Curriculum for neurogastroenterology and motility training: A report from the joint ANMS-ESNM task force

Although neurogastroenterology and motility (NGM) disorders are some of the most frequent disorders encountered by practicing gastroenterologists, a structured competency-based training curriculum developed by NGM experts is lacking. The American Neurogastroenterology and Motility Society (ANMS) and the European Society of Neurogastroenterology and Motility (ESNM) jointly evaluated the components of NGM training in North America and Europe. Eleven training domains were identified within NGM, consisting of functional gastrointestinal disorders, visceral hypersensitivity and pain pathways, motor disorders within anatomic areas (esophagus, stomach, small bowel and colon, anorectum), mucosal disorders (gastro-esophageal reflux disease, other mucosal disorders), consequences of systemic disease, consequences of therapy (surgery, endoscopic intervention, medications, other therapy), and transition of pediatric patients into adult practice. A 3-tiered training curriculum covering these domains is proposed here and endorsed by all NGM societies. Tier 1 NGM knowledge and training is expected of all gastroenterology trainees and practicing gastroenterologists. Tier 2 knowledge and training is appropriate for trainees who anticipate NGM disorder management and NGM function test interpretation being an important part of their careers, which may require competency assessment and credentialing of test interpretation skills. Tier 3 knowledge and training is undertaken by trainees interested in a dedicated NGM career and may be restricted to specific domains within the broad NGM field. The joint ANMS and ESNM task force anticipates that the NGM curriculum will streamline NGM training in North America and Europe and will lead to better identification of centers of excellence where Tier 2 and Tier 3 training can be accomplished

Impact of symptom burden and health‐related quality of life (HRQOL) on esophageal motor diagnoses

BackgroundHigh‐resolution manometry (HRM) categorizes esophageal motor processes into specific Chicago Classification (CC) diagnoses, but the clinical impact of these motor diagnoses on symptom burden remain unclear.MethodsTwo hundred and eleven subjects (56.8±1.0 years, 66.8% F) completed symptom questionnaires (GERDQ, Mayo dysphagia questionnaire [MDQ], visceral sensitivity index, short‐form 36, dominant symptom index, and global symptom severity [GSS] on a 100‐mm visual analog scale) prior to HRM. Subjects were stratified according to CC v3.0 and by dominant presenting symptom; contraction wave abnormalities (CWA) were evaluated within “normal” CC. Symptom burden, impact of diagnoses, and HRQOL were compared within and between cohorts.Key ResultsMajor motor disorders had highest global symptom burden (P=.02), “normal” had lowest (P<.01). Dysphagia (MDQ) was highest with esophageal outflow obstruction (P=.02), but reflux symptoms (GERDQ) were similar in CC cohorts (P=ns). Absent contractility aligned best with minor motor disorders. Consequently, pathophysiologic categorization into outflow obstruction, hypermotility, and hypomotility resulted in a gradient of decreasing dysphagia and increasing reflux burden (P<.05 across groups); GSS (P=.05) was highest with hypomotility and lowest with “normal” (P=.002). Within the “normal” cohort, 33.3% had CWA; this subgroup had symptom burden similar to hypermotility. Upon stratification by symptoms, symptom burden (GSS, MDQ, HRQOL) was most profound with dysphagia.Conclusions and InferencesChicago Classification v3.0 diagnoses identify subjects with highest symptom burden, but pathophysiologic categorization may allow better stratification by symptom type and burden. Contraction wave abnormalities are clinically relevant and different from true normal motor function. Transit symptoms have highest yield for a motor diagnosis.The interrelationship between esophageal symptom characteristics, symptom burden, and motor diagnoses (Chicago Classification v 3.0) were further studied by obtaining validated self‐report questionnaires in 211 patients undergoing esophageal high‐resolution manometry (HRM). Chicago Classification diagnoses (outflow obstruction, major disorders) were associated with the highest symptom burden. Symptom characteristics were best characterized by pathophysiologic categorization of motor disorders into outflow obstruction, hypermotility disorders, and hypomotility disorders. Contraction wave abnormalities in patients without a motor disorder (according to Chicago Classification) had distinct symptom characteristics and symptom burden that aligned best with hypermotility disorders.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136428/1/nmo12970_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136428/2/nmo12970.pd

Simulation-based flood fragility and vulnerability analysis for expanding cities

Accurately quantifying flood-induced impacts on buildings and other infrastructure systems is essential for risk-sensitive planning and decision-making in expanding urban regions. Flood-induced impacts are directly related to the physical components of assets damaged due to contact with water. Such components include building contents (e.g., appliances, furniture) and other non-structural components whose damage/unavailability can severely impact the buildingsﾒ functionality. Conventional fragility analysis approaches for flooding do not account for the physical damage to the individual components, mostly relying on empirical methods based on historical data. However, recent studies proposed simulation-based, assembly-based fragility models that account for the damage to the building components. Such fragility models require developing detailed inventories of vulnerable components of households and identifying building archetypes to be considered in a building portfolio for the region of interest. Content inventories and building portfolios have so far been obtained for specific socio-economic contexts such as the United States of America. However, building types and their content can significantly differ between countries, making the available fragility models and computational frameworks unsuitable for flood vulnerability analysis in rapidly expanding cities characterised by extensive informal settlements, such as low- and middle-income countries. This paper details how to adapt the available methodologies for flood vulnerability assessment to the context of formal and informal settlements of expanding cities in the global south. It also details the development of content inventories for households in these cities using field surveys. The proposed survey is deployed in various areas vulnerable to floods in Kathmandu, Nepal. Based on the survey results, each component within the household is associated with a corresponding flood capacity (resistance) distribution (in terms of water height and flood duration). These distributions are then employed in a simulation-based probabilistic framework to obtain fragility relationship and consequence models. The relevant differences between the results obtained in this study and those from previous studies are then investigated for a case-study building type. In addition, the influence of socio-economic factors (e.g., household income) and past flood experience (possibly resulting in various flood-risk mitigation strategies at a household level) on the resulting flood impacts is also included in the model

Toolbox approaches using molecular markers and 16S rRNA gene amplicon data sets for identification of fecal pollution in surface water

In this study, host-associated molecular markers and bacterial 16S rRNA gene community analysis using high-throughput sequencing were used to identify the sources of fecal pollution in environmental waters in Brisbane, Australia. A total of 92 fecal and composite wastewater samples were collected from different host groups (cat, cattle, dog, horse, human, and kangaroo), and 18 water samples were collected from six sites (BR1 to BR6) along the Brisbane River in Queensland, Australia. Bacterial communities in the fecal, wastewater, and river water samples were sequenced. Water samples were also tested for the presence of bird-associated (GFD), cattle-associated (CowM3), horse-associated, and human-associated (HF183) molecular markers, to provide multiple lines of evidence regarding the possible presence of fecal pollution associated with specific hosts. Among the 18 water samples tested, 83%, 33%, 17%, and 17% were real-time PCR positive for the GFD, HF183, CowM3, and horse markers, respectively. Among the potential sources of fecal pollution in water samples from the river, DNA sequencing tended to show relatively small contributions from wastewater treatment plants (up to 13% of sequence reads). Contributions from other animal sources were rarely detected and were very small

Many Rivers to Cross: Evaluating the Benefits and Limitations of Strategic Environmental Assessment for the Koshi River Basin

This paper assesses the value of using Strategic Environmental Assessment (SEA) to account for the spatially and temporally diverse and diffuse impacts of hydropower development in South Asia’s Koshi basin. A policy and practice review and key stakeholder interviews identified opportunities for SEA to improve existing planning procedures, but also barriers to effective adoption. Whilst stakeholders are interested in employing SEA to evaluate cumulative impacts, institutional blockages and an economic development imperative for power generation leave little space for consideration of alternative scenarios as part of SEA. The analysis is conducted through the formulation and application of a conceptual framework for SEA best practice which is then used to identify priority next-steps for SEA in the region

Managing Pain in Low Resource Settings: Healthcare Professionals’ Knowledge, Attitude and Practice Regarding Pain Management in Western Nepal

Background: Pain is a public health problem and affects millions of people globally. Effective pain management is possible through comprehensive pain management guidelines, adequate facilities, and trained healthcare professionals. Therefore, this study aims to analyze the healthcare professionals’ knowledge, attitude, and practice regarding pain management in Western Nepal. Methods: A cross-sectional study was carried out in hospitals of Pokhara, Nepal. Healthcare professionals, including doctors, pharmacists, and nurses, were enrolled. Tools for the study were “The Knowledge and Attitudes Survey Regarding Pain (KASRP)” and a validated practice-based questionnaire. Frequencies and descriptive statistics were used to describe the outcomes. Kruskal– Wallis H-test and Mann-Whitney U-test were used to analyze the association between the mean rank of KASRP score and sample characteristics. A p-value of <0.05 was considered significant for all statistical tests. Results: A total of 336 healthcare professionals were enrolled in this study (108 medical doctors, 150 nurses, and 78 pharmacists). The mean KASRP scores (% ± SD) obtained by doctors, pharmacists, and nurses were 58.48±8.98, 53.01±7.80, and 52.26±6.39, respectively. A significant difference was found between the KASRP score and sample characteristics (p<0.001). The pain assessment tool is used by 96 (29%) healthcare professionals every time they meet the patients. Doctors and nurses used it more frequently as compared to pharmacists. Many of the pharmacists, 40 (51%), reported that they counsel the patients on the prescribed medicine (analgesics, NSAIDs, and opioids) every time. As only few participants had already attended a training on pain management, most healthcare professionals, 110 (33%), agreed and 198 (59%) strongly agreed that training related to pain management is needed in Nepal Conclusion: Adequate training and support are required to enhance the knowledge, attitude and ultimately better practice for healthcare professionals regarding pain management in Nepal

Biases in study design, implementation, and data analysis that distort the appraisal of clinical benefit and ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) scoring

BACKGROUND: The European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) is a validated, widely used tool developed to score the clinical benefit from cancer medicines reported in clinical trials. ESMO-MCBS scores assume valid research methodologies and quality trial implementation. Studies incorporating flawed design, implementation, or data analysis may generate outcomes that exaggerate true benefit and are not generalisable. Failure to either indicate or penalise studies with bias undermines the intention and diminishes the integrity of ESMO-MCBS scores. This review aimed to evaluate the adequacy of the ESMO-MCBS to address bias generated by flawed design, implementation, or data analysis and identify shortcomings in need of amendment. METHODS: As part of a refinement of the ESMO-MCBS, we reviewed trial design, implementation, and data analysis issues that could bias the results. For each issue of concern, we reviewed the ESMO-MCBS v1.1 approach against standards derived from Helsinki guidelines for ethical human research and guidelines from the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use, the Food and Drugs Administration, the European Medicines Agency, and European Network for Health Technology Assessment. RESULTS: Six design, two implementation, and two data analysis and interpretation issues were evaluated and in three, the ESMO-MCBS provided adequate protections. Seven shortcomings in the ability of the ESMO-MCBS to identify and address bias were identified. These related to (i) evaluation of the control arm, (ii) crossover issues, (iii) criteria for non-inferiority, (iv) substandard post-progression treatment, (v) post hoc subgroup findings based on biomarkers, (vi) informative censoring, and (vii) publication bias against quality-of-life data. CONCLUSION: Interpretation of the ESMO-MCBS scores requires critical appraisal of trials to understand caveats in trial design, implementation, and data analysis that may have biased results and conclusions. These will be addressed in future iterations of the ESMO-MCBS.SCOPUS: re.jinfo:eu-repo/semantics/publishe

Plasmin Generation Potential and Recanalization in Acute Ischaemic Stroke; an Observational Cohort Study of Stroke Biobank Samples.

Rationale: More than half of patients who receive thrombolysis for acute ischaemic stroke fail to recanalize. Elucidating biological factors which predict recanalization could identify therapeutic targets for increasing thrombolysis success. Hypothesis: We hypothesize that individual patient plasmin potential, as measured by in vitro response to recombinant tissue-type plasminogen activator (rt-PA), is a biomarker of rt-PA response, and that patients with greater plasmin response are more likely to recanalize early. Methods: This study will use historical samples from the Barcelona Stroke Thrombolysis Biobank, comprised of 350 pre-thrombolysis plasma samples from ischaemic stroke patients who received serial transcranial-Doppler (TCD) measurements before and after thrombolysis. The plasmin potential of each patient will be measured using the level of plasmin-antiplasmin complex (PAP) generated after in-vitro addition of rt-PA. Levels of antiplasmin, plasminogen, t-PA activity, and PAI-1 activity will also be determined. Association between plasmin potential variables and time to recanalization [assessed on serial TCD using the thrombolysis in brain ischemia (TIBI) score] will be assessed using Cox proportional hazards models, adjusted for potential confounders. Outcomes: The primary outcome will be time to recanalization detected by TCD (defined as TIBI ≥4). Secondary outcomes will be recanalization within 6-h and recanalization and/or haemorrhagic transformation at 24-h. This analysis will utilize an expanded cohort including ~120 patients from the Targeting Optimal Thrombolysis Outcomes (TOTO) study. Discussion: If association between proteolytic response to rt-PA and recanalization is confirmed, future clinical treatment may customize thrombolytic therapy to maximize outcomes and minimize adverse effects for individual patients

Elementary forms and their dynamics: revisiting Mary Douglas

Mary Douglas's oeuvre furnishes the social sciences with one of the most profound and ambitious bodies of social theory ever to emerge from within anthropology. This article uses the occasion of the publication of Fardon's two volumes of her previously uncollected papers to restate her core arguments about the limited plurality of elementary forms of social organisation, about the institutional dynamics of conflict, and about conflict attenuation. In reviewing these two volumes, the article considers what those anthropologists who have been sceptical either of Douglas's importance or of the Durkheimian traditions generally, will want from these books to convince them to look afresh at her work. It concludes that the two collections will provide open-minded anthropologists with enough evidence of the creativity and significance of her achievement to encourage them to reopen her major theoretical works. An internal critique of some aspects of Douglas's handling of her arguments is offered, before the conclusion identifies the wider significance of her arguments for the social science