Hemodynamic changes during aortic valve surgery among patients with aortic stenosis.

Introduction. Patients with severe aortic stenosis (AS) undergoing surgery are at increased risk of hypotension and hypoperfusion. Although treatable with inotropic agents or fluid, little is known about how these therapies affect central hemodynamics in AS patients under general anesthesia. We measured changes in central hemodynamics after dobutamine infusion and fluid bolus among patients with severe AS and associated these changes with preoperative echocardiography. Methods. We included 33 patients with severe AS undergoing surgical AVR. After induction of general anesthesia, hemodynamic measurements were obtained with a pulmonary artery catheter, including Cardiac index (CI), stroke volume index (SVi) and pulmonary capillary wedge pressure (PCWP). Measurements were repeated during dobutamine infusion, after fluid bolus and lastly after sternotomy. Results. General anesthesia resulted in a decrease in CI and SVi compared to preoperative values. During dobutamine infusion CI increased but mean SVi did not (38 ± 12 vs 37 ± 13 ml/m2, p = .90). Higher EF and SVi before surgery and a larger decrease in SVi after induction of general anesthesia were associated with an increase in SVi during dobutamine infusion. After fluid bolus both CI, SVi (48 ± 12 vs 37 ± 13 ml/min/m2, p < .0001) and PCWP increased. PCWP increased mostly among patients with a larger LA volume index. Conclusion. In patients with AS, CI can be increased with both dobutamine and fluid during surgery. Dobutamine's effect on SVI was highly variable and associated with baseline LVEF, and an increase in CI was mostly driven by an increase in heart rate. Fluid increased SVi at the cost of an increase in PCWP.

From evidence-based to sustainable healthcare: Cochrane revisited.

Evidence-based healthcare is the prevailing model for healthcare services. In Cochrane's seminal thinking, political context was included with the purpose of promoting healthcare equity. However, the subsequent evidence-based healthcare models marginalized political context. In this paper, we argue that current models of evidence-based healthcare fail to respond to emerging healthcare challenges. We claim that reintegration of political context is crucial to make healthcare sustainable. Global communities are anticipating ecological crises with immense repercussions for healthcare. This prospect illustrates that healthcare models failing to integrate political context also risk neglecting some of the most relevant healthcare issues of our time.

Treating equivalent cases differently: A comparative analysis of substance use disorder and type 2 diabetes in Norwegian treatment guidelines.

BACKGROUND: Substance use disorder (SUD) is often understood as a chronic illness. AIMS: This paper investigates whether SUD is treated as a chronic illness. METHOD: To this aim, we have used World Health Organizations (WHO's) definition of chronic illness to conduct a comparative analysis of SUD and type 2 diabetes (T2D), which is another chronic illness. RESULTS: When analysing Norwegian treatment guidelines, we found that only the T2D guideline reflects the WHO's conceptualization of chronic illnesses. We argue that this discrepancy implies that SUD is understood as a moral and legal problem, while T2D is conceptualized as a somatic illness. We discuss how social, political and historical conditions of the possibility for understanding SUD are interwoven with normative presumptions about the clinician, patient, treatment guidelines and drug policies in a way that may impede the development of continuing care. CONCLUSION: The paper concludes that the delivery of treatment services is inequitable as SUD is not treated as a chronic illness.

Why Only Efficiency, and Not Efficacy, Matters in Psychotherapy Practice.

Evidence-based practice in psychology consists of two quality parameters. One of these quality parameters is efficacy and the other is efficiency. In this article, it is argued that the only relevant parameter for determining quality in clinical care is efficiency. Moreover, emphasising efficacy in psychotherapy practice is symptomatic of a scientocentric ideal in evidence-based practice in psychology. The proper understanding and use of scientific findings entail leaving this scientocentric ideal. In addition, it is crucial that efficiency is related to the ethical aims that constitutes psychotherapy practice.

The Re-shaping of Bodies: A Discourse Analysis of Feminine Athleticism.

Slender and skinny body ideals have been associated with psychological disorders such as eating disorders. However, the tendency to promote a "healthier" and more athletic female body ideal has received minimal critical attention. This study aims at exploring the underlying conditions for such an athletic ideal through asking: How is the female athletic body constructed in the pseudonymous contemporary women's fitness magazine, "Xrzise"? We investigated the object of inquiry through a modified version of Parker's Foucauldian discourse analysis. We analyzed the interviews of four athletic role models in "Xrzise" and identified four discourses: "Neo-liberal discourse," "Health expertise discourse," "Discourse of surveillance and control" and "Discourse of emancipation." The "Neoliberal discourse" constructs the female athletic body as something that the individual woman should strive for by appropriately managing her own resources, abilities and skills. The "Health expertise discourse" constructs the female athletic body through a homeostatic logic where the individual is responsible and healthcare experts have the mandate to intervene in order to maintain good health. The "Discourse of surveillance and control" constructs the female athletic body as an internalized panoptic stance, disciplining women to accept hegemonic beauty ideals. The "Discourse of emancipation" accentuates that the female athletic body is alleviated from a culturally rigid body image and instead improved physical performance and functionality are considered good ends. The results and discussion indicate that the female athletic body is a result of a complex nexus of different discourses associated with the powers of economy, sex differences, institutions, and ideological forces. We have advocated that magazines like "Xrzise" can have covert disciplinary effects hidden by seemingly well-intentioned motives, which can contribute to women's objectification of their bodies.

Virtue Ethics and Integration in Evidence-Based Practice in Psychology.

The policy statement for evidence-based practice in psychology is the most important document in contemporary psychotherapy. In its current form, evidence-based practice in psychology gives scientific research precedence in psychotherapy practice. However, psychotherapy practice's complexity warrants reflection beyond the limits of science. The importance of clinical expert is not recognised in the current policy statement. The clinical expert is necessary to translate psychological research into clinical practice. It is also crucial to identify, clarify and include patient preferences in psychotherapy practice. This paper argues that virtue ethics is a useful theoretical framework for conceptualising clinical expertise. Clinical expertise is conceptualised as the meta-capacity of practical wisdom (phronesis) and the virtues necessary for integrating best available research, clinical expertise and patient preferences.

How often are outcomes other than change in substance use measured? A systematic review of outcome measures in contemporary randomised controlled trials.

ISSUES: Recovery is a theoretical construct and empirical object of inquiry. The aim was to review whether outcome measures used in randomised controlled trials of drug treatment reflect a comprehensive conceptualisation of recovery. APPROACH: Systematic review using the following databases: Cochrane Database of Systematic Reviews, Cochrane Controlled Register of Trials, Database of Abstracts of Reviews of Effect, Web of Science, MEDLINE, Embase and PsycINFO. Search returned 6556 original articles and 504 met the following inclusion criteria: randomised controlled trial in English-language peer-reviewed journal; sample meets criteria for drug dependence or drug use disorder; reports non-substance use treatment outcomes. Review protocol registration: PROSPERO (CRD42018090064). KEY FINDINGS: 3.8% of the included studies had a follow up of 2 years or more. Withdrawal/craving was present in 31.1% of short-term versus 0% of long-term studies. Social functioning in 8% of short-term versus 36.8% of long-term studies. Role functioning (0.9 vs. 26.3%), risk behaviour (15.6 vs. 36.8%) and criminality (3.8 vs. 21.1%) followed a similar pattern. Housing was not examined short-term and unregularly long-term (2.0%). 'Use of health-care facilities', clinical psychological, behavioural factors were frequently reported. Physiological or somatic health (15.2 vs. 10.5%), motivation (14.2 vs. 15.8%) and quality of life (7.1 vs. 0%) were less frequently reported. CONCLUSION: The short time interval of the follow up and lack of information on relevant factors in recovery prevents the development of evidence-based approaches to improve these factors. Particularly, measures of social and role functioning should be added to reflect an adequate conceptualisation of recovery.

Reports of the benefits of drug use from individuals with substance use disorders.

Background: The perceived benefits of drug use are not currently integrated into the treatment of substance use disorder. This omission appears paradoxical and is unsubstantiated by empirical research. As the perceived benefits of drug use are catalysts for drug initiation, relapse and continuous use, increased knowledge about these benefits seems crucial to efficacious treatment. Aims: To investigate the perceived benefits of drug use in substance use disorder. Method: The study is a phenomenological-hermeneutical investigation using thematic analysis of interviews with 30 long-term recovered adult service users. Results: Our thematic analysis resulted in three themes and several sub-themes: (1) Benefits of drug use; (2) Necessity of intense experiences; and (3) Importance of being unconventional. Conclusions: Findings indicate that the benefits of non-problematic and problematic drug use are motivated by similar individual and social needs. An absolute distinction between problematic and non-problematic drug use thus seems arbitrary and potentially counterproductive for clinical practice. The benefits of drug use should be researched as a possible add-on treatment module, as this knowledge may be of significant clinical value in treatment frameworks.

Therapist self-disclosure and the problem of shared-decision making.

Therapist self-disclosure is one of the most controversial topics in the history of psychotherapy. The controversies reflect some basic discussions regarding the nature of psychotherapy practice. In psychotherapy practice, a particular concern is the interaction between the psychotherapist and the patient. The expert-patient interaction has been addressed in a novel framework for clinical practice called shared-decision making. In this paper, we discuss the relationship between self-disclosure and shared-decision making. The chief aim is to illustrate some of the principles and practical problems with shared-decision making by using therapist self-disclosure as an example.

Evidence-Based Practice in Psychology Fails to Be Tripartite: A Conceptual Critique of the Scientocentrism in Evidence-Based Practice in Psychology.

This paper criticises evidence-based practice in psychology (EBPP) for not actually being a tripartite model. According to the American Psychological Association, EBPP is defined as the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences. Nonetheless, EBPP fails to be a tripartite model because it is defined by science alone. This paper aims at explaining why this conflation may have come about. It also shows why clinical expertise and patient preferences should be defined extra-scientifically.

Social Media and Social Functioning in Psychosis: A Systematic Review.

BACKGROUND: Individuals with psychosis are heavy consumers of social media. It is unknown to what degree measures of social functioning include measures of online social activity. OBJECTIVE: To examine the inclusion of social media activity in measures of social functioning in psychosis and ultrahigh risk (UHR) for psychosis. METHODS: Two independent authors conducted a search using the following electronic databases: Epistemonikos, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE, Embase, and PsycINFO. The included articles were required to meet all of the following criteria: (1) an empirical study published in the English language in a peer-reviewed journal; (2) the study included a measure of objective or subjective offline (ie, non-Web-mediated contact) and/or online social functioning (ie, Web-mediated contact); (3) the social functioning measure had to be used in samples meeting criteria (ie, Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases) for a psychotic disorder or UHR for psychosis; and (4) the study was published between January 2004 and February 2019. Facebook was launched as the first large-scale social media platform in 2004 and, therefore, it is highly improbable that studies conducted prior to 2004 would have included measures of social media activity. RESULTS: The electronic search resulted in 11,844 distinct articles. Full-text evaluation was conducted on 719 articles, of which 597 articles met inclusion criteria. A total of 58 social functioning measures were identified. With some exceptions, reports on reliability and validity were scarce, and only one measure integrated social media social activity. CONCLUSIONS: The ecological validity of social functioning measures is challenged by the lack of assessment of social media activity, as it fails to reflect an important aspect of the current social reality of persons with psychosis. Measures should be revised to include social media activity and thus avoid the clinical consequences of inadequate assessment of social functioning. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) CRD42017058514; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017058514.

[Drowning-induced hyperfibrinolytic disseminated intravascular coagulation].

This article summarizes the current knowledge of drowning-induced hyperfibrinolytic disseminated intravascular coagulation. Drowning induces respiratory failure with ensuing cardiac arrest, hypoxaemia and ischaemia. A coagulopathy is induced by ischaemia, acidosis and hypothermia, and clinically the patient develops uncontrolled bleeding due to hyperfibrinolysis. A rapid diagnostic approach is required to recognize this hyperfibrinolytic state, since initiation of treatment with antifibrinolytics and fibrinogen concentrate may bring this life-threatening condition to cessation.

Facts and values in psychotherapy-A critique of the empirical reduction of psychotherapy within evidence-based practice.

This paper addresses an implicit presupposition in research-supported psychological treatments and evidence-based practice in psychology. It argues that the notion of research-supported psychological treatments is based on a reductive conceptualisation of psychotherapy. Research-supported psychological treatments hinge upon an empirical reduction where psychotherapy schools become conceptualized as mere collections of empirical propositions. However, this paper argues that the different psychotherapy schools have distinct ethoses that are constituted by normative claims. Consequently, the evaluation of the different psychotherapy schools and the practice of psychotherapy should include the underlying normative claims of these ethoses.

Prehospital lung ultrasound for the diagnosis of cardiogenic pulmonary oedema: a pilot study.

BACKGROUND: An improved prehospital diagnostic accuracy of cardiogenic pulmonary oedema could potentially improve initial treatment, triage, and outcome. A pilot study was conducted to assess the feasibility, time-use, and diagnostic accuracy of prehospital lung ultrasound (PLUS) for the diagnosis of cardiogenic pulmonary oedema. METHODS: A prospective observational study was conducted in a prehospital setting. Patients were included if the physician based prehospital mobile emergency care unit was activated and one or more of the following two were present: respiratory rate >30/min., oxygen saturation <90 %. Exclusion criteria were: age <18 years, permanent mental disability or PLUS causing a delay in life-saving treatment or transportation. Following clinical assessment PLUS was performed and presence or absence of interstitial syndrome was registered. Audit by three physicians using predefined diagnostic criteria for cardiogenic pulmonary oedema was used as gold standard. RESULTS: A total of 40 patients were included in the study. Feasibility of PLUS was 100 % and median time used was 3 min. The gold standard diagnosed 18 (45.0 %) patients with cardiogenic pulmonary oedema. The diagnostic accuracy of PLUS for the diagnosis of cardiogenic pulmonary oedema was: sensitivity 94.4 % (95 % confidence interval (CI) 72.7-99.9 %), specificity 77.3 % (95 % CI 54.6-92.2 %), positive predictive value 77.3 % (95 % CI 54.6-92.2 %), negative predictive value 94.4 % (95 % CI 72.7-99.9 %). DISCUSSION: The sensitivity of PLUS is high, making it a potential tool for ruling-out cardiogenic pulmonary. The observed specificity was lower than what has been described in previous studies. CONCLUSIONS: Performed, as part of a physician based prehospital emergency service, PLUS seems fast and highly feasible in patients with respiratory failure. Due to its diagnostic accuracy, PLUS may have potential as a prehospital tool, especially to rule out cardiogenic pulmonary oedema.

The influence of propofol versus sevoflurane anesthesia on outcome in 10,535 cardiac surgical procedures.

OBJECTIVE: The purpose of this study was to evaluate the possible cardioprotective effect of sevoflurane versus propofol anesthesia in patients undergoing cardiac surgery. METHODS: Ten thousand five hundred thirty-five consecutive single cardiac surgical procedures from 3 cardiac centers were reported to a common registry from 1999 to 2005. The registry was established by the National Board of Health, and reporting was obligatory for all public heart centers in Denmark. The patients were stratified according to preoperative risk factors (EuroSCORE parameters). The outcome parameters were 30-day mortality, the incidence of postoperative myocardial infarction, and the incidence of postoperative arrhythmias. RESULTS: Overall, the 30-day mortality was lower after sevoflurane (2.84%) versus propofol (3.30%), although not significantly so (p = 0.18). No difference was found in the incidence of postoperative myocardial infarction (sevoflurane, 7.76%/propofol, 7.47%). Patients with preoperative unstable angina and/or recent myocardial infarction, and thus already "preconditioned," did not show any difference in mortality between anesthetic groups, whereas patients without these predictors showed a lower postoperative mortality after sevoflurane (2.28% v 3.14%, p = 0.015), which can at least partly be explained by a preconditioning-like effect. The data suggest that patients suffering relatively severe preoperative ischemic stress benefited from propofol anesthesia, which can be related to the antioxidant effects of propofol. Patients in the sevoflurane group had a higher incidence of postoperative atrial fibrillation (28.75% v 24.87%, p < 0.001), whereas patients in the propofol group showed a higher incidence of all other arrhythmias. CONCLUSION: Sevoflurane and propofol both possess some, although different, cardioprotective properties. Sevoflurane appears to be superior to propofol in patients with little or no ischemic heart disease, such as noncoronary artery bypass graft (CABG) surgery and CABG surgery without severe preoperative ischemia, whereas propofol seems superior in patients with severe ischemia, cardiovascular instability, or in acute/urgent surgery.

Phenotypic plasticity in Carlina vulgaris: effects of geographical origin, population size, and population isolation.

If phenotypic plasticity is under genetic control, it may vary in amount and pattern on a geographical scale, e.g. among different regions of a species' distribution. It may also differ between large and small or between less and more isolated populations, due to differences in genetic diversity. In a 2-year common garden study, the responses of several traits to drought and fertilizer treatments were studied in the grassland herb Carlina vulgaris. Individuals originating from populations of different size and degree of isolation in six European countries, representing "central" and "marginal" regions, were compared. Fertilizing had a negative effect on early plant survival, as well as on flowering probability in surviving plants. However, in those plants that flowered, fertilizing strongly increased mean number of flowerheads, flowerhead area (a correlate of seed number), and seed mass. Drought had generally weaker effects but enhanced survivorship, indicating that this treatment was closer to optimal conditions than were non-drought conditions. For some traits there were significant interactions of region x fertilizer, but the geographical pattern of reaction norms was inconsistent and lent no support to the hypothesis that central and marginal populations differ in overall plasticity. Population size and isolation had hardly any influence on treatment responses, but populations within regions differed in their mean response to fertilizing with regard to survival and flowering probabilities, as well as in their response to drought with regard to survival and total flowerhead area. It is concluded that response to raised nutrient levels is highly variable within populations, ranging from death to strongly increased reproductive output, but also among populations irrespective of size or isolation. This also goes for the response to water supply, though this variation shows a more unclear pattern. There is no evidence that small or isolated/marginal populations are less plastic than large or non-isolated/central populations, and the explanation for differences in treatment responses among plant populations should be sought in other population characteristics.