[Integrative medicine for patients suffering from addictive disorders alongside other pathologies in general practice]. / Clinique intégrative des addictions coexistant avec d'autres pathologies en médecine générale.

People suffering from substance use disorders frequently suffer from concomitant affections such as other addictions, psychiatric, somatic or social problems. Clarifying objectives and priorities with the patient and coordination of care are the priority in the follow up suggested in this article. We present a clinical example in which the modality of care is adapted depending on the evolution of the patient's needs. The follow up by a general practitioner can be pursued in parallel to specialized care. The modality of this collaboration will have to adapt to the patients' and healthcare workers' needs. This follow-up aims to provide good quality health care all the while supporting the healthcare providers who can, sometimes, feel helplessness.

Les personnes souffrant d'un trouble de l'utilisation de substances présentent fréquemment plusieurs affections parallèles telles que d'autres problématiques addictologiques, psychiatriques, somatiques ou sociales. La clarification des objectifs et priorités avec le patient ainsi que la coordination des soins sont au premier plan de la prise en charge proposée dans cet article. Nous présentons, au travers d'une vignette clinique, un exemple de suivi pour lequel la modalité de prise en charge s'adapte aux besoins changeants du patient au cours du temps. Le suivi par un médecin généraliste peut être combiné à un suivi spécialisé. Le mode de collaboration devra s'adapter aux besoins des soignants et du patient. Ce suivi visera à assurer des soins de qualité tout en soutenant les soignants face à un possible sentiment d'impuissance.

Teaching receptive vocabulary to two autistic children: A replicated, clinic-based, single case experimental design.

Background and aims: This study was conducted in a clinical setting with the aim of replicating previously used procedures for teaching receptive vocabulary. Researchers increased the number of vocabulary words and maintained use of match-to-sample (MtS), prompting, and reinforcement procedures. Researchers were also interested in the efficacy of the intervention from caregivers' perspectives. Methods: Using a concurrent multiple baseline design, two autistic preschoolers with receptive language impairment were taught to identify 30 common objects. MtS, prompting, and reinforcement procedures were individualized to support each child. Maintenance checks and generalization probes were completed after a predetermined number of intervention sessions (i.e. three or four clinic sessions). A social validity questionnaire was completed by parents following the final maintenance check. Results: Receptive object identification improved significantly for both participants. Despite exposure to vocabulary targets for only three or four sessions, they generalized the vocabulary targets to non-identical pictures and maintained words at maintenance checks. Participants were most successful when researchers individualized prompting and reinforcement. Conclusion: MtS, prompting, and reinforcement were effective procedures for improving object identification, even with a limited number of intervention sessions. To support varying learner profiles, modifying prompting and reinforcement procedures was necessary. Caregivers of both participants reported positive improvements in areas such as communication, attention, and behaviors. Implications: This replicated study provides support for MtS, prompting, and reinforcement as means of teaching receptive vocabulary to autistic preschoolers in a clinical setting. The materials used were simple and cost-effective. Overall, this study outlines and supports a flexible and effective evidence-based practice to teach receptive language to autistic children.

Building a systems-thinking community workforce to scale action on determinants of health in New Zealand.

This article describes findings from the evaluation of Healthy Families NZ (HFNZ), an equity-driven, place-based community health initiative. Implemented in nine diverse communities across New Zealand, HFNZ aims to strengthen the systems that can improve health and well-being. Findings highlight local needs and priorities including the social mechanisms important for reorienting health and policy systems towards place-based communities. Lessons encompass the importance of local lived experience in putting evidence into practice; the strength of acting with systems in mind; the need for relational, learning, intentional, and well-resourced community organisation; examples of how to foster place-based 'community-up' leadership; and how to enable responsiveness between communities and local and national policy systems. A reconceptualisation of scaling in the context of complexity and systems change is offered, which recognises that relationships and agency are key to making progress on the determinants of health.

The role of collaboration in educating the global pediatric anesthesia workforce.

An estimated 1.7 billion children and adolescents do not have access to safe and affordable surgical care, and the vast majority of these are located in low-middle-income countries (LMICs). Pediatric anesthesia, a specialized field that requires a diverse set of knowledge and skills, has seen various advancements over the years and has become well-established in upper-middle and high-income countries. However, in LMICs, due to a multitude of factors including severe workforce shortages, this has not been the case. Collaborations play a vital role in increasing the capacity of pediatric anesthesiology educators and training the pediatric anesthesia workforce. These efforts directly increase access for children who require surgical intervention. Collaboration models can be operationalized through bidirectional knowledge sharing, training, resource allocation, research and innovation, quality improvement, networking, and advocacy. This article aims to highlight a few of these collaborative efforts. Specifically, the role that the World Federation of Societies of Anaesthesiologists, the Safer Anesthesia from Education program, the Asian Society of Pediatric Anaesthesiologists, Pediatric Anesthesia Training in Africa, the Paediatric Anaesthesia Network New Zealand, the Safe Pediatric Anesthesia Network and two WhatsApp™ groups (global ped anesthesia and the Pediatric Difficult Intubation Collaborative) have played in improving anesthesiology care for children.

Validation of a noninvasive cardiac output monitor in maternal cardiac disease: comparison of NICOM and transthoracic echocardiogram.

BACKGROUND: The physiological changes to the cardiovascular system during pregnancy are considerable and are more pronounced in those with cardiac disease. In the general population, noninvasive hemodynamic monitoring is a valid alternative to pulmonary artery catheterization, which poses risk in the pregnant population. There is limited data on noninvasive cardiac output monitoring in pregnancy as an alternative to pulmonary artery catheterization. OBJECTIVE: We sought to compare transthoracic echocardiography with a noninvasive cardiac output monitor (NICOM, Cheetah Medical) in pregnant patients with and without cardiac disease. STUDY DESIGN: This was a prospective, open-label validation study that compared 2-dimensional transthoracic echocardiography with NICOM estimations of cardiac output in each trimester of pregnancy and the postpartum period. Participants with and without cardiac disease with a singleton gestation were included. NICOM estimations of cardiac output were derived from thoracic bioreactance and compared with 2-dimensional transthoracic echocardiography for both precision and accuracy. A mean percentage difference of ±30% between the 2 devices was considered acceptable agreement between the 2 measurement techniques. RESULTS: A total of 58 subjects were enrolled; 36 did not have cardiac disease and 22 had cardiac disease. Heart rate measurements between the 2 devices were strongly correlated in both groups, whereas stroke volume and cardiac output measurements showed weak correlation. When comparing the techniques, the NICOM device overestimated cardiac output in the control group in all trimesters and the postpartum period (mean percentage differences were 50.3%, 52.7%, 48.1%, and 51.0% in the first, second, and third trimesters and the postpartum period, respectively). In the group with cardiac disease, the mean percentage differences were 31.9%, 29.7%, 19.6%, and 35.2% for the respective timepoints. CONCLUSION: The NICOM device consistently overestimated cardiac output when compared with 2-dimensional transthoracic echocardiography at all timepoints in the control group and in the first trimester and postpartum period for the cardiovascular disease group. The physiological changes of pregnancy, specifically the mean chest circumference and total body water, may alter the accuracy of the cardiac output measurement by the NICOM device as they are currently estimated. Although NICOM has been validated for use in the critical care setting, there is insufficient data to support its use in pregnancy.

Current pediatric pain practice in Nigeria, South Africa, Uganda, and Zambia: A prospective survey of anesthetists.

BACKGROUND: Children in hospital experience significant pain, either inherent with their pathology, or caused by diagnostic/therapeutic procedures. Little is known about pediatric pain practices in sub-Saharan Africa. This survey aimed to gain insight into current pain management practices among specialist physician anesthetists in four sub-Saharan African countries. METHODS: A survey was sent to 365 specialist physician anesthetists in Nigeria, South Africa, Uganda and Zambia. Content analysis included descriptive information about the respondents and their work environment. Thematic analysis considered resources available for pediatric pain management, personal and institutional pain practices. RESULTS: One hundred and sixty-six responses were received (response rate 45.5%), with data from 141 analyzed; Nigeria (27), South Africa (52), Uganda (41) and Zambia (21). Most respondents (71.83%) worked at tertiary/national referral hospitals. The majority of respondents (130/141, 91.55%) had received teaching in pediatric pain management. Good availability was reported for simple analgesia, opioids, ketamine, and local anesthetics. Just over half always/often had access to nurses trained in pediatric care, and infusion pumps for continuous drug delivery. Catheters for regional anesthesia techniques and for patient-controlled analgesia were largely unavailable. Two thirds (94/141, 66.67%) did not have an institutional pediatric pain management guideline, but good pharmacological pain management practices were reported, in line with World Health Organization recommendations. Eighty-eight respondents (62.41%) indicated that they felt appropriate pain control in children was always/often achieved in their setting. CONCLUSION: This survey provides insight into pediatric pain practices in these four countries. Good availability of a variety of analgesics, positive pain prescription practices, and utilization of some non-pharmacological pain management strategies are encouraging, and suggest that achieving good pain control despite limited resources is attainable. Areas for improvement include the development of institutional guidelines, routine utilization of pain assessment tools, and access to regional anesthesia and other advanced pain management techniques.

Delivery of Safe Pediatric Anesthesia Care in the First 8000 days: Realities, Challenges, and Solutions in Low- and Middle-Income Countries.

BACKGROUND: Worldwide, perioperative mortality has declined over the past 50 years, but the reduction is skewed toward high-income countries (HICs). Currently, pediatric perioperative mortality is much higher in low- and middle-income countries (LMICs) compared to HICs, despite studied cohorts being predominantly low-risk. These disparities must be studied and addressed. METHODS: A narrative review of the literature was undertaken to identify contributing factors and potential knowledge gaps. Interventions aimed at alleviating the outcomes disparities are discussed, and recommendations are made for future directions. RESULTS AND CONCLUSIONS: There is a lack of adequately trained pediatric anesthesia providers in LMICs, and the number must be bolstered by making such training available. Essential anesthesia medications and equipment, in pediatric-appropriate sizes, are often not available; neither are essential infrastructure items. Perioperative staff are underprepared for emergent situations that may arise and simulation training may help to ameliorate this. The global anesthesia community has implemented several solutions to address these issues. The World Federation of Societies of Anaesthesiologists (WFSA) and Global Initiative for Children's Surgery have published standards that outline essential items for the provision of safe perioperative pediatric care. Several short educational courses have been developed and introduced in LMICs that either specifically address pediatric patients, or contain a pediatric component. The WFSA also maintains a collection of discrete tutorials for educational purposes. Finally, in Africa, large-scale, prospective data collection is underway to examine pediatric perioperative outcomes. More work needs to be done, though, to improve perioperative outcomes for pediatric patients in LMICs.

Teaching Receptive Vocabulary to Minimally Verbal Preschoolers With Autism Spectrum Disorder: A Single-Case Multiple Baseline Design.

PURPOSE: The purpose of this multiple probe design was (a) to investigate whether the use of the match-to-sample (MtS) procedure would result in independent identification of objects and (b) to examine whether the participants could generalize to matching objects and nonidentical pictures. METHOD: Using a nonconcurrent multiple baseline design, three minimally verbal preschoolers with autism spectrum disorder and receptive language impairment were taught to identify common objects using a MtS procedure and physical prompts. Participants were taught to match identical objects to identical pictures. Maintenance checks were completed following mastery of vocabulary for a total of 22 words. Generalization probes were conducted with the objects and nonidentical pictures. Intervention was completed by a speech-language pathologist during typical speech-language pathology sessions. RESULTS: Results illustrated that all of the participants learned to match and generalize the pictures. All were able to independently identify the objects at 1-month follow-up. CONCLUSIONS: MtS and prompting appear to be effective procedures for teaching receptive vocabulary and can be easily implemented by education professionals. Learner profiles varied for the participants in this study and are an important aspect when teaching students with autism spectrum disorder and co-occurring receptive language impairment.

The use of neurone specific enolase to prognosticate neurological recovery and long term neurological outcomes in OOHCA patients.

Introduction: Hypoxic-ischaemic brain injury (HIBI), is a common sequalae following out-of-hospital cardiac arrest (OOHCA), it is reported as the cause of death in 68% of patients who survive to ICU admission, while other patients can be left with permanent neurological disability. Prediction of neurological outcome follows a multimodal approach, including use of the biomarker, neurone specific enolase (NSE). There is however no definitive cut-off value for poor neurological outcome, and little research has analysed NSE and long-term outcomes in survivors. We investigated an NSE threshold for poor short-term neurological outcome and the relationship between NSE and poor neurological outcome in survivors. Methods: A retrospective study was conducted of all adult OOHCA patients admitted to the Royal County Sussex Hospital ICU between April 2017 and November 2018. NSE levels, Targeted Temperature Management (TTM), cross-sectional imaging, mortality and GCS on ICU discharge were recorded. Assessment of neurological function after a median of 19 months (range 14-32 months) post ICU discharge was undertaken following ICU discharge and related to NSE. Results: NSE levels were measured in 59 patients; of these 36 (61%) had a poor neurological outcome due to hypoxic ischaemic brain injury. Youden's index and ROC analysis established an NSE cut-off value of 64.5 µg/L, with AUC of 0.901, sensitivity of 77.8% and specificity of 100%. Follow-up of 26 survivors after 19 months did not show a significant relationship between NSE after OOHCA and long-term neurological outcome. Conclusion: Our results show that NSE >64.5 µg/L has a poor short-term neurological outcome with 100% specificity. Whilst limited by a low sample size, NSE in survivors showed no relationship with neurological outcome post OOHCA in the long term.

Pediatric procedural sedation in African clinical settings: A mixed methods study of African providers' sedation practices.

Background: Little is known about the practice of pediatric procedural sedation in Africa, despite being incredibly useful to the emergency care of children. This study describes the clinical experiences of African medical providers who use pediatric procedural sedation, including clinical indications, medications, adverse events, training, clinical guideline use, and comfort level. The goals of this study are to describe pediatric sedation practices in resource-limited settings in Africa and identify potential barriers to the provision of safe pediatric sedation. Methods: This mixed methods study describes the pediatric procedural sedation practices of African providers using semi-structured interviews. Purposive sampling was used to identify key informants working in African resource-limited settings across a broad geographic, economic, and professional range. Quantitative data about provider background and sedation practices were collected concurrently with qualitative data about perceived barriers to pediatric procedural sedation and suggestions to improve the practice of pediatric sedation in their settings. All interviews were transcribed, coded, and analyzed for major themes. Results: Thirty-eight key informants participated, representing 19 countries and the specialties of Anesthesia, Surgery, Pediatrics, Critical Care, Emergency Medicine, and General Practice. The most common indication for pediatric sedation was imaging (42%), the most common medication used was ketamine (92%), and hypoxia was the most common adverse event (61%). Despite 92% of key informants stating that pediatric procedural sedation was critical to their practice, only half reported feeling adequately trained. The three major qualitative themes regarding barriers to safe pediatric sedation in their settings were: lack of resources, lack of education, and lack of standardization across sites and providers. Conclusions: The results of this study suggest that training specialized pediatric sedation teams, creating portable "pediatric sedation kits," and producing locally relevant pediatric sedation guidelines may help reduce current barriers to the provision of safe pediatric sedation in resource-limited African settings.

'I just wanted a change, a positive change': Locating hope for young people engaged with residential alcohol and drug services in Victoria, Australia.

In this article, we investigate young people's involvement with residential alcohol and other drug (AOD) services as part of their broader engagement with hope. This study draws on qualitative interviews conducted with 20 young people aged 17-23 from Victoria, Australia, who were either in, or had recently left, residential AOD services. Interviews explored their experiences with AOD services and included questions about their hopes for the future. We found hope located in social relationships, productive discourses and AOD settings themselves. Hope also presented differently according to the external resources young people had available to them, giving some young people greater capacity to action their hoped-for futures than others. Given many young people seek reimagined futures as part of their use of residential AOD services, this creates a valuable opportunity for services to help shape achievable hopes and boost service engagement. We suggest that hope can materialise in a variety of ways but caution against relying on it as a motivational strategy without providing young people with other resources. A more sustainable narrative of hope may require a solid foundation of resources, allowing young people with AOD problems to gain a sense of control over their lives and their imagined futures.

Impact of Virtual and Augmented Reality on Quality of Medical Education During the COVID-19 Pandemic: A Systematic Review.

Background: The COVID-19 pandemic and the subsequent mandatory social distancing led to widespread disruption of medical education. This contributed to the accelerated introduction of virtual reality (VR) and augmented reality (AR) technology in medical education. Objective: The objective of this quantitative narrative synthesis review is to summarize the recent quantitative evidence on the impact of VR and AR on medical education. Methods: A literature search for articles published between March 11, 2020 and January 31, 2022 was conducted using the following electronic databases: Embase, PubMed, MEDLINE, CINAHL, PsycINFO, AMED, EMCARE, BNI, and HMIC. Data on trainee confidence, skill transfer, information retention, and overall experience were extracted. Results: The literature search generated 448 results, of which 13 met the eligibility criteria. The studies reported positive outcomes in trainee confidence and self-reported knowledge enhancement. Additionally, studies identified significant improvement in the time required to complete surgical procedures in those trained on VR (mean procedure time 97.62±35.59) compared to traditional methods (mean procedure time 121.34±12.17). However, participants also reported technical and physical challenges with the equipment (26%, 23 of 87). Conclusions: Based on the studies reviewed, immersive technologies offer the greatest benefit in surgical skills teaching and as a replacement for lecture- and online-based learning. The review identified gaps that could be areas for future research.

Engagement and outcomes of marginalised young people in an early intervention youth alcohol and other drug program: The Street Universities model.

BACKGROUND: Early intervention alcohol and drug (AOD) programs for disadvantaged young people have the potential to substantially decrease the need for future intervention, however there is little research about how young people use these programs or the substance use and other outcomes of such programs. This paper uses data from an Australian AOD early intervention program, The Street Universities, to: describe young people's participation; examine changes in substance use and wellbeing over 90 days; and assess which young people are most positively impacted. METHODS: Data come from a prospective study of new attendees, measuring retention in and attendance patterns in an 'engagement' program focussed on arts and lifestyle activities (n = 95), and a routine service dataset collected from seven years of therapeutic intervention (n = 3,893), measuring substance dependence (SDS), psychological distress (K10) and quality of life (EQoL). RESULTS: Analysis reveals that young people were retained in the program at high proportion (63% at six months) and more than half of these returned at a frequency of weekly or more often. Young people participating in the therapeutic component of the program reported significant improvements in all key wellbeing indicators with SDS, K10 and EQoL scores significantly improving (at p < .001). These improvements occurred rapidly, within the first 30 days, and were maintained over the 90 day study period. Moreover, young people with the highest SDS and K10 scores and lowest quality of life at baseline experienced the most positive changes. CONCLUSION: Aligning engagement program with therapeutic intervention can provide comprehensive support to disadvantaged young people, producing substantial improvements in AOD use, distress and wellbeing.

The freighted social histories of HIV and hepatitis C: exploring service providers' perspectives on stigma in the current epidemics.

A virus has a social history. In the case of the hepatitis C virus (HCV) and HIV, this history is one involving stigma and discrimination, advocacy and activism, and recent dramatic improvements in treatment. These social histories influence the experience of people who live with the viruses, and those who work with them. One aspect of this is the impact of social changes on the biographical disruption and integration brought about by illness. Healthcare practitioners who see significant improvements in the effectiveness of treatment for a condition over the course of their professional life will incorporate those changes into their own history and their relationship to that condition.This article is based on a study of the experiences of serodiscordance, or mixed infection status, in families living with HIV and two types of viral hepatitis, hepatitis B and hepatitis C. The article explores the perspectives of healthcare workers who work with people affected by these viruses, who were asked about their experiences in working with serodiscordance in families. Interviews revealed that changing social meanings given to bloodborne viruses, and changes to treatment over time, held a significant place in the accounts that service providers gave of their work. In asking them to describe their work with HIV and HCV, we were also asking about work that has been shaped by changing patterns and sources of stigma, and recently reshaped by changes in treatment and outcomes. While typically the experiences of patients and their families are used to investigate the social histories of diagnosis and stigma, the professional perspectives and life stories of the service providers who work with them are also revealing. We heard accounts in which histories as well as current regimes were prominent, illuminated further by insights from the sociology of health on narrative and biographical disruption.

Professional perspectives on serodiscordant family service provision in the context of blood-borne viruses.

In recognition of the broader relational aspects of viral infections, family support is considered important when someone is diagnosed with a blood-borne virus (BBV), such as HIV, hepatitis C (HCV) and hepatitis B (HBV). However, families' own support needs are often not a priority in service provision within the BBV sector. In this article, we draw on qualitative interviews with 20 key informants working in various professional capacities in health, social policy, care and advocacy sectors in Australia, and explore their experiences and perspectives on family inclusivity in their services. Overall, key informants acknowledged the diversity of what constitutes family, and consistently viewed family engagement as beneficial to both diagnosed individuals and the wider familial networks affected by a diagnosis. However, prioritising individual care in support services presented barriers to engaging families, which are further complicated by the role of stigma in shaping the social realities of living with a BBV. Increasing understanding in service provision settings that serodiscordance can be a family experience has the potential to widen this analytic lens to consider the support needs of families in their own right.

Pediatric procedural sedation in African clinical settings: A mixed methods study of African providers' sedation practices

Background: Little is known about the practice of pediatric procedural sedation in Africa, despite being incredibly useful to the emergency care of children. This study describes the clinical experiences of African medical providers who use pediatric proceduralsedation, including clinical indications, medications, adverse events, training, clinical guideline use, and comfort level. The goals of this study are to describe pediatric sedation practices in resource-limited settings in Africa and identify potential barriers to the provision of safe pediatric sedation. Methods: This mixed methods study describes the pediatric procedural sedation practices of African providers using semi-structured interviews. Purposive sampling was used to identify key informants working in African resource-limited settings across a broad geographic, economic, and professional range. Quantitative data about provider background and sedation practices were collected concurrently with qualitative data about perceived barriers to pediatric procedural sedation and suggestions to improve the practice of pediatric sedation in their settings. All interviews were transcribed, coded, and analyzed for major themes. Results: Thirty-eight key informants participated, representing 19 countries and the specialties of Anesthesia, Surgery, Pediatrics, Critical Care, Emergency Medicine, and General Practice. The most common indication for pediatric sedation was imaging (42%), the most common medication used was ketamine (92%), and hypoxia was the most common adverse event (61%). Despite 92% of key informants stating that pediatric procedural sedation was critical to their practice, only half reported feeling adequately trained. The three major qualitative themes regarding barriers to safe pediatric sedation in their settings were: lack of resources, lack of education, and lack of standardization across sites and providers. Conclusions: The results of this study suggest that training specialized pediatric sedation teams, creating portable "pediatric sedation kits," and producing locally relevant pediatric sedation guidelines may help reduce current barriers to the provision of safe pediatric sedation in resource-limited African settings.

Patient-Perceived Satisfaction and Knowledge Uptake in a Combined Cardio-Obstetrics Clinic.

Heart disease is the leading cause of pregnancy-related mortality in the United States and has led to the development of combined cardio-obstetrics (COB) clinics as a model for prenatal care. In other areas of medicine, these types of collaborative care models have shown improvement in morbidity, mortality, and patient satisfaction. There is some data to suggest that a combined COB clinic improves maternal outcomes but there is no data to suggest patients prefer this type of care model. This study aims to evaluate patient satisfaction in a combined COB clinic and whether this type of model enhances perceived communication and knowledge uptake. A quality questionnaire was developed to assess patient perceptions regarding communication, satisfaction, and perceived knowledge. Patients who attended the clinic (n = 960) from 2014-2020 were contacted by email, with a response received from 119 (12.5%). Participants completed a questionnaire assessing satisfaction and perceived knowledge uptake with answers based on a Likert scale (7 representing very satisfied and 1 representing very unsatisfied). Safe and effective contraceptive use was evaluated by multiple choice options. Knowledge was also assessed by comparing contraceptive use before and after the clinic. Participants reported high levels of satisfaction with the clinic (6.2 ± 1.5), provider-to-patient communication (6.1 ± 1.6), and with the multidisciplinary appointment approach (6.3 ± 1.5). As well, participants reported an increase in knowledge about heart disease a result of collaborative counseling. In summary, a multidisciplinary approach to cardio-obstetrics not only improves outcomes but is a patient satisfier.

Challenges with pediatric anesthesia and intraoperative ventilation of the child in the resource-constrained setting.

The systemic challenges in providing safe anesthesia, including safe ventilation, to children in resource-constrained settings are many. For anesthesia providers caring for children, the lack of appropriate equipment, inadequate anesthesia workforce and deficiencies in postoperative care are especially difficult. The clinical decisions made by anesthesia providers around when and how to ventilate a child for surgery are influenced by all of these factors and can result in patient management which may vary significantly from that in a high-resource setting. This educational review considers the intraoperative ventilation of a small child in a resource-constrained setting and discusses specific challenges and context-sensitive solutions.