Implementing shared decision-making in nutrition clinical practice: A theory-based approach and feasibility study

<p>Abstract</p> <p>Background</p> <p>There are a growing number of dietary treatment options to choose from for the management of many chronic diseases. Shared decision making represents a promising approach to improve the quality of the decision making process needed for dietary choices that are informed by the best evidence and value-based. However, there are no studies reporting on theory-based approaches that foster the implementation of shared decision making in health professions allied to medicine. The objectives of this study are to explore the integration of shared decision making within real nutritional consultations, and to design questionnaires to assess dieticians' intention to adopt two specific behaviors related to shared decision making using the Theory of Planned Behavior.</p> <p>Methods</p> <p>Forty dieticians will audiotape one clinical encounter to explore the presence of shared decision making within the consultation. They will also participate to one of five to six focus groups that aim to identify the salient beliefs underlying the determinants of their intention to present evidence-based dietary treatment options to their patients, and clarify the values related to dietary choices that are important to their patients. These salient beliefs will be used to elaborate the items of two questionnaires. The internal consistency of theoretical constructs and the temporal stability of their measurement will be checked using the test-retest method by asking 35 dieticians to complete the questionnaire twice within a two-week interval.</p> <p>Discussion</p> <p>The proposed research project will be the first study to: provide preliminary data about the adoption of shared decision making by dieticians and theirs patients; elicit dieticians' salient beliefs regarding the intention to adopt shared decision making behaviors, report on the development of a specific questionnaire; explore dieticians' views on the implementation of shared decision making; and compare their views regarding the implementation of shared decision making in different clinical settings.</p> <p>It is anticipated that the results generated by the proposed research project will significantly contribute to the emergence of shared decision making in nutrition through a theory-based approach.</p

Laser-assisted guiding of electric discharges around objects

Electric breakdown in air occurs for electric fields exceeding 34 kV/cm and results in a large current surge that propagates along unpredictable trajectories. Guiding such currents across specific paths in a controllable manner could allow protection against lightning strikes and high-voltage capacitor discharges. Such capabilities can be used for delivering charge to specific targets, for electronic jamming, or for applications associated with electric welding and machining. We show that judiciously shaped laser radiation can be effectively used to manipulate the discharge along a complex path and to produce electric discharges that unfold along a predefined trajectory. Remarkably, such laser-induced arcing can even circumvent an object that completely occludes the line of sight

Instabilities in the nonsymmetric theory of gravitation

We consider the linearized nonsymmetric theory of gravitation (NGT) within the background of an expanding universe and near a Schwarzschild metric. We show that the theory always develops instabilities unless the linearized nonsymmetric lagrangian reduces to a particular simple form. This theory contains a gauge invariant kinetic term, a mass term for the antisymmetric metric-field and a coupling with the Ricci curvature scalar. This form cannot be obtained within NGT. Next we discuss NGT beyond linearized level and conjecture that the instabilities are not a relic of the linearization, but are a general feature of the full theory. Finally we show that one cannot add ad-hoc constraints to remove the instabilities as is possible with the instabilities found in NGT by Clayton.Comment: 29 page

Adult cardiac surgery during the COVID-19 Pandemic: A Tiered Patient Triage Guidance Statement

In the setting of the current novel coronavirus pandemic, this document has been generated to provide guiding statements for the adult cardiac surgeon to consider in a rapidly evolving national landscape. Acknowledging the risk for a potentially prolonged need for cardiac surgery procedure deferral, the authors have created this proposed template for physicians and interdisciplinary teams to consider in protecting their patients, institution and their highly specialized cardiac surgery team. In addition, recommendations on the transition from traditional in-person patient assessments and outpatient follow-up are provided. Lastly, we advocate that the cardiac surgeon must continue to serve as leaders, experts, and relevant members of our medical community, shifting our role as necessary in this time of need

Exploring dietitians' salient beliefs about shared decision-making behaviors

<p>Abstract</p> <p>Background</p> <p>Shared decision making (SDM), a process by which health professionals and patients go through the decision-making process together to agree on treatment, is a promising strategy for promoting diet-related decisions that are informed and value based and to which patients adhere well. The objective of the present study was to identify dietitians' salient beliefs regarding their exercise of two behaviors during the clinical encounter, both of which have been deemed essential for SDM to take place: (1) presenting patients with all dietary treatment options for a given health condition and (2) helping patients clarify their values and preferences regarding the options.</p> <p>Methods</p> <p>Twenty-one dietitians were allocated to four focus groups. Facilitators conducted the focus groups using a semistructured interview guide based on the Theory of Planned Behavior. Discussions were audiotaped, transcribed verbatim, coded, and analyzed with NVivo8 (QSR International, Cambridge, MA) software.</p> <p>Results</p> <p>Most participants stated that better patient adherence to treatment was an advantage of adopting the two SDM behaviors. Dietitians identified patients, physicians, and the multidisciplinary team as normative referents who would approve or disapprove of their adoption of the SDM behaviors. The most often reported barriers and facilitators for the behaviors concerned patients' characteristics, patients' clinical situation, and time.</p> <p>Conclusions</p> <p>The implementation of SDM in nutrition clinical practice can be guided by addressing dietitians' salient beliefs. Identifying these beliefs also provides the theoretical framework needed for developing a quantitative survey questionnaire to further study the determinants of dietitians' adoption of SDM behaviors.</p

A conceptual framework for interprofessional shared decision making in home care: Protocol for a feasibility study

<p>Abstract</p> <p>Background</p> <p>Shared decision making (SDM) is fundamental to informed consent and client-centered care. So far, SDM frameworks have been limited to the client-physician dyad, even though care is increasingly delivered by interprofessional (IP) teams. IP collaboration is especially essential in home care, one of health care's most rapidly growing areas. This study will assess whether it is possible to practice SDM in IP home care.</p> <p>Methods/Design</p> <p>We will use a qualitative case study and a quantitative survey to capture the macro, meso and micro levels of stakeholders in home care. The case study will follow the knowledge-to-action process framework to evaluate the work of an IP home care team at a Quebec City health center. Sources of data will include one-on-one interviews with patients, family caregivers or surrogates and significant others, and administrators; a focus group of home care health professionals; organizational documents; and government policies and standards. The interview guide for the interviews and the focus group will explore current practices and clinical problems addressed in home care; factors that could influence the implementation of the proposed IP approach to SDM; the face and content validity of the approach; and interventions to facilitate the implementation and evaluation of the approach. The survey will ask 300 health professionals working in home care at the health center to complete a questionnaire based on the Theory of Planned Behaviour that measures their intentions to engage in an IP approach to SDM. We will use our analysis of the individual interviews, the focus group and the survey to elaborate a toolkit for implementing an IP approach to SDM in home care. Finally, we will conduct a pilot study in Alberta to assess the transferability of our findings.</p> <p>Discussion</p> <p>We believe that developing tools to implement IP SDM in home care is essential to strengthening Canada's healthcare system and furthering patient-centered care. This study will contribute to the evaluation of IP SDM delivery models in home care. It will also generate practical, policy-oriented knowledge regarding the barriers and facilitators likely to influence the practice of IP SDM in home care.</p

Ramping up Delivery of Cardiac Surgery During the COVID-19 Pandemic: A Guidance Statement from The Society of Thoracic Surgeons COVID-19 Task Force

The COVID-19 pandemic has had a profound global impact. Its rapid transmissibility has transformed healthcare delivery and forced countries to adopt strict measures to contain its spread. The vast majority of U.S. cardiac surgical programs have deferred all but truly emergent/urgent operative procedures in an effort to reduce the burden on the healthcare system and to mobilize resources to combat the pandemic surge. While the number of COVID-19 cases continues to increase worldwide, the incidence of new cases has begun to decline in many North American cities. This flattening of the curve has prompted interest in re-opening the economy, relaxing public health restrictions, and resuming non-urgent health care delivery

Causal learning across culture and socioeconomic status

Extensive research has explored the ability of young children to learn about the causal structure of the world from patterns of evidence. These studies, however, have been conducted with middle-class samples from North America and Europe. In the present study, low-income Peruvian 4- and 5-year-olds and adults, low-income U.S. 4- and 5-year-olds in Head Start programs, and middle-class children from the United States participated in a causal learning task (N = 435). Consistent with previous studies, children learned both specific causal relations and more abstract causal principles across culture and socioeconomic status (SES). The Peruvian children and adults generally performed like middle-class U.S. children and adults, but the low-SES U.S. children showed some differences

Nonperturbative harmonic generation in graphene from intense midinfrared pulsed light

In solids, high harmonic radiation arises from the subcycle dynamics of electrons and holes under the action of an intense laser field. The strong-field regime opens new opportunities to understand and control carrier dynamics on ultrafast time scales, including the coherent dynamics of quasiparticles such as massless Dirac fermions. Here, we irradiate monolayer and few-layer graphene with intense infrared light to produce nonperturbative harmonics of the fundamental up to the seventh order. We find that the polarization dependence shows surprising agreement with gas-phase harmonics. Using a two-band model, we explore the nonlinear current due to electrons near the Dirac points, and we discuss the interplay between intraband and interband contributions to the harmonic spectrum. This interplay opens new opportunities to access ultrafast and strong-field physics of graphene.Peer reviewed: YesNRC publication: Ye