Slow Medicine and Choosing Wisely: a synergistic alliance

Choosing Wisely® is an initiative of the American Board of Internal Medicine Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices. Choosing Wisely campaigns are now active and present in 25 countries around the world, on five continents. Italy is the only country where a Choosing Wisely campaign was launched, and it is currently steered by a Nationwide association (Slow Medicine), creating a synergistic alliance. The Slow Medicine Association was founded in 2011 when a group of health professionals and citizens shared a new paradigm of values, methodology, and interventions and decided to establish an association with the mission of working for a health system driven by ethics and quality principles. Three keywords summarize the philosophy of Slow Medicine: measured because it acts with moderation, gradualness, and without waste; respectful because it is attentive to the dignity of individuals recognizing their values; and equitable because it is committed to ensuring appropriate care based on the best available evidence. Slow Medicine allowed the spread of Choosing Wisely in Italy involving several professional societies and participating at the National meetings of the Societies as well as numerous other meetings, in which the mission of the Association is combined with the principle of the ‘do not’ recommendations. Numerous other initiatives were carried out, and new projects were planned in synergy with Choosing Wisely.

Use of Physical Accessibility Modelling in Diagnostic Network Optimization: A Review

Diagnostic networks are complex systems that include both laboratory-tested and community-based diagnostics, as well as a specimen referral system that links health tiers. Since diagnostics are the first step before accessing appropriate care, diagnostic network optimization (DNO) is crucial to improving the overall healthcare system. The aim of our review was to understand whether the field of DNO, and especially route optimization, has benefited from the recent advances in geospatial modeling, and notably physical accessibility modeling, that have been used in numerous health systems assessment and strengthening studies. All publications published in English between the journal’s inception and 12 August 2021 that dealt with DNO, geographical accessibility and optimization, were systematically searched for in Web of Science and PubMed, this search was complemented by a snowball search. Studies from any country were considered. Seven relevant publications were selected and charted, with a variety of geospatial approaches used for optimization. This paucity of publications calls for exploring the linkage of DNO procedures with realistic accessibility modeling framework. The potential benefits could be notably better-informed travel times of either the specimens or population, better estimates of the demand for diagnostics through realistic population catchments, and innovative ways of considering disease epidemiology to inform DNO.

The perception of episiotomy among Iranian women: a qualitative study

Background Around 70% of women who give birth vaginally experience perineal injury during childbirth, which may happen spontaneously or as a result of the incision made to facilitate childbirth. There are very few studies on the perceptions of episiotomy recipients about these services. Therefore, investigating these women's perception is crucial for providing appropriate care. Methods This qualitative study examined 20 women from hospitals and health centres who had undergone episiotomy using in-depth semi-structured interviews. Data were analysed using conventional content analysis and the accuracy and rigour of the data were assessed using the Lincoln and Guba criteria. Results The ‘change in perception and behaviour’ theme encompassed one category of negative experiences and views about episiotomy and a second category covering positive views. Conclusions Women's perceptions of episiotomy contained both positive and negative views. Since healthcare systems should support mothers' physical and mental health, it is recommended that health policymakers devise plans to boost factors that lead to positive views and eliminate those contributing to negative experiences and views.

A systematic review of the systematic review of post COVID-19 syndrome

Background: The declaration of the COVID-19 pandemic triggered a global inquiry into the transmission, mortality, risk factors, and management of the disease. Recently, however, attention has shifted toward its long-term consequences. There is a need for a better understanding of the predictors and symptoms of post-COVID syndrome, to ensure appropriate care for patients recovering from COVID-19 beyond the acute phase. Methods: We searched PubMed, Google Scholar, Cochrane databases, and available data in the PROSPERO databases. We also explored the reference lists of included articles and any systematic reviews identified therein. We searched the keywords "Post Covid", "Post COVID syndrome", "Post- Covid" and "PostCOVID", until July 2021. Results: Of 8167 articles, 13 were included. The syndrome affects several systems with variable prevalence. Fatigue and sleep disturbance is the most common symptom of acute post-COVID syndrome, observed in more than two-thirds of patients, while a reduction in quality of life and general health status was noted in up to 69%. Furthermore, a reduced aerobic and diffusion capacity was seen in 38% of patients up to one month after presumed recovery from infection. Radiologically, in up to 52% of patients, a ground-glass opacity (GGO) was noted beyond three months post-infection. The incidence of new psychiatric illness increased from as early as 14 days after infection and up to three or six months. Hearing impairment or loss, whether sensorineural or conductive, was noted in up to 8.3% of patients, and tinnitus was seen in up to 4.2%. Conclusion: Overall, given the variability in the manifestation of post-COVID syndrome, a multidisciplinary team is required to better serve these patients. We therefore urge the establishment of such teams, encompassing internal medicine, pulmonology, cardiology, and neurocognitive services.

Talus Visualization in Ankle Fractures: How Much Are We Really Seeing?

Background: Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time. Purpose: To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus. Study Design: Descriptive laboratory study. Methods: Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated. Results: Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm2 (95% CI, 13.3-14.7 cm2), while the mean area visible via an open approach was 2.1 cm2 (95% CI, 0.5-3.6 cm2). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%). Conclusion: These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate. Clinical Relevance: Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

Evaluation of Liver Enzymes and calculation of AST to ALT ratio in patients with acute viral hepatitis

Background: Acute viral hepatitis is a common liver-associated abnormality encountered in clinical practice. The number of biochemical parameters is estimated to detect a hepatic abnormality, which can measure the severity and types of damage to hepatocytes, among which liver enzymes and bilirubin levels are assessed routinely which are raised in acute viral hepatitis.Objective: This study aims to assess the liver enzymes, such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, and calculation of AST to ALT ratio in acute viral hepatitis and to compare these parameters with the control group.Methodology: This study included a total of 81 subjects diagnosed with acute viral hepatitis as cases and age and sex-matched, the same number of healthy subjects as control. Serum levels of AST and ALT, alkaline phosphatase (ALP), and bilirubin were analyzed using standard methods. Serum AST to ALT ratio was calculated. Data analysis was done using SPSS Version 17.0 and the results were expressed as mean ±standard deviation (SD).Results: A mean serum activities of aminotransferases were statistically significantly raised in viral hepatitis compared to that in control.AST (514.85±350.66 VS 25.65±5.29; p<0.001) and ALT (781.65±525.69 VS 27.94±6.50; p<0.001). Similarly, serum levels of(ALP)were significantly increased in acute viral hepatitis compared to that in control (202.17±75.46 VS 98.83±27.99; p<0.001. However, a ratio of AST to ALT was decreased significantly (0.66±0.15 VS 0.94±0.21; p= 0.001) in acute viral hepatitis compared to that in control.Conclusion: Both the aminotransferases and bilirubin levels are raised significantly, where, a rise in ALT is greater than a rise in AST, hence, the ratio of AST to ALT is decreased significantly in acute viral hepatitis than that in control. Thus, this decreased pattern of AST to ALT can diagnose acute viral hepatitis at an early stage and can help appropriate care and treatment to the patients.

The personal recovery movement in Singapore – past, present and future

The personal recovery movement is beginning to gain traction within Singapore’s mental healthcare systems. We believe it is timely to give a broad overview of how it developed and provide suggestions on how it can evolve further. From the early custodial care in the 1800s to the community-centric programmes of the 1900s and early 2000s, we now find ourselves at the forefront of yet another paradigm shift towards a more consumer-centric model of care. The following decades will allow personal recovery practitioners and researchers to innovate and identify unique but culturally appropriate care frameworks. We also discuss how the movement can continue to complement existing mental healthcare systems and efforts. Keywords: Asia, legislation, lived experience, mental health services, personal recovery

Attributions About Self-Harm: A Comparison Between Young People’s Self-Report and the Functions Ascribed by Preservice Teachers and School Counsellors

Globally, adolescent self-harm rates remain high, while help-seeking behaviour remains low. School staff are in a position to facilitate access to appropriate care for young people who self-harm (YPS-H), but little is known about gatekeepers’ attributions of self-harm or whether these attributions influence the support they provide. This study investigates the perceived functions of self-harm reported by potential gatekeepers and examines how these compare to the self-reported functions of self-harm in young people; 386 students from postgraduate teaching (n = 111), school counselling (n = 37), and undergraduate psychology (n = 238) programs completed a survey regarding their beliefs about YPS-H, which included the Inventory of Statements about Self-Harm. Responses were compared to those of 281 young people attending treatment at a suicide prevention program who completed the same measure. Preservice teachers, school counsellors and psychology students endorsed all functions of self-harm at a higher rate than treatment-seeking young people themselves. In particular, they endorsed interpersonal functions to a greater extent than the clinical reference group. The potential effect of greater endorsement of interpersonal influence as a function of self-harm gatekeeper’s responding to YPS-H is discussed.

The clinical and laboratory evaluation of patients with suspected hypocellular marrow failure

The overlap in clinical presentation and bone marrow features of acquired and inherited causes of hypocellular marrow failure poses a significant diagnostic challenge in real case scenarios, particularly in nonsevere disease. The distinction between acquired aplastic anemia (aAA), hypocellular myelodysplastic syndrome (MDS), and inherited bone marrow failure syndromes presenting with marrow hypocellularity is critical to inform appropriate care. Here, we review the workup of hypocellular marrow failure in adolescents through adults. Given the limitations of relying on clinical stigmata or family history to identify patients with inherited etiologies, we outline a diagnostic approach incorporating comprehensive genetic testing in patients with hypocellular marrow failure that does not require immediate therapy and thus allows time to complete the evaluation. We also review the clinical utility of marrow array to detect acquired 6p copy number-neutral loss of heterozygosity to support a diagnosis of aAA, the complexities of telomere length testing in patients with aAA, short telomere syndromes, and other inherited bone marrow failure syndromes, as well as the limitations of somatic mutation testing for mutations in myeloid malignancy genes for discriminating between the various diagnostic possibilities.