Storylines of family medicine VIII: clinical approaches

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In ‘VIII: clinical approaches’, authors address the following themes: ‘Evaluation, diagnosis and management I—toward a working diagnosis’, ‘Evaluation, diagnosis and management II—process steps’, ‘Interweaving integrative medicine and family medicine’, ‘Halfway—the art of clinical judgment’, ‘Seamless integration in family medicine—team-based care’, ‘Technology—uncovering stories from noise’ and ‘Caring for patients with multiple long-term conditions’. May readers recognise in these essays the uniqueness of a family medicine approach to care.<br/

Ringed, Bearded, and Ribbon Seal Vocalizations North of Barrow, Alaska: Seasonal Presence and Relationship with Sea Ice

The acoustic repertoires of ringed, bearded, and ribbon seals are described, along with their seasonal occurrence and relationship to sea ice concentration. Acoustic recordings were made between September and June over three years (2006 – 09) along the continental slope break in the Chukchi Sea, 120 km north-northwest of Barrow, Alaska. Vocalizations of ringed and bearded seals occurred in winter and during periods of 80% – 100% ice cover but were mostly absent during open water periods. The presence of ringed and bearded seal calls throughout winter and spring suggests that some portion of their population is overwintering. Analysis of the repertoire of ringed and bearded seal calls shows seasonal variation. Ringed seal calls are primarily barks in winter and yelps in spring, while bearded seal moans increase during spring. Ribbon seal calls were detected only in the fall of 2008 during the open water period. The repertoire of known ribbon seal vocalizations was expanded to include three additional calls, and two stereotyped call sequences were common. Retrospective analyses of ringed seal recordings from 1982 and ribbon seal recordings from 1967 showed a high degree of stability in call repertoire across large spatial and temporal scales.Le répertoire acoustique des phoques annelés, des phoques barbus et des phoques à bandes sont décrits, de même que leur présence saisonnière et leur rapport avec la concentration de glace de mer. Des enregistrements acoustiques ont été effectués entre septembre et juin sur une période de trois ans (2006 – 2009), le long de la rupture de la pente continentale, dans la mer des Tchouktches, à 120 km au nord-nord-ouest de Barrow, en Alaska. Les vocalisations de phoques annelés et de phoques barbus étaient présentes pendant l’hiver et pendant les périodes où la concentration de glace était de 80 % à 100 %, mais elles se faisaient rares pendant les périodes d’eau libre. La présence des cris de phoques annelés et de phoques barbus tout au long de l’hiver et du printemps suggère qu’une partie de leur population hiverne. L’analyse du répertoire de cris de phoques annelés et de phoques barbus indique une variation saisonnière. L’hiver, le cri du phoque annelé prend principalement la forme d’aboiements, tandis que le printemps, il prend la forme de glapissements. Les gémissements du phoque barbu s’intensifient au printemps. Le cri des phoques à bandes n’a été capté qu’à l’automne 2008, pendant la période des eaux libres. Le répertoire des vocalisations connues du phoque à bandes a été élargi pour inclure trois autres cris, bien que deux séquences de cris stéréotypées étaient courantes. L’analyse rétrospective des enregistrements de cris de phoques annelés de 1982 et de phoques à bandes de 1967 a laissé entrevoir une grande stabilité du point de vue du répertoire des cris, et ce, sur de vastes échelles spatiales et temporelles

The barriers and facilitators to young people's engagement with bidirectional digital sexual health interventions: A mixed methods systematic review

Background: Sexual health is fundamental to the overall health and wellbeing of individuals and to the social and economic development of communities and countries. However, internationally young people endure a disproportionate burden of sexually transmitted infections and unintended pregnancies which can be associated with poor psycho-social outcomes. Digital sexual health interventions have been developed to increase young people’s access to sexual health services, but are currently underutilised. Aim: This systematic review sought to identify the barriers and facilitators to young people’s engagement with bidirectional digital sexual health interventions, which are standalone two-way tailored interventions between a young person and healthcare professional. Methods: The review was conducted in accordance with the JBI methodology for mixed methods systematic reviews, following a convergent integrated approach to synthesis and integration of qualitative and quantitative evidence. Searches of ten electronic databases were conducted, spanning database inception to January 2022. No restrictions were imposed on language, geographical location or community setting. All included studies were critically appraised with JBI Critical Appraisal tools. Data extraction was performed using standardised tools, followed by data transformation. Data synthesis followed the convergent integrated approach. Each stage was conducted by two independent reviewers. Results: Eight thousand four hundred thirty-nine titles and abstracts and, subsequently, 255 full-texts underwent review. Nine studies were selected for inclusion with no studies added following forward and backward citation tracking. The included studies comprised three qualitative and six quantitative designs. Three meta synthesised findings were identified: (1) The design of a digital intervention for adolescent sexual health needs to reflect the end users’ specific needs (2) Young people need to feel comfortable when using a digital sexual health intervention (3) Potential barriers to engagement need to be addressed. The review identified that although barriers and facilitators to promoting young people’s engagement with bidirectional digital sexual health interventions are nuanced, young people’s privacy and security need to be prioritised for them to engage with digital interventions, regardless of the platform of choice. Conclusions: Co-production of digital sexual health services, in partnership with young people, has shaped many of the insights reported in this systematic review. Further international research which places an emphasis on young people’s perspectives is vital to unleash the full potential of digital technology in this domain

Validity of biomarkers of early circulatory impairment to predict outcome: a retrospective analysis

Objectives: The definition of circulatory impairment in the premature infant is controversial. Current research suggests overdiagnosis and overtreatment. We aimed to analyse which biomarkers move clinicians to initiate cardiovascular treatment (CVT). The prognostic capacity for adverse outcome (death and/or moderate-severe brain damage by cranial ultrasound at term equivalent) of these biomarkers was evaluated. Study Design: Retrospective data analysis from preterm infants enrolled in a placebo-controlled trial on dobutamine for low superior vena cava (SVC) flow, who showed normal SVC flow within the first 24 h (not randomized). Five positive biomarkers were considered: MABP 4 mmol/L; BE < −9 mmol/L; SVC flow <51 ml/kg/min. Results: Ninety eight infants formed the study cohort. Thirty six received CVT (2–95 h). Logistic regression models adjusted for gestational age showed a positive association between CVT and the risk of death or moderate-severe abnormal cranial ultrasound at term equivalent [(OR 5.2, 95%CI: 1.8–15.1) p = 0.002]. MABP 4 mmol/L were the most prevalent biomarkers at start of treatment. Low BE, high serum lactate and low SVC flow at first echocardiography showed a trend toward being associated with adverse outcome, although not statistically significant. Conclusions: Low blood pressure and high lactate are the most prevalent biomarkers used for CVT prescription. Lactic acidosis and low SVC flow early after birth showed a trend toward being associated with adverse outcome. These findings support using a combination of biomarkers for inclusion in a placebo-controlled trial on CVT during transitional circulation

Fever, hyperglycaemia and swallowing dysfunction management in acute stroke: A cluster randomised controlled trial of knowledge transfer

Background: Hyperglycaemia, fever, and swallowing dysfunction are poorly managed in the admission phase of acute stroke, and patient outcomes are compromised. Use of evidence-based guidelines could improve care but have not been effectively implemented. Our study aims to develop and trial an intervention based on multidisciplinary team-building to improve management of fever, hyperglycaemia, and swallowing dysfunction in patients following acute stroke. Methods and design: Metropolitan acute stroke units (ASUs) located in New South Wales, Australia will be stratified by service category (A or B) and, within strata, by baseline patient recruitment numbers (high or low) in this prospective, multicentre, single-blind, cluster randomised controlled trial (CRCT). ASUs then will be randomised independently to either intervention or control groups. ASUs allocated to the intervention group will receive: unit-based workshops to identify local barriers and enablers; a standardised core education program; evidence-based clinical treatment protocols; and ongoing engagement of local staff. Control group ASUs will receive only an abridged version of the National Clinical Guidelines for Acute Stroke Management. The following outcome measures will be collected at 90 days post-hospital admission: patient death, disability (modified Rankin Score); dependency (Barthel Index) and Health Status (SF-36). Additional measures include: performance of swallowing screening within 24 hours of admission; glycaemic control and temperature control. Discussion: This is a unique study of research transfer in acute stroke. Providing optimal inpatient care during the admission phase is essential if we are to combat the rising incidence of debilitating stroke. Our CRCT will also allow us to test interventions focussed on multidisciplinary ASU teams rather than individual disciplines, an imperative of modern hospital services

Study protocol for the recreational stimulation for elders as a vehicle to resolve delirium superimposed on dementia (Reserve For DSD) trial

<p>Abstract</p> <p>Background</p> <p>Delirium is a state of confusion characterized by an acute and fluctuating decline in cognitive functioning. Delirium is common and deadly in older adults with dementia, and is often referred to as delirium superimposed on dementia, or DSD. Interventions that treat DSD are not well-developed because the mechanisms involved in its etiology are not completely understood. We have developed a theory-based intervention for DSD that is derived from the literature on cognitive reserve and based on our prior interdisciplinary work on delirium, recreational activities, and cognitive stimulation in people with dementia. Our preliminary work indicate that use of simple, cognitively stimulating activities may help resolve delirium by helping to focus inattention, the primary neuropsychological deficit in delirium. Our primary aim in this trial is to test the efficacy of Recreational Stimulation for Elders as a Vehicle to resolve DSD (RESERVE- DSD).</p> <p>Methods/Design</p> <p>This randomized repeated measures clinical trial will involve participants being recruited and enrolled at the time of admission to post acute care. We will randomize 256 subjects to intervention (RESERVE-DSD) or control (usual care). Intervention subjects will receive 30-minute sessions of tailored cognitively stimulating recreational activities for up to 30 days. We hypothesize that subjects who receive RESERVE-DSD will have: decreased severity and duration of delirium; greater gains in attention, orientation, memory, abstract thinking, and executive functioning; and greater gains in physical function compared to subjects with DSD who receive usual care. We will also evaluate potential moderators of intervention efficacy (lifetime of complex mental activities and APOE status). Our secondary aim is to describe the costs associated with RESERVE-DSD.</p> <p>Discussion</p> <p>Our theory-based intervention, which uses simple, inexpensive recreational activities for delivering cognitive stimulation, is innovative because, to our knowledge it has not been tested as a treatment for DSD. This novel intervention for DSD builds on our prior delirium, recreational activity and cognitive stimulation research, and draws support from cognitive reserve theory.</p> <p>Trial registration</p> <p>ClinicalTrials.gov identifier: <a href="http://www.clinicaltrials.gov/ct2/show/NCT01267682">NCT01267682</a></p

Mutual fund performance: Measurement and evidence

The paper provides a critical review of empirical findings on the performance of mutual funds, mainly for the US and UK. Ex-post, there are around 0-5% of top performing UK and US equity mutual funds with truly positive-alpha performance (after fees) and around 20% of funds that have truly poor alpha performance, with about 75% of active funds which are effectively zero-alpha funds. Key drivers of relative performance are, load fees, expenses and turnover. There is little evidence of successful market timing. Evidence suggests past winner funds persist, when rebalancing is frequent (i.e., less than one year) and when using sophisticated sorting rules (e.g., Bayesian approaches) - but transactions costs (load and advisory fees) imply that economic gains to investors from winner funds may be marginal. The US evidence clearly supports the view that past loser funds remain losers. Broadly speaking results for bond mutual funds are similar to those for equity funds. Sensible advice for most investors would be to hold low cost index funds and avoid holding past 'active' loser funds. Only sophisticated investors should pursue an active ex-ante investment strategy of trying to pick winners - and then with much caution. © 2010 New York University Salomon Center and Wiley Periodicals, Inc

Towards a model of contemporary parenting: The parenting behaviours and dimensions questionnaire

The assessment of parenting has been problematic due to theoretical disagreement, concerns over generalisability, and problems with the psychometric properties of current parenting measures. The aim of this study was to develop a comprehensive, psychometrically sound self-report parenting measure for use with parents of preadolescent children, and to use this empirical scale development process to identify the core dimensions of contemporary parenting behaviour. Following item generation and parent review, 846 parents completed an online survey comprising 116 parenting items. Exploratory and confirmatory factor analyses supported a six factor parenting model, comprising Emotional Warmth, Punitive Discipline, Anxious Intrusiveness, Autonomy Support, Permissive Discipline and Democratic Discipline. This measure will allow for the comprehensive and consistent assessment of parenting in future research and practice

A legal analysis of Australian criminal cases involving defendants with autism spectrum disorder charged with online sexual offending

This paper examines how the symptomology of the small number of individuals with autism spectrum disorder (ASD) charged with online sexual offenses in Australia is established during legal arguments and conceived by the judiciary to impact legal liability and offending behavior. This study aims to provide empirical support for the proposition that judicial discourses regarding the connection between ASD and online sexual offending, including conduct related to child exploitation material (CEM), have little bearing on overall questions of criminal liability or the use of alternative penal dispositions. It does so by exploring a sample of nine recent Australian criminal cases, involving ten rulings, that examine how evidence of ASD is raised in legal arguments in ways that suggest a diagnosed condition may have contributed significantly to the alleged wrongdoing. We conclude by suggesting current Australian judicial practice requires more sensitivity to the impact of clinical factors associated with ASD in shaping alternative supervisory and non-custodial dispositions for individuals convicted of online sexual offenses. Previous article in issu

Like gold dust these days’: domestic violence fact-finding hearings in child contact cases

Fact-finding hearings may be held to determine disputed allegations of domestic violence in child contact cases in England and Wales, and can play a vital role for mothers seeking protection and autonomy from violent fathers. Drawing on the author’s empirical study, this article examines the implications for the holding of fact-finding hearings of judges’ and professionals’ understandings of domestic violence and the extent to which they perceive it to be relevant to contact. While more judges and professionals are developing their understanding of domestic violence, the ambit of when and how it is considered relevant to contact has grown increasingly narrow, which suggests that many disputed allegations of domestic violence are disregarded and women and children continue to be put at risk from violent fathers. This bifurcated approach is likely to have significant implications for recent developments in this area of family law which are considered in this article