Comparison of factors influencing the decision to withdraw life-sustaining treatment in intensive care unit patients after implementation of the Life-Sustaining Treatment Act in Korea.

BACKGROUND: The decision to discontinue intensive care unit (ICU) treatment during the end-oflife stage has recently become a significant concern in Korea, with an observed increase in life-sustaining treatment (LST) withdrawal. There is a growing demand for evidence-based support for patients, families, and clinicians in making LST decisions. This study aimed to identify factors influencing LST decisions in ICU inpatients and to analyze their impact on healthcare utilization. METHODS: We retrospectively reviewed medical records of ICU patients with neurological disorders, infectious disorders, or cancer who were treated at a single university hospital between January 1, 2019 and July 7, 2021. Factors influencing the decision to withdraw LST were compared between those who withdrew LST and those who did not. RESULTS: Among 54,699 hospital admissions, LST was withdrawn in 550 cases (1%). Cancer was the most common diagnosis, followed by pneumonia and cerebral infarction. Among ICU inpatients, LST was withdrawn from 215 (withdrawal group). The withdrawal group was older (78 vs. 75 years, P=0.002), had longer total hospital stays (16 vs. 11 days, P<0.001), and higher ICU readmission rates than the control group. There were no significant differences in the healthcare costs of ICU stay between the two groups. Most LST decisions (86%) were made by family. CONCLUSIONS: The decisions to withdraw LST of ICU inpatients were influenced by age, readmission, and disease category. ICU costs were similar between the withdrawal and control groups. Further research is needed to tailor LST decisions in the ICU.

Time-specific impact of trace metals on breast density of adolescent girls in Santiago, Chile.

Whether trace metals modify breast density, the strongest predictor for breast cancer, during critical developmental stages such as puberty remains understudied. Our study prospectively evaluated the association between trace metals at Tanner breast stage B1 (n = 291) and at stages both B1 and B4 (n = 253) and breast density at 2 years post-menarche among Chilean girls from the Growth and Obesity Cohort Study. Dual-energy x-ray absorptiometry assessed the volume of dense breast tissue (absolute fibroglandular volume [FGV]) and percent breast density (%FGV). Urine trace metals included arsenic, barium, cadmium, cobalt, cesium, copper, magnesium, manganese, molybdenum, nickel, lead, antimony, selenium, tin, thallium, vanadium, and zinc. At B1, a doubling of thallium concentration resulted in 13.69 cm3 increase in absolute FGV (ß: 13.69, 95% confidence interval [CI]: 2.81, 24.52), while a doubling of lead concentration resulted in a 7.76 cm3 decrease in absolute FGV (ß: -7.76, 95%CI: -14.71, -0.73). At B4, a doubling of barium concentration was associated with a 10.06 cm3 increase (ß: 10.06, 95% CI: 1.44, 18.60), copper concentration with a 12.29 cm3 increase (ß: 12.29, 95% CI: 2.78, 21.56), lead concentration with a 9.86 cm3 increase (ß: 9.86, 95% CI: 0.73, 18.98), antimony concentration with a 12.97 cm3 increase (ß: 12.97, 95% CI: 1.98, 23.79) and vanadium concentration with a 13.14 cm3 increase in absolute FGV (ß: 13.14, 95% CI: 2.73, 23.58). Trace metals may affect pubertal breast density at varying developmental stages with implications for increased susceptibility for breast cancer.

Effectiveness of lumacaftor/ivacaftor initiation in children with cystic fibrosis aged 2 through 5 years on disease progression: Interim results from an ongoing registry-based study.

BACKGROUND: Lumacaftor/ivacaftor (LUM/IVA) has been shown to be safe and efficacious in people with cystic fibrosis (CF) ≥1 year of age. To assess the impact of early LUM/IVA initiation on CF disease progression, a 6-year observational study leveraging data from existing CF patient registries is being conducted in children with CF homozygous for F508del (F/F genotype) who were aged 2 through 5 years at treatment initiation. Here we present interim results from this study focusing on data from the European CF Society Patient Registry (ECFSPR). METHODS: The LUM/IVA cohort included children in the ECFSPR who started LUM/IVA between 15 January 2019 and 31 December 2020. Longitudinal trends in growth parameters, pulmonary exacerbations, hospitalizations, safety outcomes, and other effectiveness outcomes in the LUM/IVA cohort were compared to those in two modulator-naïve cohorts: (i) matched concurrent cohort heterozygous for F508del and a minimal function mutation (F/MF concurrent comparator cohort) and (ii) matched concurrent cohort with the F/F genotype from countries without commercial access to LUM/IVA as of 2020 (F/F concurrent comparator cohort). RESULTS: The LUM/IVA cohort matched to the F/MF concurrent comparator cohort had 681 children and the LUM/IVA cohort matched to the F/F concurrent comparator cohort had 183 children. LUM/IVA cohorts had increases in body mass index percentiles relative to the matched F/MF and F/F concurrent comparator cohorts (mean difference in change from baseline: 8.4 [95% CI: 5.5, 11.3] and 11.8 [95% CI: 5.9, 17.7], respectively). Increases in height and weight percentiles were also observed in the LUM/IVA cohort relative to the F/MF and F/F concurrent comparator cohorts. Reductions in pulmonary exacerbations and hospitalizations relative to baseline and the F/F concurrent comparator cohort were seen in 2021. CONCLUSIONS: This interim analysis showed favorable trends in clinical outcomes, including growth parameters, pulmonary exacerbations, and hospitalizations, suggesting an early beneficial effect of LUM/IVA treatment in children aged 2 through 5 years at treatment initiation.

The Impact of Withdrawing or Withholding of Life-Sustaining Treatment: A Nationwide Case-Control Study Based on Medical Cost Analysis.

This study measured the impact of the Decisions on Life-Sustaining Treatment Act by analyzing medical cost data from the National Health Insurance Service-National Sample Cohort. After identifying the patients who died in 2018 and 2019, the case and control groups were set using the presence of codes for managing the implementation of life-sustaining treatment with propensity score matching. Regarding medical costs, the case group had higher medical costs for all periods before death. The subdivided items of medical costs with significant differences were as follows: consultation, admission, injection, laboratory tests, imaging and radiation therapy, nursing hospital bundled payment, and special equipment. This study is the first analysis carried out to measure the impact of the Decision on Life-Sustaining Treatment Act through a cost analysis and to refute the common expectation that patients who decided to withhold or withdraw life-sustaining treatment would go through fewer unnecessary tests or treatments.

Supervised Inhalation Sites: Preventing Overdose and Reducing Health Inequities among People Who Use Drugs.

Policy and research on the implementation of services for people who inhale drugs lag behind similar efforts for people who inject drugs, limiting access to adequate harm reduction resources for people who inhale drugs. This commentary considers why supervised inhalation sites (SIS) are needed, highlights operational characteristics of four existing services, and advocates for future SIS research. Our hope is to encourage the expansion of SIS worldwide for overdose prevention and reduction of health inequities. Given the limited literature regarding SIS, more extensive study of these programs is warranted to incorporate inhalation into the implementation of supervised consumption sites to provide fair opportunities for all people who use drugs to do so safely without fear of stigma and overdose.

Time-specific impact of mono-benzyl phthalate (MBzP) and perfluorooctanoic acid (PFOA) on breast density of a Chilean adolescent Cohort.

INTRODUCTION: High mammographic density is among the strongest and most established predictors for breast cancer risk. Puberty, the period during which breasts undergo exponential mammary growth, is considered one of the critical stages of breast development for environmental exposures. Benzylbutyl phthalate (BBP) and perfluorooctanoic acid (PFOA) are pervasive endocrine disrupting chemicals that may increase hormone-sensitive cancers. Evaluating the potential impact of BBP and PFOA exposure on pubertal breast density is important to our understanding of early-life environmental influences on breast cancer etiology. OBJECTIVE: To prospectively assess the effect of biomarker concentrations of monobenzyl phthalate (MBzP) and PFOA at specific pubertal window of susceptibility (WOS) on adolescent breast density. METHOD: This study included 376 Chilean girls from the Growth and Obesity Cohort Study with data collection at four timepoints: Tanner breast stages 1 (B1) and 4 (B4), 1- year post- menarche (1YPM) and 2-years post-menarche (2YPM). Dual-energy X-ray absorptiometry was used to assess the absolute fibroglandular volume (FGV) and percent breast density (%FGV) at 2YPM. We used concentrations of PFOA in serum and MBzP in urine as an index of exposure to PFOA and BBP, respectively. Parametric G-formula was used to estimate the time-specific effects of MBzP and PFOA on breast density. The models included body fat percentage as a time-varying confounder and age, birthweight, age at menarche, and maternal education as fixed covariates. RESULTS: A doubling of serum PFOA concentration at B4 resulted in a non-significant increase in absolute FGV (ß:11.25, 95% confidence interval (CI): -0.28, 23.49)), while a doubling of PFOA concentration at 1YPM resulted in a decrease in % FGV (ß:-4.61, 95% CI: -7.45, -1.78). We observed no associations between urine MBzP and breast density measures. CONCLUSION: In this cohort of Latina girls, PFOA serum concentrations corresponded to a decrease in % FGV. No effect was observed between MBzP and breast density measures across pubertal WOS.

Civilian Medical Responder Perspectives to a Federal Military Medical Deployment in New York City during the COVID-19 Pandemic.

OBJECTIVES: This study aims to describe the civilian experience and perceptions of the patient coordination and management at the interface of the New York City (NYC) civilian and the military health systems during a large-scale public health emergency. METHODS: A qualitative study design was implemented with interviews conducted using a basic descriptive approach. Purposive sampling was used to recruit participants with experience working during the first wave of COVID-19 in NYC. Inclusion criteria were civilians who worked at the Javits Center, the USNS Comfort, or NYC hospitals, who interfaced with patient transfer and military personnel during the city-wide medical response to COVID-19. Semi-structured video interviews were conducted between July 20, 2021 and March 11, 2022. RESULTS: Civilian responders working in the clinical and transfer operations of patients to military facilities in NYC during March and April of 2020 described initial confusion, as well as logistical (patient selection, transfer logistics, patient tracking), communication, and leadership challenges. While the military deployment was felt to be necessary to address the surge capacity in hospitals, the lack of clarity about military medical resources and frameworks for response resulted in confusion about what was being offered by the military deployment. This was balanced by the positive impression of working with military members and the resources that they brought to the response more generally. The need for future trainings and exercises were highlighted. CONCLUSIONS: Initial challenges with civilian-military roles and responsibilities, regional needs assessment, patient selection, and logistics were ultimately resolved through adaptation of civilian and military leadership. Improvements in patient tracking, medical records, and standard hospital admission and discharge functions for patients in military alternative care facilities were identified as areas for improvement. Civilian government, health care, and military leaders should consider these ideas when planning for future military deployments in support of a domestic medical response.

Cosmetic Outcome and Toxicity After Stereotactic Accelerated Partial Breast Irradiation in Early Breast Cancer: A Prospective Observational Cohort Study.

PURPOSE: The aim of this work was to prospectively evaluate the toxicity and cosmetic outcomes of 5-fraction, stereotactic, accelerated partial breast irradiation (APBI). METHODS AND MATERIALS: This prospective observational cohort study enrolled women who underwent APBI for invasive carcinoma or carcinoma in situ of the breast. APBI was delivered using a CyberKnife M6 robotic radiosurgery system at 30 Gy in 5 nonconsecutive, once-daily fractions. Women undergoing whole breast irradiation (WBI) were also enrolled for comparison. Patient-reported and physician-assessed adverse events were recorded. Breast fibrosis was measured using a tissue compliance meter, and breast cosmesis was assessed using BCCT.core (an automatic, computer-based software). Outcomes were collected until 24 months posttreatment according to the study protocol. RESULTS: In total, 204 patients (APBI, n = 103; WBI, n = 101) were enrolled. Regarding patient-reported outcomes, the APBI group reported significantly less skin dryness (6.9% vs 18.3%; P = .015), radiation skin reaction (9.9% vs 23.5%; P = .010), and breast hardness (8.0% vs 20.4%; P = .011) at 6 months than the WBI group. On physician assessment, the APBI group had significantly less dermatitis at 12 months (1.0% vs 7.2%; P = .027) than the WBI group. Any severe toxicities after APBI were rare in patient-reported outcomes (score ≥3, 3.0%) and physician assessments (grade ≥3, 2.0%). In the uninvolved quadrants, measured fibrosis in the APBI group was significantly lower than that in the WBI group at 6 (P = .001) and 12 (P = .029) months but not at 24 months. In the involved quadrant, measured fibrosis in the APBI group was not significantly different from that in the WBI group at any time. Cosmetic outcomes in the APBI group were mostly excellent or good (77.6%) at 24 months, and there was no significant cosmetic detriment from the baseline. CONCLUSIONS: Stereotactic APBI was associated with less fibrosis in the uninvolved breast quadrants than WBI. Patients showed minimal toxicity and no detrimental effects on cosmesis after APBI.

Peer Social Environment Impacts Behavior and Dopamine D1 Receptor Density in Prairie Voles (Microtus ochrogaster).

Prairie voles (Microtus ochrogaster) are socially monogamous rodents that form selective, long-lasting relationships with mates and with same-sex peers. It is unknown to what extent mechanisms supporting 'peer relationships' are similar to those involved in mate relationships. The formation of pair bonds is dependent on dopamine neurotransmission, whereas the formation of peer relationships is not, providing evidence of relationship type-specificity. The current study assessed endogenous structural changes in dopamine D1 receptor density in male and female voles across different social environments, including long-term same-sex partnerships, new same-sex partnerships, social isolation, and group housing. We also related dopamine D1 receptor density and social environment to behavior in social interaction and partner preference tests. Unlike prior findings in mate pairs, voles paired with new same-sex partners did not exhibit upregulated D1 binding in the nucleus accumbens (NAcc) relative to controls paired from weaning. This is consistent with differences in relationship type: D1 upregulation in pair bonds aids in maintaining exclusive relationships through selective aggression, and we found that formation of new peer relationships did not enhance aggression. Isolation led to increases in NAcc D1 binding, and even across socially housed voles, individuals with higher D1 binding exhibited increased social avoidance. These findings suggest that elevated D1 binding may be both a cause and a consequence of reduced prosociality. These results highlight the neural and behavioral consequences of different non-reproductive social environments and contribute to growing evidence that the mechanisms underlying reproductive and non-reproductive relationship formation are distinct. Elucidation of the latter is necessary to understand mechanisms underlying social behavior beyond a mating context.

The creative touch: the influence of haptics on creativity.

An increasing number of firms rely on consumers to develop new ideas for the marketplace. While many firms rely on online crowdsourcing communities, some have created facilities that encourage in-person ideation through which consumers can interact with product design materials. This research proposes that active touch engenders a positive effect on new product creativity and highlights the importance of touch during idea generation. We further suggest that interacting with an object via active touch increases positive mood, which enhances creative performance. Results from two studies provide support for these hypotheses. Study 1 demonstrates the positive effect of active touch on new product creativity. Study 2 replicates this effect in a different product development context and provides evidence that a positive mood mediates the active touch-creativity relationship. Supplementary Information: The online version contains supplementary material available at 10.1007/s11002-022-09628-5.

Military Response to Medical Crises-Consensus Recommendations for Military-Civilian Transitions of Care.

OBJECTIVE: The threat that New York faced in 2020, as the COVID-19 pandemic unfolded, prompted an unprecedented response. The US military deployed active-duty medical professionals and equipment to NYC in a first of its kind response to a "medical" domestic disaster. Transitions of care for patients surfaced as a key challenge. Uniformed Services University and the Icahn School of Medicine at Mount Sinai hosted a consensus conference of civilian and military healthcare professionals to identify care transition best practices for future military-civilian responses. METHODS: We performed individual interviews followed by a modified Delphi technique during a two-day virtual conference. Patient transitions of care emerged as a key theme from pre-conference interviews. Twelve participants attended the two-day virtual conference and generated best practice recommendations from an iterative process. RESULTS: Participants identified 19 recommendations in 10 "sub-themes" related to patient transitions of care: needs assessment and capability analysis; unified command; equipment; patient handoffs; role of in-person facilitation; dynamic updates; patient selection; patient tracking; daily operations; and resource typing. CONCLUSIONS: The COVID-19 pandemic resulted in an unprecedented military response. This study created 19 consensus recommendations for care transitions between military and civilian healthcare assets that may be useful in future military-civilian medical engagements.

The Impact of Prebiotic, Probiotic, and Synbiotic Supplements and Yogurt Consumption on the Risk of Colorectal Neoplasia among Adults: A Systematic Review.

Prebiotic and probiotic supplementation and yogurt consumption (a probiotic food) alter gut microbial diversity, which may influence colorectal carcinogenesis. This systematic review evaluates the existing literature on the effect of these nutritional supplements and yogurt consumption on colorectal neoplasia incidence among adults. We systematically identified ten randomized controlled trials and observational studies in adults age ≥ 18 without baseline gastrointestinal disease. Prebiotics included inulin, fructooligosaccharides, galactooligosaccharides, xylooligosaccharides, isomaltooligosaccharides, and ß-glucans. Probiotics included bacterial strains of Lactobacillus, Bifidobacterium, Saccharomyces, Streptococcus, Enterococcus, Bacillus, Pediococcus, Leuconostoc, and Escherichia coli. Synbiotic supplements, a mixture of both prebiotic and probiotic supplements, and yogurt, a commonly consumed dietary source of live microbes, were also included. We defined colorectal neoplasia as colorectal adenomas, sessile serrated polyps, and colorectal cancer (CRC). Overall, findings suggest a moderate decrease in risk of adenoma and CRC for high levels of yogurt consumption compared to low or no consumption. Prebiotic supplementation was not associated with colorectal neoplasia risk. There was some evidence that probiotic supplementation may be associated with lower risk of adenomas but not with CRC incidence. Higher yogurt consumption may be associated with lower incidence of colorectal neoplasia. We found little evidence to suggest that prebiotic or probiotic supplements are associated with significant decreases in CRC occurrence.

Evaluation of an ultrasound program in nationwide Continuing Professional Development (CPD) in Korean public health and medical institutions.

BACKGROUND: The Education and Training Centre for Public Healthcare of the National Medical Centre plays a key role in providing continuing professional development (CPD) to 221 public health and medical institutions in South Korea. To assess the realization of the Centre's core value and the intended changes, program evaluations are required. The context, input, process, and product (CIPP) model is particularly suitable for evaluating CPD in the public sector, as it allows for recognizing the dynamic nature of the program environment. METHODS: This research applied the CIPP model to the evaluation of CPD programs, particularly abdominal and thoracic ultrasound programs implemented in 2017 and 2018. Data were collected from 2017 to 2019. The program and its feedback were reviewed in the context evaluation. Based on this, a subsequent program strategy was established for the input evaluation. Observing the program in real time and recording its progress was followed in process evaluation. Finally, the outcomes and impacts of the program were reviewed and compared with baseline data in the product evaluation. RESULTS: In context evaluation, the educational needs of the Centre's CPD program recipients, impediments that inhibit participation in education, and resources that the Centre can utilize were identified through an online survey, focus group interviews and expert consultation. Through input evaluation, we identified the best alternative that satisfied all pre-selected criteria, which were responsiveness to priority system needs, potential effectiveness, fit with existing services, affordability, and administrative feasibility. Observing the program in real time and recording its progress were conducted in process evaluation, demonstrating that the augmented program went as planned, and even had to be expanded due to increased demand. The impact of the program was measured, interpreted, and assessed in the product evaluation. The review committee decided that the intended change had been occurred, thus the Centre decided to maintain the program. CONCLUSION: A thorough evaluation is necessary to determine the potential benefits of CPD. The CIPP methodology is valuable for executing formative and summative evaluations. The CIPP model is particularly useful for securing accountability data for large-scale nationwide educational programs supplied by public funds.

Peer support facilitator and peer perspectives of an inner-regional Australian diabetes prevention and self-management peer support program.

Peer support programmes have been shown to facilitate diabetes prevention and improvements in diabetes self-management. Worldwide, few studies have qualitatively evaluated peer support programs in inner-regional (semi-rural) areas, and none involving mixtures of people with and without diabetes. This study researched an inner-regional peer support programme underway over 2 years in Australia. Fifteen participants, including ten peers and five peer support facilitators (PSFs) were interviewed using semi-structured focus group and one-to-one interviews with the aim of understanding their perceptions and experiences of the programme, barriers, and ways of overcoming barriers. Participants were those with and without diabetes. The main themes identified were; benefits of the programme, factors affecting recruitment and retention, challenges and barriers to programme participation, PSF reflections on peer support training, and recommendations to improve the programme. Participants identified increased knowledge of diet, diabetes and complications as key benefits, with greater social support and well-being the main reasons for initial participation. The main challenges for the programme were the lack of wide community engagement before setting up the peer groups, difficulty with peer recruitment and personal difficulties in maintaining a healthy lifestyle. The peer support programme was well received within an inner-regional area and was perceived as useful in providing support and motivation to make lifestyle behavioural changes from shared experiences with peers. Whilst considered beneficial to those with and without diabetes, ways of overcoming identified challenges are required.

Nurse roles in the advance directive system in Korea.

BACKGROUND: In 2016, the Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care was implemented in Korea, providing a broad framework for end-of-life decision-making for the first time and making advance directives legally recognized documents. This Act can correct long-standing under-recognition of patients as valid decision makers for their own treatment choices. However, limited recognition of patient self-determination, rigid legal forms for documenting patient wishes, and the roles of family under the Act may pose challenges both to patients and nurses. AIM: This paper critiques whether this newly introduced system of advance directives can truly guarantee protection of the patient's interests and respect for patient autonomy in real life​, and discusses ethical and legal issues regarding the Act. SOURCE OF EVIDENCE: We reviewed the current system of advance directives by raising three questions: (1) Do advance directives reflect a competent person's voluntary and informed choice?, (2) Are advance directives applicable in diverse clinical situations?, and (3) Does the Korean advance directive system ensure that such directives are honored in reality? CONCLUSION: Although the Act is an important first step in respecting patient autonomy in end-of-life decision-making, it remains inadequate as it fails to provide thorough guidance in terms of the quality of writing process, applicability, and the guaranteed effects of advance directives. IMPLICATIONS FOR NURSING AND HEALTH POLICY: As nurses are best situated for addressing these limitations due to their roles and competencies in clinical practice, expanding the roles of nurses in every stage of advance directive practice could help achieve the original purpose of advance directives. This calls for a policy that promotes an expanded role of nurses to improve the quality of advance directive practice.

Barriers to Informed refusal in Korea / Obstáculos al rechazo informado en Corea / Barreiras à recusa informada na Coreia

Abstract In South Korea, the legal and cultural environment keeps terminally ill patients from making an informed refusal to a treatment the discontinuation of which can cause death. Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life allows several forms of informed refusal, but it is not enough. There is no explicit guarantee, at least under this law, of the right to refuse a treatment given during a period that has not reached an end-of-life process prescribed in the law. Dori, which the family of a terminal patient feels obligated to follow, makes them commit to doing what they believe is right as a family member without asking the patient's intention. Because it reduces the family's motivation to have a difficult talk about death and end-of-life with the patient, the patient is deprived of an opportunity to make a decision based on accurate information. In making a decision for the patient while patient is excluded, the family often ends up choosing a safe decision that puts physical survival first. In conclusion, the culture and the culturally influenced law are making it impractical for terminal patients to make an informed refusal.

Resumen: En Corea del Sur, el entorno legal y cultural impide a los pacientes terminales rechazar con conocimiento de causa un tratamiento cuya interrupción puede causar la muerte. La Ley de Decisiones sobre el Tratamiento de Mantenimiento de la Vida para Pacientes en Hospicio y Cuidados Paliativos o al Final de la Vida permite varias formas de rechazo informado, pero no es suficiente. No se garantiza explícitamente, al menos en esta ley, el derecho a rechazar un tratamiento administrado durante un periodo que no ha llegado a un proceso de final de vida prescrito en la ley. La ley Dori, que la familia de un paciente terminal se siente obligada a seguir, les hace comprometerse a hacer lo que creen correcto como familiares, sin preguntar la intención del paciente. Dado que reduce la motivación de la familia para tener una charla difícil sobre la muerte y el final de la vida con el paciente, éste se ve privado de la oportunidad de tomar una decisión basada en información precisa. Al tomar una decisión por el paciente mientras se le excluye, la familia suele acabar eligiendo una decisión segura que antepone la supervivencia física. En conclusión, la ley, influenciada por la cultura, está haciendo que sea poco práctico para los pacientes terminales hacer un rechazo informado.

Resumo Na Coreia do Sul, o ambiente legal e cultural mantém pacientes com doença terminal à parte de fazer uma recusa informada a um tratamento cuja descontinuação pode causar morte. O Ato sobre Decisões a respeito de Tratamento de Suporte à Vida para Pacientes em Lares de Idosos e Cuidados Paliativos ou ao Fim da Vida permite diversas formas de recusa informada mas não é suficiente. Não há uma garantia explícita, pelo menos sob esta lei, do direito de recusar um dado tratamento durante um período que não alcançou um processo de fim-da-vida prescrito na lei. Dori, que a família de um paciente terminal sente-se obrigada a seguir, faz com que eles se comprometam a fazer o que eles acreditam ser certo como um membro da família, sem perguntar a intenção do paciente. Na medida em que isto reduz a motivação da família em ter uma conversa difícil sobre morte e fim-da-vida com o paciente, o paciente é privado de uma oportunidade de tomar uma decisão baseada em informação precisa. Ao tomar uma decisão pelo paciente enquanto ele é excluído, a família frequentemente termina escolhendo uma decisão segura que coloca a sobrevivência física em primeiro lugar. Em conclusão, a cultura e a lei influenciada pela cultura estão tornando impraticável para pacientes terminais fazer uma recusa informada.

Association of the SNP rs112369934 near TRIM66 Gene with POAG Endophenotypes in African Americans.

We investigated the association of the single nucleotide polymorphism (SNP) rs112369934 near the TRIM66 gene with qualitative and quantitative phenotypes of primary open-angle glaucoma (POAG) in African Americans (AA). AA subjects over 35 years old were recruited for the Primary Open-Angle African American Glaucoma Genetics (POAAGG) study in Philadelphia, PA. Glaucoma cases were evaluated for phenotypes associated with POAG pathogenesis, and the associations between rs112369934 and phenotypes were investigated by logistic regression analysis and in gender-stratified case cohorts: The SNP rs112369934 was found to have a suggestive association with retinal nerve fiber layer (RNFL) thickness and cup-to-disc ratio (CDR) in 1087 male AA POAG cases, individuals with the TC genotype having thinner RNFL (95% CI 0.85 to 6.61, p = 0.01) and larger CDR (95% CI -0.07 to -0.01, p = 0.02) than those with wildtype TT. No other significant associations were found. In conclusion SNP rs112369934 may play a role in POAG pathogenesis in male AA individuals. However, this SNP has been implicated in higher POAG risk in both male and female AA POAG cases.

An audit of the effect of SGLT2 inhibitor cessation in a pre-admission clinic before and after Australian Diabetes Society guidelines.

Perioperative ketoacidosis is an important adverse event related to the use of sodium glucose co-transporter 2 inhibitor (SGLT2i). We compared perioperative outcomes in patients on SGLT2i, before and after protocolised pre-operative cessation of the drug. There were no cases of clinically detected diabetic ketoacidosis in the 96 patients included in the study. Withdrawal of SGLT2i did not appear to alter significantly pre-operative glycaemia.

Exploring approaches to identify, incorporate and report patient preferences in clinical guidelines: Qualitative interviews with guideline developers.

BACKGROUND: Clinical guidelines informed by patient preferences are more likely to be used and widely advocated, yet research shows that few guidelines reflect patient preferences. OBJECTIVE: Explore how developers generate guidelines informed by patient preferences. PATIENT INVOLVEMENT: Seventeen patients were involved as interview participants. METHODS: Using a basic descriptive approach, we conducted and analyzed semi-structured telephone interviews with 50 participants who were involved in developing guidelines on various topics. The sample included 17 patients, 16 clinicians and 17 managers from a total of 7 countries. RESULTS: Participants used one or more approaches to identify preferences, patient panelists, focus groups, surveys and review of published research, despite acknowledging they identified similar preferences. Participants said they incorporated preferences in all guideline development steps, but provided little detail of specific processes. Few participants said their guidelines explicitly reported how patients were engaged, preferences identified, or how preferences influenced development processes or the guideline. Enablers were patient and clinician training, supportive coordinators and chairs, involving experienced patients, and assistance from qualitative and review experts. Barriers were finding and preparing patients, clinician skepticism about benefits, and token patient involvement. Participants recommended research on how to generate preference-informed guidelines. DISCUSSION: Ideal approaches to identify, incorporate and report patient preferences in guidelines are unclear and unproven. PRACTICAL VALUE: Findings revealed specific ways that developers can enhance their processes (e.g. patient training, supportive coordinators and chairs, involve experts in qualitative researcher and systematic reviews) and key issues that warrant ongoing research (e.g. how best to incorporate and report preferences).