Protective factors for psychosocial outcomes following cumulative childhood adversity: systematic review.

BACKGROUND: The long-term cumulative impact of exposure to childhood adversity is well documented. There is an increasing body of literature examining protective factors following childhood adversity. However, no known reviews have summarised studies examining protective factors for broad psychosocial outcomes following childhood adversity. AIMS: To summarise the current evidence from longitudinal studies of protective factors for adult psychosocial outcomes following cumulative exposure to childhood adversity. METHOD: We conducted a formal systematic review of studies that were longitudinal; were published in a peer-reviewed journal; examined social, environmental or psychological factors that were measured following a cumulative measure of childhood adversity; and resulted in more positive adult psychosocial outcomes. RESULTS: A total of 28 studies from 23 cohorts were included. Because of significant heterogeneity and conceptual differences in the final sample of articles, a meta-analysis was not conducted. The narrative review identified that social support is a protective factor specifically for mental health outcomes following childhood adversity. Findings also suggest that aspects of education are protective factors to adult socioeconomic, mental health and social outcomes following childhood adversity. Personality factors were protective for a variety of outcomes, particularly mental health. The personality factors were too various to summarise into meaningful combined effects. Overall GRADE quality assessments were low and very low, although these scores mostly reflect that all observational studies are low quality by default. CONCLUSIONS: These findings support strategies that improve connection and access to education following childhood adversity exposure. Further research is needed for the roles of personality and dispositional factors, romantic relationship factors and the combined influences of multiple protective factors.

In Situ Simulation Training for Frailty.

BACKGROUND: People living with frailty account for a significant proportion of hospital inpatients and are at increased risk of adverse events during admission. The understanding of frailty remains variable among hospital staff, and there is a need for effective frailty training across multidisciplinary teams. Simulation is known to be advantageous for improving human factor skills in multidisciplinary teams. In situ simulation can increase accessibility and promote ward team learning, but its effectiveness with respect to frailty has not been explored. METHOD: A single-centre, multi-fidelity, inter-professional in situ frailty simulation programme was developed. One-hour sessions were delivered weekly using frailty-based clinical scenarios. Mixed-method evaluation was used, with data collected pre- and post-session for comparison. RESULTS: In total, 86 multidisciplinary participants attended 19 sessions. There were significant improvements in self-efficacy rating across 10 of 12 human factor domains and in all frailty domains (p < 0.05). The common learning themes were situational awareness, communication and teamwork. Participants commented on the value of learning within ward teams and having the opportunity to debrief. CONCLUSION: In situ simulation can improve the self-efficacy of clinical and human factor skills related to frailty. The results are limited by the nature of self-reporting methods, and further studies assessing behavioural change and clinical outcomes are warranted.

Consumer experiences of care coordination for people living with chronic conditions and other complex needs: an inclusive and co-produced research study.

Objective The aim of this study was to explore consumer experiences of care coordination within Barwon Health's Hospital Admission Risk Program (HARP) located in Geelong, Victoria. Methods The study design was qualitative description informed by phenomenology and inclusive and co-production methodology. Semi-structured interviews were conducted with a purposive sample of six consumers living with chronic conditions and other complex needs. Participants were asked about their lived experience related to accessing the service, communication, and health and supports before and after accessing the service using an interview guide. Interviews were audio-recorded and transcribed verbatim for thematic analysis. Results Five themes were identified: (1) experiencing authentic, values-based care; (2) collaborative care and working together; (3) gaining independence; (4) improved health and quality of life; and (5) limited understanding of HARP at the start. Overall, participants' experiences were positive, which related to improved health, quality of life, and sustainable supports. Although gains were experienced, most of the participants identified that their knowledge of HARP was limited when services commenced, which is an area for service improvement. Conclusion This research begins to address the knowledge gap related to consumer experiences of care coordination. Findings highlight the importance of providing person-centred, authentic and values-based care, listening authentically, and promoting consumer voice within services. The study demonstrates that inclusive, co-design research is feasible in this service context, and further research is recommended into how stakeholders understand the function of care coordination services to promote health and prevent hospital readmissions, and improve consumer participation. What is known about the topic? Care coordination is multifaceted, with the primary purpose of facilitating person-centred care through appropriate and timely delivery of healthcare services. Despite the effectiveness of care coordination programs in preventing avoidable hospital admissions and reducing hospital length of stay, there is a paucity of research that has investigated consumer perspectives. There is also limited research that has adopted an inclusive research design of knowledge co-production where clinicians and consumers are included as equal members of the research team. What does this paper add? The study findings provide evidence into the value of care coordination from the perspective of consumers living with chronic conditions and other complex health and psychosocial issues. The findings also extend evidence into person- and consumer-centred care through understanding the qualities of care coordination practice that promote authenticity, integrity and positive health outcomes. Listening is identified as a critical element of authentic, values-based care, and as a care coordination intervention. Finally, the study demonstrates that inclusive, co-design research is feasible in this service context, and a larger-scale Experience-Based Co-Design study is recommended to investigate how stakeholders understand the function of care coordination services to promote health and prevent hospital readmissions and improve consumer participation. What are the implications for practitioners? The study informs practitioners of consumer lived experience of care coordination. Practitioners are recommended to apply the findings to practice by adopting an authentic, values-based and person-centred care approach described in the study findings. Service improvement initiatives are recommended to focus on increasing awareness of care coordination services through consumer participation and the meaningful inclusion of consumer voice, which could focus on education for referring health and social care professionals.

Percent body fat, but not lean mass, is associated with objectively measured physical function in middle-aged women.

OBJECTIVES: The relationship between components of body composition and physical function is not well characterized among middle-aged women. This cross-sectional study examined the strength of the associations between lean mass and percent fat and physical function in middle-aged women. STUDY DESIGN: Body composition, physical function and physical activity were objectively measured in 80 women (mean age 52.58 ± 6.10 years; range = 40-63 years). MAIN OUTCOME MEASURES: Adiposity (%Fat) and lean mass were measured via dual-energy x-ray absorptiometry. Steps/day and minutes of low-, moderate- and vigorous-intensity physical activity were assessed via accelerometer. Physical function was measured via a seated transfer task, 30-second chair stand, a six-minute walk task, 8-foot timed up and go, and a lift and carry task. RESULTS: When controlling for steps/day, measures of lean mass were related to performance on the seated transfer task (r = .25) and 30-second chair stand (-.26) (both p > 0.05), while %Fat was related to performance on the seated transfer task (r = .53), 8-foot timed up and go (r = .32), 30-second chair stand (r = -.35), and six-minute walk (r = -.48; all p ≤ 0.05). Linear regression analyses revealed: (1) age, steps/day, and %Fat were independently related to performance on the seated transfer task and 30-second chair stand (both p ≤ 0.05), (2) %Fat was associated with six-minute walk and 8-foot up-and-go performance (p ≤ 0.01); none of the variables included were associated with lift and carry. CONCLUSIONS: Adiposity but not lean mass was associated with objectively measured physical function in middle-aged women. Interventions that focus on reducing body fat may be an effective method for improving functional performance among women in this age group.

Effect of Propofol on Acid Reflux Measured with the Bravo pH Monitoring System.

Background/Aim. The aim of this study was to determine the effect of propofol on acid reflux as measured with the Bravo pH monitoring system. Methods. 48-hour pH tracings of 88 children were retrospectively evaluated after placement of the Bravo capsule under propofol. Comparisons between day 1 and day 2, as well as 6-hour corresponding segments from day 1 and day 2, were made. Results. The number of reflux episodes was significantly increased during the first six-hour period on day one as compared to day 2 (P = 0.006). The fraction of time the pH was <4 was also increased during this period, though it did not reach statistical significance. When comparing full 24-hour periods, there was no difference noted in either the number of reflux episodes or the fraction of time pH < 4 between day one and day two. Conclusion. Our data suggest an increase in gastroesophageal reflux during the postanesthesia period. This could be a direct effect of propofol, or related to other factors. Regardless of the cause, monitoring of pH for the first 6 hours following propofol administration may not be reliable when assessing these patients. Monitoring pH over a prolonged 48-hour time period can overcome this obstacle.

Association of smoking and flat adenomas: results from an asymptomatic population screened with a high-definition colonoscope.

BACKGROUND: Flat adenomas represent a morphologically distinct class of polyps that may be difficult to detect, and little is known regarding risk factors for these lesions. Identification of risk factors for these lesions may aid in colorectal cancer (CRC) screening, because patients at risk for these lesions may require special imaging techniques. Smoking, an important risk factor for CRC, may be associated with molecular changes that increase the risk for flat adenomas. OBJECTIVE: The aim of this study was to examine the association between smoking and flat adenomas. DESIGN: Prospective cross-sectional study. SETTING: University hospital endoscopy center. PATIENTS: We enrolled asymptomatic patients presenting for CRC screening. INTERVENTIONS: We screened patients with a high-definition (1080i signal) wide-angle (170 degrees field of view) Olympus 180-series colonoscope. We collected demographics, medication use, family history of CRC, diet history, and smoking history. MAIN OUTCOME MEASUREMENTS: Polyp morphology, assessed by using the Japanese Research Society Classification (JRSC). RESULTS: A total of 600 patients were enrolled. We observed that smoking was associated with having a flat adenoma of any size (adjusted odds ratio [OR], 2.53; 95% CI, 1.60-4.00), having only flat adenomas that were > or = 6 mm in diameter (adjusted OR, 3.84; 95% CI, 2.02-7.32), as well as flat advanced adenomas (adjusted OR, 2.81; 95% CI, 1.08-7.30). LIMITATIONS: The study design may not account for some confounding variables and provides no information regarding smoking status at the time of initiation of flat adenomas. CONCLUSION: Smoking was associated with flat adenomas in our population. Our findings may explain the earlier onset of CRC in smokers as well as the advanced stage with which they present, with compared with nonsmokers. Smokers may require screening with high-definition colonoscopes to detect flat adenomas.

Body mass index as a predictor of colorectal neoplasia in ethnically diverse screening population.

BACKGROUND: Recent guidelines from the American College of Gastroenterology for screening for colorectal cancer have included obesity as an important risk factor. The recommendation for screening obese people at earlier age was tempered by the need for more data regarding obesity and colorectal neoplasia. AIMS: We designed a cross-sectional study to further examine the predictive value of obesity for colorectal adenomas in asymptomatic patients. METHODS: We prospectively collected demographic, medical, lifestyle, and dietary history from asymptomatic patients presenting for screening colonoscopy. Patients underwent complete colonoscopy using high-definition colonoscope to detect colorectal adenomas. We defined advanced neoplasia as large (≥ 1 cm) adenoma, villous adenoma, high-grade dysplasia or cancer. RESULTS: Six hundred patients with median age of 56 years completed the study. Over 40% of these patients did not consider themselves Caucasian, and less than 5% had a first-degree relative with colorectal cancer. Overall, 40 patients (6.7%) had advanced neoplasia and 216 (36.3%) had any adenoma. There were 185 obese patients (30.8%), who had a prevalence of 44.3% for any adenoma and 13.0% for advanced neoplasia. After multivariate analysis, obesity [body mass index (BMI) ≥ 30 kg/m(2)] was significantly associated with increased risk of advanced neoplasia [odds ratio (OR) = 3.83; 95% confidence interval (CI): 1.94-7.55]. CONCLUSIONS: Obesity was associated with advanced neoplasia in this screening population. Our data regarding the association of colorectal neoplasia with this modifiable risk factor has implications for screening and prevention of colorectal cancer.

Tapered colonoscope performs better than the pediatric colonoscope in female patients: a direct comparison through tandem colonoscopy.

BACKGROUND: The pediatric variable-stiffness colonoscope (PVSC) is used by many endoscopists to negotiate the colon that requires a flexible colonoscope; it has a smaller diameter, but may lead to excessive looping. A prototype colonoscope tapers from an adult width to a pediatric diameter at approximately 25 cm. The tapered colonoscope (TC), while retaining the flexibility of the PVSC, has the column strength of the adult colonoscope to help negotiate the proximal colon. OBJECTIVE: Our hypothesis is that use of the TC in female patients would be associated with less looping than the PVSC during the procedure, fewer required maneuvers, and thus a quicker examination. DESIGN: Direct comparison through tandem colonoscopies. SETTING: University endoscopy suite. PATIENTS: Forty unselected female patients. INTERVENTIONS: Tandem colonoscopies with PVSC and TC. MAIN OUTCOME MEASUREMENTS: Time to the cecum and the ability to retroflex in the cecum. RESULTS: Compared with the PVSC, the TC had faster times to achieve cecal intubation (mean [standard deviation], 8.83+/-4.68 minutes versus 6.88+/-4.08 minutes; P=.013) and a higher rate of retroflexion in the cecum (31/40 patients vs 39/40 patients; P<.01). Use of the TC was associated with a decreased need for abdominal pressure (P<.001). CONCLUSIONS: The TC achieved faster cecal intubation rates and had a higher success of cecal retroflexion than a PVSC. This performance likely was because of diminished looping and thus a decreased need for maneuvers. The TC may be preferable to the PVSC for female patients.

Sampling geometries for ocular aberrometry: A model for evaluation of performance.

The purpose of this work is to outline a simple model to assess the relative merits of different sampling grids for ocular aberrometry and illustrate it with an example. While in traditional Hartmann-Shack setups the sampling grid geometries have been somewhat restricted by the geometries of the available microlens arrays, other techniques such as laser ray tracing or spatially resolved refractometry allow for a greater freedom of choice. For all available setups, including HS, it is worth studying which of these choices perform better in terms of accuracy (closeness of the obtained results to the actual ones) and precision (uncertainty of the obtained results). Whilst the mathematical model presented in this paper is quite general and it can be applied to optimise existing or new aberrometers, the numerical results presented in the example are only valid for the particular aberration sample used and centroiding algorithms studied, and should not be generalised outside of these boundaries.

Reasons for poor colonic preparation with inpatients.

In patients often require repeated colonoscopy as a result of poor colonic preparation. A study of 101 inpatients was conducted to determine the most effective bowel preparation strategies. Results suggest patients on certain medications and with certain medical histories react differently to bowel preparation. Patients with diabetes, renal disease, chronic obstructive pulmonary disease, or chronic constipation should receive a more aggressive preparation to obtain optimal results. Likewise, patients who are taking narcotics and laxatives need to be identified and can be expected to require additional preparation to be properly cleansed. Clear liquid diet prior to the administration of the bowel preparation was the only diet modification that affected quality of preparation. The optimal bowel preparation was a 6-liter Golytely preparation along with a secondary preparation (e.g., tap water enema, Fleets enema, Dulcolax tablets). Results showed a 50% satisfactory rating of bowel preparation was achieved in patients who took 3/4 to all of their preparation. The best results were obtained when the colonoscopy procedure was conducted within 6-11 hours of bowel preparation completion.