Paediatric Residents and Fellows Ethics (PERFEct) survey: perceptions of European trainees regarding ethical dilemmas.

With an increasingly complex healthcare environment, ethics is becoming a more critical part of medical education. We aimed to explore European paediatric trainees' experiences of facing ethical dilemmas and their medical ethics education whilst assessing their perceptions of ethical dilemmas in current and future practice. The Young Sections of the European Academy of Paediatrics and European Society of Paediatric and Neonatal Intensive Care developed an explorative online survey covering demographics, ethical dilemmas faced and ethics training. The survey was made available in nine languages from November 2019 to January 2020 via newsletters and social media. Participants (n = 253) from 22 countries, predominantly female (82%) and residents (70%), with a median age of 29-years, completed the survey. The majority (58%) faced ethical dilemmas monthly or more frequently. Most ethics training was received by ethics lectures in medical school (81%) and on the job (60%). A disagreement between the healthcare team and patient/family was the most frequently faced moral dilemma (45%); the second was withholding/withdrawing life-prolonging measures (33%). The latter was considered the most challenging dilemma to resolve (50%). Respondents reported that ethical issues are not sufficiently addressed during their training and wished for more case-based teaching. Many have been personally affected by moral dilemmas, especially regarding withholding/withdrawing life-prolonging measures, and often felt inadequately supported.Conclusion: Paediatric trainees face many moral issues in daily practice and consider that training about managing current and future ethical dilemmas should be improved, such as by the provision of a core European paediatric ethics curriculum. What is Known: • Paediatric services are becoming more complex with an increase in ethical dilemmas asking for rigorous training in ethics. • Ethics training is often lacking or covered poorly in both pre- and postgraduate medical education curricula. • Existing ethics training for European paediatric trainees is haphazard and lacks standardisation. What is New: • The PaEdiatric Residents and Fellows Ethics (PERFEct) survey provides insight into the European paediatric trainees' views regarding ethical dilemmas in their current and future practice. • European paediatric trainees report a lack of ethics training during paediatric residency and fellowship. • This study provides content suggestions for standardised medical ethics training for paediatric trainees in Europe.

[Confusion and abdominal pain after COVID-19 vaccination]. / Verwardheid en buikpijn na covid-19-vaccinatie.

BACKGROUND: Vaccine-induced immune thrombotic trombocytopenia (VITT) is a rare phenomenon, that may present with diffuse and atypical symptoms. CASE DESCRIPTION: We present a case of 63 years old female patient with abdominal pain, confusion and tromboctytopenia. CT scan shows sinustrombosis and trombosis of the vena renalis. The diagnosis VITT was confirmed by a positive HIT test. After initiating treatment with immunoglobulines and a non-heparinoid anticoagulans, symptoms improved and platelet count increased. CONCLUSION: This case illustrates that awareness in case of atypical symptoms and a history of vaccination is important to recognize this phenomenon.

Gastroesophageal reflux disease in intellectually disabled individuals: how often, how serious, how manageable?

Gastroesophageal reflux disease (GERD) is an important and frequently occurring problem among intellectually disabled individuals (IDI). Early suspicion and recognition of the presence of GERD in IDI is the cornerstone of adequate management of these patients. The prevalence of GERD among institutionalized IDI with an IQ < 50 is about 50%, with 70% of these reflux patients having endoscopically established reflux esophagitis. In case of symptoms as hematemesis, rumination, or dental erosions, there is an increased risk for GERD. GERD has also been shown to be associated with cerebral palsy, an IQ < 35, scoliosis, and the use of anticonvulsant drugs or benzodiazepines. To establish the diagnosis, 24-h pH measurement or endoscopy should be used in all those intellectually disabled individuals in whom GERD clinically is suspected. The efficacy of proton-pump inhibitors (PPIs) in IDI with GERD is indisputable. In IDI, adults as well as children, PPIs are highly effective, independent of the severity of esophagitis. Marked improvement of symptoms and quality of life can be noticed after medical treatment, thereby decreasing the need for surgery in this complicated group of patients.

[Gastroesophageal reflux disease in mentally retarded persons: prevalence, diagnosis and treatment]. / Gastro-oesofageale refluxziekte bij verstandelijk gehandicapten: prevalentie, diagnostiek en behandeling.

The prevalence of gastroesophageal reflux disease among institutionalised intellectually disabled individuals with an IQ < 50 is high: about 50% have an deviant 24-hour pH measurement and 70% of them have refluxoesophagitis. Intellectually disabled individuals have an increased risk of gastroesophageal reflux disease in case of cerebral palsy, IQ < 35, scoliosis, use of anticonvulsant drugs or benzodiazepines, not being ambulant, and in case of symptoms such as haematemesis, rumination or dental erosions. To establish the diagnosis is difficult because of the aspecific symptoms. Reflux disease is only diagnosed at a late stage. 24-hour pH measurement should be used in all those intellectually disabled individuals in whom gastroesophageal reflux disease is clinically suspected. For the treatment of gastro-oesophageal reflux disease in adults as well as children, proton pump inhibitors are highly effective, independent of the severity of oesophagitis. Marked improvement of symptoms and quality of life can be noticed after treatment.

The prevalence of gastroesophageal reflux disease in institutionalized intellectually disabled individuals.

OBJECTIVE: The prevalence of gastroesophageal reflux disease (GERD) was randomly investigated among Dutch and Belgian intellectually disabled individuals. METHODS: In six institutes including 1607 residents, 435 persons with IQ <50 underwent 24-h esophageal pH-metry and were scored for possible predisposing factors and characteristic reflux symptoms. In 49 (11.2%) cases the test failed because of technical reasons. A pathological pH test was defined as a pH <4 for >4.5% of the measured time. Subjects with a pathological pH test (patients) were compared with those with a normal pH test (controls). RESULTS: Of the remaining individuals, 51.8% (200/386) showed a normal pH test, whereas 186 showed a pathological pH test (median duration pH <4: 14.2%, range: 4.5-78.4%). As possible predisposing factors scoliosis, cerebral palsy, use of anticonvulsant drugs or other benzodiazepines, and IQ <35 were found, whereas symptoms such as vomiting, hematemesis, rumination, and depressive symptoms were indicative for reflux. At endoscopy reflux esophagitis was diagnosed in 129 of the 186 patients (69.4%). In 61 (47.3%) of 129 patients, grade I, 43 (33.3%) grade II, 25 (19.4%) grade III/IV (Savary-Miller) were found. Barrett's esophagus was found in 18 (14.0%) and peptic strictures in five (3.9%) cases. CONCLUSIONS: An abnormal 24-h pH-metry and symptoms suggestive for GERD were documented frequently in a large cohort of institutionalized intellectually disabled individuals. Further endoscopical evaluation confirmed the diagnosis of reflux esophagitis in the majority of these individuals.

Gastroesophageal reflux disease in intellectually disabled individuals: leads for diagnosis and the effect of omeprazole therapy.

OBJECTIVES: The therapeutic approach to gastroesophageal reflux disease (GERD) in intellectually disabled individuals has not been studied extensively. So far, only low response rates to medical and surgical therapy of GERD have been reported. However, the efficacy of proton pump inhibitors, to date the most effective medical therapy for GERD, has never been evaluated in this population. Our purpose, therefore, was to study the effect of omeprazole on healing and symptom relief in the intellectually disabled. METHODS: The treatment scheme was as follows: omeprazole 40 mg was given once daily (o.d.) as a healing dose for 3 months, and omeprazole 20 mg o.d. was given as a maintenance dose for another 3 months, to intellectually disabled subjects with endoscopically proven esophagitis, grades I-IV, according to Savary-Miller classification. After 3 and 6 months, the result of this treatment was evaluated by symptom scoring and/or endoscopy. In case of relapse, the dose was increased. RESULTS: At the first endoscopy, 40 of 107 patients (37%) had grade I, 36 (34%) grade II, 18 (17%) grade III, and 13 (12%) grade IV esophagitis. In 92 of 104 patients (88%), the treatment scheme was effective in healing the esophagitis and keeping patients in remission, independent of the severity of esophagitis. In 11 of 104 (11%) patients, a symptomatic relapse was observed after the dose was decreased to 20 mg o.d. However, all of these patients became symptom free again after the dose was increased to 40 mg o.d., and all were healed endoscopically at the end of the study. One (1%) patient needed omeprazole 60 mg o.d. for healing, but in this patient, no relapse was seen while on a maintenance dose of omeprazole 40 mg o.d. Marked improvement of persistent vomiting, hematemesis, regurgitation, food refusal, iron deficiency anemia, and depressive symptoms was seen at the end of the study. CONCLUSIONS: This study indicates that omeprazole is highly effective for all grades of esophagitis in the intellectually disabled. The dose needed to maintain them in remission can be titrated according to the reflux symptoms.

The prevalence of Helicobacter pylori infection among inhabitants and healthy employees of institutes for the intellectually disabled.

OBJECTIVES: The prevalence of Helicobacter pylori infection varies in the Netherlands from 5% in children to about 50% in the elderly. In the institutionalized intellectually disabled, a high prevalence of infection has been reported. It is unknown whether there are specific risk factors to obtain H. pylori infection in this population, and whether employees of such institutes are at risk for H. pylori infection. METHODS: Therefore, we analyzed the seroprevalence of H. pylori antibodies by ELISA among 338 intellectually disabled inhabitants and 254 employees of two institutes. H. pylori-positive patients were compared with H. pylori-negative controls. The intellectually disabled and the employees were evaluated for possible risk factors. RESULTS: Of the 338 intellectually disabled, 280 (82.8%, median age 51 yr) were infected with H. pylori. This rate is significantly higher than the prevalence of H. pylori in the Dutch population. The presence of H. pylori was significantly associated with male gender, longer duration of institutionalization, an IQ < 50, rumination, and a history of upper abdominal symptoms. Of the 254 employees, 69 (27.2%) were infected, which is equal to the rate for the total Dutch population. The presence of H. pylori infection among employees was, however, significantly associated with a higher level of physical contact with the intellectually disabled, longer duration of employment, and having upper abdominal symptoms. CONCLUSIONS: Intellectually disabled persons are at high risk of developing H. pylori infection. Employees with close physical contact to the intellectually disabled population for a considerable period of time are also at increased risk. H. pylori infection should be considered a job attributable risk in this profession.

Effects of alcohol and expectancy on self-disclosure and anxiety in male and female social drinkers.

To study the effects of alcohol consumption and expectancy on self-disclosure and self-reported anxiety during a social interaction, 32 male and 32 female social drinkers were assigned to one of four groups comprising a 2 x 2 factorial balanced-placebo design. Alcohol expectancy reduced the intimacy level of self-disclosure but not the amount of self-disclosure. Alcohol consumption had no effect. Thus, in contrast to the common view that alcohol functions as a "social lubricant," it served to inhibit social interaction. There was a three-way interaction among alcohol consumption, expectancy, and gender of subjects, such that the largest increase in anxiety was reported by male subjects who expected but did not receive alcohol. Thus, the previously reported inverse relationship between anxiety and self-disclosure was not confirmed, and alcohol's effect on anxiety seems unrelated to its effect on self-disclosure.

Dental erosions and gastro-oesophageal reflux disease in institutionalized intellectually disabled individuals.

OBJECTIVE: Both exogenous acids, from the diet, and endogenous acids, from stomach juice, can dissolve the enamel mineral, resulting in dental erosions. Gastric acid may reach the mouth by gastro-oesophageal reflux disease (GERD), recurrent vomiting, rumination and regurgitation. These conditions are frequently found in the intellectually disabled population. Therefore, we investigated the presence of dental erosions in combination with GERD among intellectually disabled inhabitants, with an IQ < 50, taken from three Dutch institutes. MATERIALS AND METHODS: At random 63 individuals underwent an oesophageal pH test and dental screening and possible predisposing and attributable factors were determined. An abnormal pH level was defined as a pH < 4, > 4.5% of the measured time. Subjects with dental erosions were compared to those without dental erosions. RESULTS: In 29 out of 63 (46.0%) cases evidence of dental erosions was found. In 19 of these 29 subjects with erosions (65.5%) GERD was diagnosed, compared to nine (26.5%) out of 34 subjects without erosions (P = 0.04). In the subjects with erosions mean duration of pH < 4 was 15.6% (range: 0.5-90.5) compared to 6.3% (range 0-40.4) in subjects without erosions (P = 0.02). An IQ < 35 was found to be predisposing (P < 0.001). CONCLUSION: In this population of 63 institutionalised intellectually disabled persons dental erosions were diagnosed in 46%. Sixty-five per cent of them had GERD. Individuals with longer duration of pH < 4 than 6.3% of the measured time and with an IQ < 35 were at higher risk to develop dental erosions. This study shows that dental erosions in the intellectually disabled population might be an oral manifestation of GERD.

Gastro-oesophageal reflux disease in institutionalised intellectually disabled individuals.

BACKGROUND: The prevalence of reflux oesophagitis (RO) in the normally intellectual population is about 2%, while this condition in the intellectually disabled has an estimated prevalence of 10%. METHODS: We investigated the presence of RO among 1687 intellectually disabled, with an IQ < 50, from 5 different institutes in the Netherlands. All were scored for possible associated factors and reflux symptoms, and compared with the overall population (n = 1580) from the same institutes (controls). Also, the effect of treatment on symptoms was evaluated after at least one year of therapy. RESULTS: Gastro-oesophageal reflux disease (GORD) was suspected clinically in 169 patients based on the following symptoms: vomiting, haematemesis, anaemia, rumination or behaviour problems. At endoscopy RO was diagnosed in 107 of 1687 patients (6.4%): 17 (15.9%) grade I, 34 (31.8%) gr. II, 42 (39.3%) gr. III and 14 (13.1%) gr. IV RO (Savary-Miller classification). Cerebral palsy, constipation, anticonvulsant drugs, an IQ < 35, underweight and gastrostomy feeding appeared to be possible associated factors, while as reflux symptoms persistent vomiting, haematemesis, iron deficiency anaemia, rumination, and behaviour problems were found. Concerning therapy, surgery was found to be effective in 38%, H2 receptor antagonists in 60% and the proton-pump inhibitor omeprazole in 96%. CONCLUSIONS: In this group of Dutch intellectually disabled patients with IQ < 50 RO was diagnosed in about 6% (107 of 1687), mostly severe grades of oesophagitis. Several possible associated factors were significantly present. From non-specific reflux symptoms persistent vomiting was the most indicative factor. In this population the most effective treatment of RO was long-term omeprazole therapy.

The effects of alcohol, expectancy, and alcohol beliefs on anxiety and self-disclosure in women: do beliefs moderate alcohol effects?

This study investigates the effects of alcohol, expectancy, and alcohol-related beliefs on self-reported anxiety and self-disclosure behavior in a social interaction situation. Seventy-two female social drinkers were assigned to eight conditions in a 2 x 2 x 2 factorial balanced-placebo design, controlling for drink content, expectancy, and beliefs. Results show that alcohol expectancy resulted in an anxiety reduction in subjects who believed that alcohol has a positive influence on social behavior, whereas expectancy had no effect in subjects with negative alcohol beliefs. Furthermore, subjects who expected alcohol were less anxious when they had positive alcohol beliefs than when they had negative beliefs, whereas beliefs made no difference in subjects who expected tonic. Our results suggest that the effect of alcohol expectancy on social anxiety in women is moderated by differences in the content of their alcohol-related beliefs. We conclude that the inconsistency in previous results about the effect of alcohol expectancy on social behavior might be explained by differences in subjects' alcohol beliefs. Finally, as neither of the three factors had any effect on self-disclosure behavior, we suggest that this behavioral measure is unrelated to self-reported anxiety.

Alcohol and social anxiety in women and men: pharmacological and expectancy effects.

A replication study was conducted to determine pharmacological and expectancy effects of alcohol on self-reported anxiety in a social interaction situation. Thirty-two male and thirty-two female social drinkers were randomly assigned to four conditions in a 2 x 2 factorial balanced placebo design, controlling for drink content and expectations. Results show that in women alcohol expectancy reduced self-reported anxiety, whereas in men there was no significant effect of expectancy. Alcohol consumption reduced anxiety in both men and women. Controlling for beliefs increased some of the effects we found. We conclude that although cognitive factors do mediate the effects of alcohol on self-reported anxiety, this influence seems to be different for men and women and the role of pharmacological factors might be more crucial.