describe alcohol consumption patterns across European regions and adherence to the current guidelines in patients with a recent CHD event. Methods The ESC-EORP survey (EUROASPIRE V) has been conducted in 2016–2017 at 131 centers in 27 European countries in 7350 patients with a recent CHD. Median alcohol consumption, as well as the proportion of abstainers and excessive drinkers (i.e. >70 g/week for women and >140 for men, as recommended by the European guidelines on cardiovascular prevention), was calculated for each region. To assess adherence to guidelines, proportions of participants who were advised to reduce excessive alcohol consumption and participants who were incorrectly not advised were calculated per region. Results Mean age was 64 years (SD: 9.5), 75% were male. Abstention rates were 53% in males and 77% in females, whereas excessive drinking was reported by 9% and 5% of them, respectively. Overall, 57% of the participants were advised to reduce alcohol consumption. In the total population, 3% were incorrectly not advised, however, this percentage differed per region (range: 1%–9%). In regions where alcohol consumption was highest, participants were less often advised to reduce their consumption. Conclusion In this EUROASPIRE V survey, the majority of CHD patients adhere to the current drinking guidelines, but substantial heterogeneity exists between European regions.

Objectives The objective of our study was to determine the effects of science-based communications on the attitude toward pneumococcal vaccination and understand how nonwhite racial and ethnic populations respond to these messages. Design Our team tested several science-based communications using a nationally representative survey, and validated them in a local community pharmacy as a field experiment. Setting and participants The nationally representative sample phase was a survey of 3276 participants, conducted by YouGov, a leading online survey firm. The field experiment was conducted at a community pharmacy in the northeastern United States and included 86 participants. Outcome measures In the national survey, participants were assigned to treatment groups or a control group to determine the effects of messaging strategies on influencing favorable views of pneumococcal vaccination. In the field experiment, participants were assigned to treatment or control groups to determine if the messaging strategies affected intent to ask a medical professional about the vaccine. Results The nationally representative sample survey identified that messaging that focused on community and family duty had statistically significant treatment effects toward increasing individuals’ perception of personal importance to have the vaccine in both the nonwhite (increase of 12.2% points relative to control) and white respondents (increase of 8.7% points relative to control). These results were validated through a field experiment, which showed that a combination message, emphasizing duty, increased the individual’s intent to vaccinate by 25% points in a diverse ethnic population as compared with the control. Conclusions Messaging focused on appeals to community and family duty produced statistically significant increases in favorable attitudes toward pneumococcal vaccines and behavioral intent to seek medical advice about the vaccine in white and nonwhite populations across both the nationally representative survey and the field experiment. Medical professionals should highlight the duty to family and community when communicating with patients, as it may motivate vaccination in all populations.

This paper offers a typology of different groups of “experts” in relation to crisis. While decision-making and leadership are frequently analysed in crisis research, the role of experts who offer advice in crisis is widely underexplored in social scientific research. Based on qualitative interviews, we distinguish between the trouble shooter, the emergency expert, the situative expert, the accidental expert and the trusted advisor. Each of the respective types differs with respect to the specific contribution in dealing with crisis (in terms of expertise in or for crisis), the point in crisis when they are usually called for assistance, as well as their relationship to decision-makers. The proposed typology provides insights into the diversity of experts involved in crisis response and demonstrates the influence expert advisors have on decision-makers during, but also before and after a crisis.

Resumen Il s’agit d’une étude observationnelle prospective concernant les 500 premiers patients pris en charge pour une téléconsultation d’urgence ophtalmologique lors de la première quinzaine du confinement en France. Il s’agit de la première étude montrant l’utilité de la télé ophtalmologie à l’aide seule d’un smartphone ou d’un navigateur internet équipés d’une webcam pour trier et organiser la prise en charge des urgences ophtalmologiques dans une population soudainement restreinte dans son accès aux soins. Dans cette étude, tout patient réclamant une consultation au centre ophtalmologique (« SOS Œil ») à Paris se voyait proposer un rendez-vous de téléconsultation préalable afin d’évaluer l’indication ou non à une consultation physique et à une rupture du confinement. Sur avis médical, un rendez-vous physique était donné le jour même si nécessaire. L’objectif de l’étude était de décrire la population, les pathologies avec pour critère de jugement principal ‘la capacité de la téléconsultation à indiquer un rendez-vous physique pour un diagnostic et une prise en charge adéquat’. Cette organisation a permis aux praticiens et aux patients un maintien des mesures de distanciation sociale tout en évitant 3 consultations physiques sur 4. 27% des téléconsultations aboutissaient à un rendez-vous physique. Le délai moyen entre l’apparition des symptômes et la téléconsultation était de 4.12 jours, mais moins d’1 jour pour les traumatismes, corps étrangers et troubles neuro-ophtalmologiques. La téléconsultation a montré une sensibilité de 96% et une spécificité de 95% à poser une indication correcte de consultation physique avec seulement 1% d’erreurs diagnostiques conduisant à un retard de prise en charge. De fait la téléconsultation a permis un maintien satisfaisant de l’accès aux soins ophtalmologiques d’urgence tout en préservant les mesures d’hygiène et de distanciation sociale. La téléconsultation peut être considérée comme un moyen efficace pour réguler l’accès aux services d’urgences ophtalmologiques, et ce particulièrement pour les patients ayant un accès aux soins spécialisés limité.

Background Maternal lifestyle in the months leading up to conception and throughout pregnancy has both immediate and transgenerational impacts on offspring health. Aim To explore how women’s lifestyles change when they become pregnant, and their perspectives of the lifestyle advice they receive throughout pregnancy. Methods A descriptive qualitative approach was used. Semi-structured interviews with 17 childbearing women (mean gestational age, 30.2 ± 2.0 weeks) recruited from a large hospital network in Victoria, Australia between July and October 2018 were transcribed and analysed using an inductive process of thematic analysis. Findings Three themes and six sub-themes were identified. Lifestyle change during pregnancy was highly influenced by participants’ preconception lifestyle, the physiological demands of pregnancy and the pressures of daily life. While participants proactively sought lifestyle advice from a range of sources, including the Internet, they were generally less proactive in seeking advice during routine maternity care visits. Participants appreciated the lifestyle advice they received from health professionals, including midwives, as part of their maternity care despite acknowledging that they often received it only if they asked. Overall, it seemed that the lifestyle advice received from health professionals was much less influential on maternal lifestyle behaviour change than the broader socio-ecological environment. Conclusion Childbearing women want lifestyle advice that supports positive lifestyle change during pregnancy and health professionals, including midwives, must be proactive as they provide it. Other factors that impact on childbearing women’s capability and opportunity to make lifestyle change should be considered when providing advice that supports positive lifestyle behaviour change.

Background Exercise during pregnancy is associated with a variety of health benefits for both mother and child. Despite these benefits, few Australian pregnant women are sufficiently active to meet current exercise during pregnancy guidelines. Healthcare practitioners can play an instrumental role in encouraging women to be active during their pregnancy through the provision of clear and accurate exercise advice. However, little is known about the exercise advice that pregnant women receive from Healthcare practitioners. Methods Regionally-based Australian women were asked to self-report the exercise advice they received from their Healthcare practitioners during their pregnancy via a survey during one of their clinic visits. Results Of the 131 participants, 53% (n = 70) reported receiving some form of exercise advice from their Healthcare practitioner. Specifically, frequency of exercise was discussed among 34% of the participants (n = 23) while exercise intensity 57% was discussed among 57% of the participants (n = 38). Exercise duration was discussed among 39% of participants (n = 26) and types of exercise was discussed among 84% of the participants (n = 56). In most instances, participants report receiving advice not in accordance with current exercise during pregnancy guidelines. Conclusions Healthcare practitioners may not be actively providing advice to pregnant women about their exercise behaviours. Of the advice that is provided, it may not in accordance with current evidence-based exercise during pregnancy guidelines. Whilst healthcare practitioners may be uniquely positioned to provide exercise advice to pregnant women, they may not have the necessary knowledge, training or support to provide specific exercise advice.

Notice and Disclaimer This statement reflects recommendations based on expert opinion, national guidelines, and available evidence. Our knowledge with regard to COVID-19 continues to evolve, as do our institutional protocols for dealing with invasive and non-invasive procedures and practice of personal protective equipment. Readers are urged to follow national guidelines and their institutional recommendations regarding best practices to protect their patients and themselves. These reports are made available by ASE as a courtesy reference source for its members. The reports contain recommendations only and should not be used as the sole basis to make medical practice decisions or for disciplinary action against any employee. The statements and recommendations contained in these reports are primarily based on the opinions of experts, rather than on scientifically-verified data. ASE makes no express or implied warranties regarding the completeness or accuracy of the information in these reports, including the warranty of merchantability or fitness for a particular purpose. In no event shall ASE be liable to you, your patients, or any other third parties for any decision made or action taken by you or such other parties in reliance on this information. Nor does your use of this information constitute the offering of medical advice by ASE or create any physician-patient relationship between ASE and your patients or anyone else.

There is limited information about readmissions to index compared with nonindex hospitals after percutaneous coronary intervention (PCI). This study aims to evaluate the rates, causes, and outcomes for unplanned readmissions following PCI depending on whether the patients were admitted to the index or nonindex hospital. Patients who underwent PCI between 2010 and 2014 in the United States. Nationwide Readmission Database were evaluated for unplanned readmissions at 30 days to index and nonindex hospitals. A total of 2,183,851 procedures were analyzed, with a 9.2% 30-day unplanned readmission rate documented, and 7.1 % and 2.1 % of these readmissions were admitted to the index and nonindex hospitals, respectively. There was also a higher prevalence of co-morbidities among patients readmitted to nonindex hospitals, and more patients who were discharged against medical advice at index PCI. Noncardiac readmissions were lower among patients who were readmitted to the index compared with nonindex hospital (53.4% vs 61.1 %, p < 0.001). There were greater adjusted odds of acute myocardial infarction (AMI) (odds ratio [OR] 1.14 95 % CI 1.06 to 1.22), PCI (OR 2.25 95% CI 2.06 to 2.46), and composite outcome (AMI, readmission PCI, and all-cause death) (OR 1.64 95% CI 1.53 to 1.75) for patients readmitted to the index hospital but their odds of all-cause death were lower (OR 0.77 95% CI 0.68 to 0.88). The majority of readmissions after PCI are to the index hospital that the PCI was undertaken, and these patients are more likely to have a readmission diagnosis of AMI and undergo a repeat PCI but less likely to die compared with patients admitted to a nonindex hospital.

Introduction Since the application of Law 35/2015, the Legal and Forensic Medicine Institutes provide extrajudicial expert advice at the request of individuals for the resolution of traffic accident claims. The objective is to analyze the most relevant medical-legal aspects of this expert advice. Material and method This is a retrospective descriptive study of the extrajudicial expert advice in the divisions of Barcelona and l’Hospitalet, and Tarragona of the Catalonian Legal and Forensic Medicine Institute from 2016–2017. The data was obtained from the extrajudicial expert records of both divisions. Results 547 medical-forensic reports were made. The accidents were mainly caused by a rear collision between cars on urban routes. The injuries were mostly minor, with cervical involvement being the most frequent. A high percentage were resolved with conservative treatment in an average of 69 days, there were mild sequelae in almost half of the cases. Aesthetic damage was reported in 14%. There were no differences between the two divisions. Conclusion Extrajudicial expert advice is a valuable source of information for assessing the damage caused to traffic accident victims. As in other studies, most injuries are mild and are associated with collisions between cars, causing sequelae in half of the cases. It seems that the extrajudicial route is effective in helping resolve traffic accident claims, but more studies are needed to obtain a more complete vision.

Leading academics in business-to-business marketing were asked to reflect on their careers and to provide advice for doctoral students and early-career academics. Contributors responded to four broad, open-ended questions on this subject: what worked for them in their careers, what did not work, what were the dilemmas they encountered, and what overall advice would they give to junior researchers starting their academic career. This editorial distills the comments and reflections of the contributors into a collective wisdom, organized around the four interview questions, which combine to form a rich set of guidelines for early-career academics.

Expert advice is often biased in ways that benefit the advisor. We demonstrate how self-deception helps advisors be biased while preserving their self-image as ethical and identify limits to advisors' ability to self-deceive. In experiments where advisors recommend one of two investments to a client and receive a commission that depends on their recommendation, we vary the timing at which advisors learn about their own incentives. When advisors learn about their incentives before evaluating the available investments, they are more likely to be biased than when they learn about their incentives only after privately evaluating the investments. Consistent with self-deception, learning about the incentive before evaluating the options affects advisors' beliefs and preferences over the investments. Biased advice persists with minimal justifications but is eliminated when all justifications are removed. These findings show how self-deception can be constrained to improve advice provision.

Background and aims For children with heterozygous familial hypercholesterolaemia (HeFH), European guidelines recommend consideration of statin therapy by age 8–10 years for those with a low density lipoprotein cholesterol (LDL-C) >3.5 mmol/l, and dietary and lifestyle advice. Here we compare the characteristics and lipid levels in HeFH children from Norway, UK, Netherlands, Belgium, Czech Republic, Austria, Portugal and Greece. Methods Fully-anonymized data were analysed at the London centre. Differences in registration and on treatment characteristics were compared by standard statistical tests. Results Data was obtained from 3064 children. The median age at diagnosis differed significantly between countries (range 3–11 years) reflecting differences in diagnostic strategies. Mean (SD) LDL-C at diagnosis was 5.70 (±1.4) mmol/l, with 88% having LDL-C>4.0 mmol/l. The proportion of children older than 10 years at follow-up who were receiving statins varied significantly (99% in Greece, 56% in UK), as did the proportion taking Ezetimibe (0% in UK, 78% in Greece). Overall, treatment reduced LDL-C by between 28 and 57%, however, in those >10 years, 23% of on-treatment children still had LDL-C>3.5 mmol/l and 66% of those not on a statin had LDL-C>3.5 mmol/l. Conclusions The age of HeFH diagnosis in children varies significantly across 8 countries, as does the proportion of those >10 years being treated with statin and/or ezetimibe. Approximately a quarter of the treated children and almost three quarters of the untreated children older than 10 years still have LDL-C concentrations over 3.5 mmol/l. These data suggest that many children with FH are not receiving the full potential benefit of early identification and appropriate lipid-lowering treatment according to recommendations., Graphical abstract Image 1, Highlights • The age of HeFH diagnosis varies significantly between 8 European countries. • The proportion of HeFH children being treated varies across 8 European countries. • A quarter of FH children on statins have LDL-C above the target (>3.5 mmol/L). • Many FH children are not getting the full benefit of early diagnosis and treatment.

Health care is increasingly focused on health at the individual level. In the rapidly evolving field of precision nutrition, researchers aim to identify how genetics, epigenetics, and the microbiome interact to shape an individual's response to diet. With this understanding, personalized responses can be predicted and dietary advice can be tailored to the individual. With the integration of these complex sources of data, an important aspect of precision nutrition research is the methodology used for studying interindividual variability in response to diet. This article stands as the first in a 2-part review of current research investigating the contribution of the gut microbiota to interindividual variability in response to diet. Part I reviews the methods used by researchers to design and carry out such studies as well as the statistical and bioinformatic methods used to analyze results. Part II reviews the findings of these studies, discusses gaps in our current knowledge, and summarizes directions for future research. Taken together, these reviews summarize the current state of knowledge and provide a foundation for future research on the role of the gut microbiome in precision nutrition.

This consensus statement on the management of children and young people with heterozygous familial hypercholesterolaemia (FH) addresses management of paediatric FH in the UK, identified by cascade testing when a parent is diagnosed with FH and for those diagnosed following incidental lipid tests. Lifestyle and dietary advice appropriate for children with FH; suggested low density lipoprotein cholesterol (LDL-C) targets and the most appropriate lipid-lowering therapies to achieve these are discussed in this statement of care. Based on the population prevalence of FH as ~1/250 and the UK paediatric population, there are approximately 50,000 FH children under 18 years. Currently only about 550 of these children and young people have been identified and are under paediatric care.

Introduction The uptake of the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 chronic kidney disease (CKD) Guideline is not fully described in real-world nephrology practice across the world. Methods We used baseline data from the CKD Outcomes and Practice Patterns Study (2013–2017), a 4-country cohort of patients with estimated glomerular filtration rate, Graphical abstract

The aim of this study was to explore the effect of pelvic floor muscle training as an adjunct for prolapse surgery. Participants were randomly allocated into 2 groups receiving lifestyle advice (n = 48) and lifestyle advice + pelvic floor muscle training (n = 49). This study compared the total score (Pelvic Floor Distress Inventory-20) and the scores of the Urinary Distress Inventory-6/Colorectal Anal Distress Inventory-8/Pelvic Organ Prolapse Distress Inventory-6 at admission, discharge, and 42 and 60 days after surgery. The UDI-6 score in the lifestyle advice + pelvic floor muscle training group was lower than that in the lifestyle advice group 42 and 60 days after surgery. Pelvic floor muscle training can improve the bladder-related symptoms to have positive significance for pelvic floor rehabilitation after pelvic organ prolapse surgery.

Conflicts of interest create an incentive for advisors to give biased advice, and disclosure is a popular remedy. Across a series of studies, with monetary stakes creating conflicts of interest, I show that disclosure of the conflict of interest can increase as well as decrease bias in advice. The effect of disclosure depends on whether the perceived norms of the context in which the advice is provided are “clients first” or “self-interests first.” Disclosure increases the salience of these norms, which in turn, affects the level of bias in advice. As people draw on multiple sources of information to perceive norms, norms will vary by context and for expert versus non-expert advisors. For non-experts (research participants asked to play the role of advisors), disclosure tends to increase bias in settings in which self-interested advice is deemed to be the norm (e.g., giving financial advice) and decrease bias in settings in which placing advisees first is deemed to be the norm (e.g., giving medical advice). However, for experts (professional financial and medical advisors), whose norms often emphasize placing advisees’ interests first, disclosure (typically) decreases bias in advice. When considering the benefits and pitfalls of disclosure, professional norms toward clients or self-interests appear to play an important role.

The current paradigm in the nutrition sciences states that the basic nutritional unit is not the nutrients, but the foods that contain them (oils, nuts, dairy products, eggs, red or processed meats, etc.). These act as a food matrix in which the different nutrients synergistically or antagonistically modulate their effects on the various metabolic pathways determining health and disease. Food is not based on nutrients or isolated foods but on complex mixtures of one and the other that are part of a specific food pattern, a concept that has been targeted as the most pertinent to evaluate the associations between nutrition and health or disease. This document presents a summary of the available evidence on the relationship between different foods and cardiovascular health, and offers simple recommendations to be implemented in the dietary advice offered by the health professional.

Introduction Since 2005, the federal government's Dietary Guidelines for Americans have recommended at least half of total grain intake be whole grains. Beginning with the 2012–2013 school year, the U.S. Department of Agriculture updated school meal regulations to align with this recommendation. Methods Nationally representative food consumption survey data spanning 1994–2014 were analyzed in 2018 to construct a sample of 17,016 schoolchildren aged 5–19 years. Regression models were used to examine changes in whole grain/total grain intake by food source. For school-obtained foods, changes in whole grain intake are decomposed into changes in propensity (proportion of students consuming whole grains) and intensity (amount consumed by whole grain consumers). Results The whole grain/total grain ratio from all sources fell from 9.67% (1994–1998) to 7.6% (2005–2006) before climbing to 13.48% (2013–2014). Home-prepared foods topped the whole grain/total grain ratio among all sources until surpassed by school foods in 2013–2014 (17.16% vs 21.48%). The whole grain/total grain ratio from school rose from 4.02% to 21.48% during 1994–2014. Among those consuming school foods, increased intensity contributed more than propensity to increases in whole grain intake from school between 2005–2010 and 2011–2012; the opposite occurred between 2011–2012 and 2013–2014 because of increasing propensity, from one in four to one in two students consuming whole grains. Conclusions During 1994–2006, the whole grain/total grain ratio of schoolchildren's diets declined, contrary to expert advice. Following the 2012 U.S. Department of Agriculture school meal regulations, both the propensity and the intensity of whole grain consumption from school rose considerably, demonstrating the important role school meals may play in improving children's diets.

Metabolic syndrome comprises the association of risk factors for future cardiovascular disease (hypertension, altered glucose metabolism, dyslipidaemia, and abdominal obesity). It is thought to affect up to 40% of overweight or obese children in the UK. This has coincided with a rise in obesity-related type 2 diabetes in children. The characterisation of co-morbidities has improved since the last review in 2015. This review discusses some of the current theories about disease mechanisms, and reviews the current guidelines to propose a practical screening checklist for identifying and managing affected children. Metabolic syndrome in children impacts on all of us as paediatricians. Careful attention to screening for and management of complications, and consistent diet, exercise and lifestyle advice, can minimise the effects of our obesogenic environment.

Introduction For children with autism spectrum disorder (ASD) and sensory-processing disorder (SPD), an unexpected visit to the emergency department can be an overwhelming experience that creates intensifying behaviors and an unsafe clinical interaction for the child, nurses, and providers. Although resources exist to help nurses work with this specialized group, there are limited examples of the challenges and opportunities of modifying an emergency department to be a place where nurses can provide sensory-informed care. Methods Guided by Watson’s Theory of Caring, nurses and child life specialists in our pediatric emergency department initiated a practice improvement (PI) project to create a sensory-friendly emergency department. The nurses (1) engaged with community members and families, (2) examined current practices, (3) modified the patient care environment, (4) collaborated in an interprofessional educational session, and (5) created a shared vision for the modified patient-care environment. Results This article describes the nurse-initiated PI process and the journey to create an evidence-based sensory-friendly pediatric emergency department. A model is presented so that other facilities can embark on their own initiative, and case studies are used to evaluate project outcomes. Discussion Integrating current evidence, staff suggestions, community input, and expert advice allowed us to find creative solutions to the unique sensory needs of children who visit our emergency department. Modifying both the patient-care environment and the patient-flow process to accommodate for the needs of children with ASD/SPD created a more peaceful and healing environment for children and their families and gave nurses the support they needed to provide sensory-informed care.

Question-answering systems like Watson beat humans when it comes to processing speed and memory. But what happens if we compensate for this? What are the fundamental differences in power between human and artificial agents in question answering? We explore this issue by defining new computational models for both agents and comparing their computational efficiency in interactive sessions. Concretely, human agents are modeled by means of cognitive automata, augmented with a form of background intelligence which gives the automata the possibility to query a given Turing machine and use the answers from one interaction to the next. On the other hand, artificial question-answering agents are modeled by QA-machines, which are Turing machines that can access a predefined, potentially infinite knowledge base (‘advice’) and have a bounded amount of learning space at their disposal. We show that cognitive automata and QA-machines have exactly the same potential in realizing question-answering sessions, provided the resource bounds in one model are sufficient to match the abilities of the other. In particular, polynomially bounded cognitive automata with background intelligence (i.e. human agents) prove to be equivalent to polynomially bounded QA-machines with logarithmic learning space. It generalizes Pippenger's theorem on the computational power of switching circuits (without background intelligence) to a foundational result for question answering in cognitive science. The framework reveals why QA-machines have a fundamental advantage.

There is an ongoing misperception that women under 60 years of age are at low risk of cardiovascular disease (CVD). As there is an important variation in risk among women in this age group, we need to tailor risk assessment by using additional risk parameters during their life-course. For this, valuable tools are family risk, female-specific risk factors and inflammatory co-morbidities, which can be enriched by measuring the coronary artery calcium (CAC) score using computerized tomography. Depending on the results, we can readily adapt lifestyle advice and preventive treatment to every individual woman. Progress has been made in the recognition of stable and unstable manifestations of ischemic heart disease in middle-aged women. Whereas the traditional cardiovascular risk factors are involved in classic obstructive coronary disease, female-specific risk variables, inflammatory co-morbidities and psychosocial stress are also involved in other types of ischemic disease. We therefore need a more sex- and gender-sensitive way to look at women's cardiovascular health.

الملخص: أهداف البحث: الخروج ضد المشورة الطبية من المستشفى قد يكون له تأثير سلبي على صحة المريض. هدفت هذه الدراسة إلى التحقيق في الأسباب الرئيسة للخروج ضد المشورة الطبية من قبل آباء الأطفال المنومين في جناح الأطفال في مستشفى علي بن أبي طالب في زاهدان، إيران. طرق البحث: أجريت هذه الدراسة للحالات على ١٣٠ طفلا تم تنويمهم في جناح الأطفال في المستشفى. تم تقسيم الأطفال بالتساوي إلى مجموعتين؛ من هم غير مكتملي العلاج وأولئك الذين تم بقائهم في المستشفى حتى إنتهاء علاجهم واتبعوا الخروج العادي. تم تطبيق استبانة تعبأ ذاتيا لجمع البيانات. النتائج: تضمنت مجموعة الدراسة ١٣٠ طفلا أعمارهم أقل من ١ إلى ١٨ عاما بمتوسط ٣.٣±٣.٧عاما. وكان هناك ٥١.٥٪ (٦٧) من الفتيات و٤٨.٥٪ (٦٣) من الفتيان. أظهرت النتائج علاقة كبيرة بين تعليم الآباء ومدة العلاج في المستشفى، ومدة العلاج والخروج ضد المشورة الطبية عندما لم تكن هناك عوامل أخرى ذات علاقة هامة. الاستنتاجات: كانت الأسباب الرئيسة للخروج ضد المشورة الطبية هو عدم الرضا من الأطباء والعاملين في المستشفى، واضطراب الأسرة بسبب وجود أطفال آخرين في المنزل، وعدم كفاية الوضع الاقتصادي والبقاء بعيدا عن البيت. يمكن لإعطاء ثقافة مناسبة للآباء والشرح عن الفوائد والأضرار لرفض إكمال العلاج أن يساعد الآباء لاتخاذ قرارات أفضل. Abstract: Objectives: Discharge against medical advice (DAMA) from the hospital may negatively impact patients’ well-being. The present study aimed to investigate the main reasons for DAMA among parents of children admitted to the paediatric ward of the Ali Ebne Abitaleb Hospital in Zahedan, Iran. Methods: Participants in this case–control study included 130 children who had been admitted to the hospital's paediatric ward. Participants were divided into two equal groups: (1) those with incomplete treatment and (2) those who stayed in the hospital until the completion of their management and followed regular discharge procedures. A self-administered questionnaire was utilised for data collection. Results: Participants included 130 children aged 0.05). Conclusion: This study found that the key reasons for DAMA were as follows: lack of satisfaction with physicians and hospital staff, family disturbance due to the presence of other children at home, inadequate economic situation, and being away from home. Providing professional education to parents and expressing the benefits and disadvantages of refusing complete treatment may help parents make better decisions. الكلمات المفتاحية: الخروج ضد المشورة الطبية, الخروج العادي, مقارنة, جناح الأطفال, رضا المريض, Keywords: Comparison, Discharge against medical advice, Normal discharge, Paediatric wards, Patient satisfaction

Purpose To compare long-term treatment outcomes in epilepsy patients from a single-visit outreach clinic on the Lifeline Express (LLE) with a conventional hospital (AIIMS) based epilepsy clinic in India. Methods Using a cross-sectional observational study design, consecutive epilepsy patients from fifteen LLE clinics conducted from 2009 to 2014 were compared to epilepsy patients registered in the same duration at the AIIMS epilepsy clinic. The primary outcome was to determine if patients were still taking AEDs. To determine current AED status, patients from the LLE clinic were contacted telephonically. For the AIIMS patients, hospital records were reviewed and phone calls made to those patients who had not followed-up for more than a year. Results In the 5 years under review, 1923 and 1257 patients had consulted at the LLE and AIIMS clinics respectively. Long-term outcomes were available for analysis in 688 AIIMS and 531 LLE clinic patients. Of the AIIMS patients, 581(87%) were continuing AEDs, 49(7%) had discontinued AEDs after being seizure-free for at least 5 years, 39(6%) had discontinued AEDs without medical advice and 19(2.8%) were dead. Outcomes in 531 LLE patients revealed that 351(72%) continued to be on AEDs, 34(7%) had discontinued AEDs on advice, 106 (22%) had discontinued AEDs without any medical advice and 40 (7.5%) were dead. The treatment gap in the LLE patients was reduced from 49% at first contact to 22% at follow-up 2–8 years later. Conclusions Even single-visit epilepsy clinics may be an effective option for reducing treatment gap in limited-resource regions of the world.

Background Factors associated with risk with leaving hospital against medical advice (AMA) in neurology patients is unknown. Objective To determine prospectively, the association of gender, age, religion, care type received, economic status and prognosis of the neurology patients, with the discharge AMA (DAMA) and correlate them with the reasons for DAMA cited by the patients or their relatives. Material and Methods In-patients who left AMA between the year 2013 and 2016 (n=689), were prospectively included in the study. Determinants of DAMA and the factors associated with DAMA within eight hours of admission (AMAe; n=177) were analysed. A pre-AMA questionnaire was completed by those who left AMA after 8hours (AMAd; n=512). Results Higher odds of AMA were associated with female gender (OR:1.48), age beyond 50years (OR:1.35) and admission to intensive care (OR:2.59). Financial constraint was cited as reason of AMAd by the patients with low income (OR:1.72). Higher odds of association of influence of a first degree relative in the decision of AMAd were found in women (OR: 1.33) and persons more than 50years (OR: 2.95). Discussion Women and person older than 50years had higher risk of DAMA, mostly due to the influence of a first-degree relative. The risk of leaving AMA was significant in those admitted in the neurological intensive care unit. Of all cited reasons of leaving AMA, financial constraint was most significant. Conclusion The study provides an insight into the factors for associated with risk of DAMA from neurology wards.

Many patients worldwide seek medical advice regarding safety of fasting during pregnancy. This issue lacks high quality evidence, which makes giving medical advice challenging. To aid decision making on this subject we performed an internet mediated survey to determine the expert opinion on this issue. The survey was answered by one hundred and eight obstetricians and gynecologists (OB/GYN). The questions were aimed at the content of the medical advice given to pregnant patients on Ramadan (for Muslim patients) and Yom Kippur (for Jewish patients) fasts. For both fasts, most physicians recommended against fasting on the second or third trimester, while fasting on the first trimester was controversial. Differences were found between medical advices provided by physicians according to their demographical characteristics. Regarding Ramadan fast, senior specialists were more lenient about fasting than younger specialists (62% and 35%, respectively, p = 0.01). As to Yom Kippur fast, religious and traditional physicians were more likely to permit fasting compared to their secular colleagues (53% and 25%, respectively, p = 0.01). Additionally, a comprehensive literature review was conducted revealing possible adverse maternal and fetal outcomes of fasting; however the risk for long term clinical complications is yet to be defined.

Background Entering the paediatric intensive care unit with a critically ill child is a stressful experience for parents. In addition to fearing for their child’s well-being, parents must navigate both a challenging environment and numerous new relationships with healthcare staff. How parents form relationships with staff and how they perceive both their own and the healthcare providers’ roles in this early stage of their paediatric intensive care journey is currently unknown. Purpose This paper explores bereaved parents’ perceptions of their role and their relationships with healthcare providers when their child is admitted to the intensive care unit, as part of a larger study exploring their experiences when their child dies in intensive care. Methods A constructivist grounded theory approach was utilised to recruit 26 bereaved parents from 4 Australian intensive care units. Parents participated in audio-recorded, semi-structured interviews lasting 90–150 min. All data were analysed using the constant comparative analysis processes, supported by theoretical memos. Results Upon admission, parents viewed healthcare providers as experts, both of their child’s medical care and of the hospital system. This expertise was welcomed, with the parent–healthcare provider relationship developing around the child’s need for medical care. Parents engaged in 2 key behaviours in their relationships with staff: prioritising survival, and learning ‘the system’. Within each of these behaviours are several subcategories, including ‘Stepping back’, ‘Accepting restrictions’ and ‘Deferring to medical advice’. Conclusions The relationships between parents and staff shift and change across the child’s admission and subsequent death in the paediatric intensive care unit. However, upon admission, this relationship centres around the child’s potential survival and their need for medical care, and the parent’s recognition of the healthcare staff as experts of both the child’s care and the hospital system.

This paper examines household debt in the United Kingdom, using the practices and organisation of the debt advice sector as a prism for understanding the changing role of debt in shaping the experience of poverty. Based upon fieldwork carried out with debt advisers within the Citizens Advice service, I explore how the mapping practices carried out by advisers reflect the varied connections between debtors and different creditors, as well as with significant others who become entangled in previous and ongoing money problems. In contrast to recent analyses of debt focusing on re-compositions of subjectivity through enfoldings of the temporal, I propose that the multiple connections with creditors, friends and family that constitute a debt problem suggest the need for a topological approach. Indeed, I argue that the specific form of interventions into debt sought and achieved by debt advisers need to be understood in these terms – as an attempt to disrupt and recompose these topologies. Taking into account the significant shift in the UK from consumer’ debts to ‘priority’ debts, the paper asks whether the UK debt advice sector can be seen as a challenge to the logic of ‘governing through debt’, or whether it serves to further the central role played by debt in the neoliberal re-structuring of the subject.

Background Plasma cell disorders (PCDs) are chronic incurable conditions with an opportunity to positively impact outcomes with nutritional changes. Epidemiologic studies show that inflammatory/insulinemic diets are linked to PCDs (Lee IJC 2020), while vegetarians/vegans have a reduced risk (Key AJCN 2014). MGUS/SMM present a unique opportunity for early intervention, given the standard of care is observation. Though patients often inquire about the role of nutrition and whether they should alter habits to eat healthfully, their oncologists are frequently not prepared to address these concerns. The purpose of this survey was to provide insights into patient nutrition perceptions/practices and identify areas for further research. Methods We utilized HealthTree® Cure Hub (HealthTree® Foundation, Lehi, Utah, USA) and invited participants with PCDs to answer questions pertaining to their diet/nutrition and related experience with their oncologist in an online survey. De-identified aggregated responses were reviewed. Results Of 421 participants, 82% reported having dietary questions post-diagnosis, yet 23% stated this was not addressed by their oncologists despite asking. Among those who discussed it with their oncologist, 50% received no specific advice or were recommended a ‘balanced diet’ lacking details. Of the participants that received clear guidance from their oncologists, 88% attempted to follow it, reflecting the positive influence their oncologists can have. Lack of knowledge/conflicting advice were barriers to change for 23%. Although the American Institute of Cancer Research (AICR) has published dietary guidelines, only 34% were aware of them. Patients also more frequently reported following a healthier diet after diagnosis – 75% pre-diagnosis vs 88% post-diagnosis. 78% patients with unhealthy diets pre-diagnosis improved their diet post-diagnosis and 7% with healthy diets pre-diagnosis worsened their diet post-diagnosis. Post-diagnosis, more patients reported consuming whole fruits and vegetables ≥1 times/day and whole grains and seafood ≥3 times/week. Post-diagnosis dietary changes were based on online/media information and advice from non-medical friends in 47%, compared to advice from PCPs/oncologists/nutritionists in 22%. Conclusions Patients with PCDs are interested in dietary advice and make dietary changes when faced with a cancer diagnosis. Most patients currently receive this advice from non-medical sources and report barriers related to lack of consistent information. Oncologists who provide clear guidance can positively impact dietary changes among patients. Our results reflect a missed opportunity between patients’ need for dietary advice and the potential for oncologists to provide helpful counsel. Our findings highlight a need for further research into standardized guideline (AICR) implementation as well as for the development of PCD-specific guidelines. Further disease focused dietary studies are needed to fill this gap.

Aim Although commonly the first port of call for medical information, the internet provides unregulated information of variable quality. We aimed to evaluate commonly accessed web-based patient information on diverticulitis using validated and novel scoring systems. Methods The top internet search engines (Google/Bing/Yahoo) were queried using the keyword ‘diverticulitis.’ The first 20 websites from each were graded using the DISCERN and Journal of the American Medical Association (JAMA) benchmark criteria. A novel diverticulitis-specific score was devised and applied. Results Thirty-six unique websites were identified. The mean total DISCERN score for all websites was 39.92 ± 12.44 (range = 18–62). No website achieved the maximum DISCERN score of 75. The mean JAMA and diverticulitis scores were 2.5 ± 1.08 (maximum possible score = 4) and 11.08 ± 4.17 (19 points possible) respectively. Fourteen (35.9%) and 20 (51.2%) did not provide the date of last update and authorship respectively. Thirty-three (84.6%) mentioned surgery as a treatment option; however, the majority (69.7%) did not describe the surgery or the possibility of a stoma. All except two described disease symptoms. Only ten (25.64%) provided information on when to seek further medical advice or help. Conclusion Web-based information on diverticulitis is of variable content and quality. The majority of top websites describe disease symptoms and aetiology; however, information to prompt seeking medical attention if required, descriptions of surgical procedures and the possibility of stoma creation are poorly described in the majority of websites. These findings should be highlighted to patients utilising the internet to obtain information on diverticulitis.

Background Malpractice in emergency medicine is of high concern for medical providers, the fear of which continues to drive decision-making. The body of evidence evaluating risk specific to emergency physicians is disjointed, and thus it remains difficult to derive cohesive themes and strategies for risk minimization. Objective This review evaluates the state of malpractice in emergency medicine and summarizes a concise approach for the emergency physician to minimize risk. Discussion The environment of the emergency department (ED) represents moderate overall malpractice risk and yields a heavy burden in finance and time. Key areas of relatively high litigation occurrence include missed acute myocardial infarction, missed fractures/foreign bodies, abdominal pain/appendicitis, wounds, intracranial bleeding, aortic aneurysm, and pediatric meningitis. Mitigation of risk is best accomplished through constructive communication, intelligent documentation, utilization of clinical practice guidelines and generalizable diagnoses, careful management of discharge against medical advice, and establishing follow-up for diagnostic studies ordered while in the ED (especially x-ray studies). Communication breakdown seems to be more predictive of malpractice litigation than injury experienced. Conclusions There are consistent diagnoses that are associated with increased litigation incidence. A combination of mitigation approaches may assist providers in mitigation of malpractice risk.

Familial hypercholesterolaemia (FH) is the commonest monogenic disorder that accelerates atherosclerotic cardiovascular disease. We compared and contrasted the characteristics of patients from three specialist centres in the southern hemisphere.Adult index-cases with molecularly diagnosed heterozygous FH attending specialist lipid centres in Cape Town, Perth and São Paulo were studied. Myocardial infarction, revascularisation, hypertension, diabetes, smoking and lipid-lowering treatment were recorded at the time of diagnosis and compared across the three centres.The spectrum of genetic variants causative of FH was significantly different in patients attending the centres in South Africa compared with Australia and Brazil. Hypertension and diabetes were more prevalent in Brazilian and Australian patients, than in South African patients, but the frequency of smoking was significantly greater in South Africa than the other two centres (p0.01). Age, male sex and smoking were significant independent predictors of coronary artery disease (CAD) in all three countries (p0.05).Patients with FH in three specialist centres in the southern hemisphere exhibit a high prevalence of non-cholesterol cardiovascular disease risk factors. Older age, male sex and smoking were more common among subjects with CAD. In all three countries, there should be vigorous programmes for the control of risk factors beyond good control of hypercholesterolaemia among patients with FH. Promotion of a healthy lifestyle, especially anti-smoking advice, is of paramount importance.

The nature of interactions between farmers and advisors is the focus of a growing body of research. While many studies explore the potential role of advisors in facilitating farmers' practice change in practices related to agricultural production such as soil, water, pest and animal health management, studies that specifically investigate how advisors support farmers with financial management (FM) are limited. The contribution this paper makes is to identify who farmers' FM advisors are and to shed light on how farmer-advisor interactions about FM are shaped. Semi-structured interviews with both farmers and a range of advisors (bankers, accountants, farm management consultants, specialist financial advisors and industry funded advisors) were conducted. The main findings are that farm financial information and FM are considered to be sensitive topics and being good at FM is not central to farmers' identity (relative to e.g. production management). Due to the sensitivity and taboo around the topic and the low level of interest in FM, most farmers do not actively seek to acquire financial advice. Farmers most openly discuss FM with their banker and accountant and some seek advice from farm management consultants. Advice seeking from other advisors was limited. Theoretical implications are that FM as a topic of advice introduces unique dynamics to interactions between farmer and advisor, which highlights the importance of better consideration of taboo and sensitive topics in advisory interactions. Furthermore, the findings on how the bankers’ authority impacts on the advisory relationship with farmers indicated that issues of power in view of such authoritative advisory relationships need to be better considered. To enhance effective provisioning on FM advice, policy could focus on improving the match between demand and supply, and help create awareness about the importance of discussing FM to reduce the sensitivity of the topic.

To determine the readmission rate in patients with acute heart failure (AHF) discharged against medical advice (AMA).We performed a retrospective analysis using the 2014 National Readmission Database. Patients admitted with a primary diagnosis of AHF were selected. Only those discharged to home and who left AMA were included in the study. The primary outcome was 30-day readmission. We compared the readmission rates among those discharged AMA vs routinely discharged patients using propensity score matching (PSM) to address imbalance in variables between the 2 groups. We matched 3 routinely discharged patients to 1 patient who left AMA.We identified 273,489 patients with AHF, of whom 116,869 qualified for further study analysis. A total of 2014 patients (1.7%) were in the AMA group and 114,855 (98.3%) were in the routinely discharged group. After PSM, 6042 routinely discharged patients were matched with 2014 patients from the AMA group. The standard mean difference for each variable was less than 10% postmatching. The 30-day readmission rate among those who left AMA was higher than among those routinely discharged (33% vs 20.1%; P.001). Heart failure (44.8%) was the most common cause of readmission in the AMA group. Patients who left AMA were more likely to be readmitted to a different hospital compared with those routinely discharged (37.4 vs 23.1%; P.001). They also had a high rate of leaving AMA during the readmission (18 vs 2%; P.001).Patients with AHF discharged AMA had a significantly higher 30-day readmission rate than did the routinely discharged group.