Clinical Opinion Research Articles

Technology-Based Psychotherapeutic Interventions for Decreasing Cannabis Use in People with Psychosis: A Systematic Review Update.

Cannabis use is highly prevalent in people with psychotic disorders and is associated with adverse outcomes. We updated our 2020 systematic review related to the efficacy of technology-based psychological interventions (TBPIs) to decrease cannabis use in individuals with psychosis, the design of TBPIs, and their acceptability. We searched Medline, PubMed, Embase, CINAHL, PsycINFO, and EMB Reviews for references indexed between November 27, 2019, and July 27, 2023, and used the PRISMA guidelines to report the results. We screened 5083 unique records and retained three studies for the narrative synthesis. Two quantitative studies showed promising results of internet or virtual reality-based psychological interventions that incorporate cognitive behavioral therapy, motivational interviewing, and psychoeducation principles on the frequency and quantity of cannabis use. A qualitative exploratory study provided an integrative synthesis of patient and clinician opinions pertaining to the use of psychological approaches and technology to tackle cannabis misuse in individuals with psychosis. In contradiction with the rapidly expanding mobile-health solutions in the field of mental health, there is a dearth of research related to the use of internet and app-based psychological interventions for cannabis use in individuals with psychosis. The use of qualitative research is pivotal in the development of TBPIs. Our initial review and its update show that only 11 peer-reviewed journal articles that met our inclusion criteria have been published so far.

Measuring the impact: Severity of harm from laboratory errors in 195 tests.

This study aimed to objectively assess the potential severity of harm associated with erroneous results in 195 laboratory tests by surveying 514 specialist physicians and medical biochemistry experts. The survey obtained participants' (75 medical biochemists, 439 clinicians) opinions on severity of harm for the erroneous results of 195 tests. The comprehensive list of errors and their effects on test results were obtained from the literature, and then matched with severity of harm scores, from 1 (negligible effect) to 5 (life-threatening injury/death), obtained from the survey responses. Participants perceived tests such as cardiac biomarkers, blood gases, coagulation parameters (activated partial thromboplastin time, prothrombin time, international normalized ratio, and dimerized plasmin fragment D), critical ions (potassium, sodium), toxic trace elements (lead, mercury), and specific serum drug levels (lithium, digoxin) to have a greater potential for patient harm in case of errors. Medical biochemistry specialists assigned higher severity scores to some laboratory tests, including total bilirubin, pseudocholinesterase, platelet indices, and some drug levels (cyclosporine, methotrexate, vancomycin). A substantial agreement (91%) was observed between medical biochemists and clinicians in terms of the most frequently chosen severity of harm score. The study provided objective severity scores and identified high-risk tests for targeted quality improvement.

An Instructional Module for Functional Dissociative Seizures (FDS) in Hindi: Enhancing Communication and Management in India.

Functional dissociative seizures (FDS) are very common in neurology clinics, they straddle both neurology and psychiatry. In India, scarce resources and guidelines are available for effectively conveying their diagnosis and management, which leads to a substantial gap in care. We aimed to provide an instructional module for FDS, tailored to clinicians, patients, and caregivers in Hindi, to enhance communication of diagnosis and facilitate suitable management strategies. The instructional module development process was based on clinical settings and expert opinions. A standard translation process was performed to ensure the linguistic and cultural equivalence. Validation was carried out by a panel of 15 validators, comprising 13 neurologists and two psychiatrists, to identify key psychoeducation components and their significance. They were provided a questionnaire consisting of five questions that were related to completeness, understandability, legibility, clarification, and usefulness of educational material for clinicians, patients, and caregivers. Items were rated using a 5-point Likert scale. There was agreement on four items (Q1, Q3, Q4, and Q5), whereas approximately 85% of the validators agreed on the remaining one item (Q2). The instructional module demonstrated high content validity as indicated by both item level-content validity index (0.98) and scale-level content validity index (0.97), alongside content validity ratio and modified kappa statistics. The developed Hindi instructional module for FDS serves as a valuable tool to enhance the communication of FDS diagnosis and dispel misconceptions. This offers a comprehensive resource for clinicians, patients, and caregivers in India, potentially bridging gap in FDS care.

18F-FDG-PET/CT Scan for Detection of Large Vessel Involvement in Giant Cell Arteritis: Arteser Spanish Registry.

Background/Objectives: Imaging studies have transformed the diagnosis of large vessel vasculitis (LVV) involvement in giant cell arteritis (GCA). A positron emission tomography/computed tomography (PET/CT) scan with 18-fluorodeoxyglucose (18F-FDG) has emerged as a valuable tool for assessing LVV. We aimed to determine the utility of an 18F-FDG-PET/CT scan in detecting LVV in GCA in the ARTESER registry. Methods: The ARTESER study is a large multicenter, retrospective, longitudinal, and observational study, promoted by the Spanish Society of Rheumatology. It included patients newly diagnosed with GCA across 26 tertiary hospitals from 1 June 2013 to 29 March 2019. Patients with a diagnosis of incidental GCA were included if they fulfilled specific criteria, including the ACR 1990 criteria, positive imaging examinations, or the expert clinical opinion of investigators. Differences between patients with positive and negative 18F-FDG-PET/CT scan results were analyzed using a bivariate model. A regression model assessed associations in patients with a positive scan, and the predictive capacity of the cumulative dose of glucocorticoids (GC) on PET scan outcomes was evaluated using ROC curve analysis. Results: Out of 1675 GCA patients included in the registry, 377 met the inclusion criteria of having an 18F-FDG-PET/CT scan. The majority were diagnosed with a cranial GCA phenotype, and 65% had LVV. The thoracic aorta was the most frequently affected. Cardiovascular disease, diabetes, and older age had a negative association with a positive scan outcome. The OR for having a positive 18F-FDG-PET/CTC scan was lower as the number of days increased. Depending on the cumulative dosage of the GC, the 18F-FDG-PET/CT scan showed an AUC of 0.74, with a Youden index > 60 mg/day. Conclusions: Younger patients showed a higher probability of presenting LVV as detected by the 18F-FDG-PET/CT scan. The timing of the examination and the cumulative dosage of the GC influenced the likelihood of a positive result, with earlier tests being more likely to detect inflammation.

Assessment of pediatric breast ultrasound less is more: a practical imaging approach.

Breast cancer in pediatric patients is rare, but ultrasound (US) is widely utilized for symptomatic cases. To determine biopsy and cancer detection rates of pediatric patients and to assess if breast US can be omitted. A retrospective review of a 5-year period was conducted of single-center breast US performed in patients aged <19 years. Data regarding presentation, clinical opinion (P1-5 score), and US (U1-5 score) were collected. If biopsy or surgery was performed, pathology was reviewed (B1-5 score). In total, 579 patients were included (19 boys, 560 girls; mean age=16.2±1.9 years; age range=0-18 years). Clinical examination was normal or benign (P1/P2) in all boys (100%) and 557/560 (99.5%) girls, and P3 in 3 (0.5%) girls. Of US, 52% demonstrated normal findings (U1) for both sexes (300/579); in the remaining cases, the most frequent findings were gynecomastia in 12/19 boys and well-defined breast masses in 208/560 girls. Of the 560 girls, 6 (1%) underwent US-guided biopsy, with final histology of fibroadenoma (B2) in all cases, while 27 (5%) had a surgical excision, with final histology of fibroadenoma (22/27, 81.5%), hamartoma (2/27, 7.4%), benign phyllodes tumor (2/27, 7.4%), and angiomyxoma skin lesion (1/27, 3.7%). No malignant lesions were diagnosed at the time of clinical referral or during the 18-month follow-up in patients with a well-defined mass on US. Breast malignancy is extremely rare in pediatric population. US can be safely omitted if clinical examination is normal; this approach would have avoided breast US in 52% of patients in this study.

B-120 Reference Interval (RI) Estimation for Pediatric Magnesium using an Indirect Method with Unsupervised Machine Learning Tool and Programming Language

Abstract Background Magnesium is an important intracellular component present in all enzymatic reactions involving Adenosine Triphosphate (ATP) utilization, with the majority stored in bones. In the blood, it exists as a free fraction and another bound to proteins. Regulation occurs through renal processes, and for this reason, hypermagnesemia is associated with renal insufficiency, compromising the central nervous system. On the other hand, hypomagnesemia cases are related to pancreatitis, intestinal malabsorption, childhood malnutrition, among other factors. Following complaints from pediatric doctors that our reference intervals (RI), as suggested by the manufacturer, would yield falsely elevated results in healthy patients, we estimated a new RI in the population served Methods We employed data mining followed by estimation using an indirect method through the LabRI™ algorithm with parametric, non-parametric, and robust statistical treatments for outlier exclusion, implemented in the R language. Latent abnormal values of outpatient pediatric patients were considered. We defined three pediatric partitions for both sexes, aged 0 to 6 years, 7 to 12 years, and above 12 years, using the comparative RI described by the Roche manufacturer. Data were extracted from our Data Lake between January and December 2022 in the Federal District of Brazil, from a laboratory part of a large network. Exclusion criteria included: Potassium &amp;gt; 5.5 and &amp;lt; 3.0 mmol/L; Phosphorus &amp;gt; 8.0 and &amp;lt; 1.5 mg/dL; Total Calcium &amp;gt; 12 mg/dL and &amp;lt; 7 mg/dL; Ionized Calcium &amp;gt; 1.5 mmol/L and &amp;lt; 0.8 mmol/L; Creatinine &amp;gt; 2.0 mg/dL; C-reactive protein (CRP) &amp;gt; 10 mg/dL; Ferritin &amp;gt; 700 ng/mL; A1C &amp;gt; 7.0%; LDL Cholesterol &amp;gt; 200 mg/dL; Magnesium repeated within &amp;lt; 12 months, and samples of hospital origin. Results The evaluated population after exclusion criteria totaled 6,865 children, distributed as follows: 26.0% aged 0 to 6 years, 30.3% aged 7 to 12 years, and 43.7% above 12 years. Outliers were excluded in 1.5%, 0.9%, and 1.0%, respectively. In all partitions, there was a significant discrepancy compared to the reference intervals recommended by Roche. In our estimation, there was an expansion of the upper limit of the reference interval in all partitions, supporting the clinical opinion. The new reference intervals became: 0-6 yrs: from 1.7-2.3 to 2.0-2.7; 7-12 yrs: from 1.7-2.1 to 2.0-2.6; and &amp;gt;12 yrs: from 1.7-2.2 to 1.9-2.6. The standard deviation varied between 0.19 and 0.20, and the median between 2.20 and 2.32 Conclusions The manufacturer states in the package insert that they did not assess the RI for the pediatric population and that each laboratory should verify the RI in the population served. We approve the adoption of the estimated RI for the pediatric population calculated by the LabRI™ tool in the partitions of 0-6 years, 7-12 years, and &amp;gt;12 years, stating in the report “Reference interval established by an indirect method in 6865 children tested in the laboratory, partitioned by age group.”

Clinical management of stopping or continuing perioperative angiotensin II converting enzyme inhibitors and/or angiotensin receptor blockers: a survey of clinical opinion

Clinical management of stopping or continuing perioperative angiotensin II converting enzyme inhibitors and/or angiotensin receptor blockers: a survey of clinical opinion

Clinical opinion spotlight: A sustainable model for improving access to mobile mammography for underserved populations

Minority women face disproportionately higher risks of breast cancer diagnosis and mortality under 50. Mobile mammography vans enhance screening accessibility but face challenges like long-term funding and operational viability. This study assesses existing mobile mammography van programs and proposes a sustainable model through literature review and qualitative interviews at a tertiary care academic medical center. The proposed model emphasizes partnerships, sponsorships and long-term funding for ensuring workforce sustainability. Organizational structure, budget allocation, patient workflow and follow-up protocols are aimed at transitioning towards serving primarily uninsured patients while maintaining financial stability. This sustainable approach hopes to enhance screening rates and timely care for underserved women, suggesting scalability and potential to reduce late-stage diagnoses and mortality. Continued implementation and evaluation are essential for validating feasibility and effectiveness, ensuring long-term improvement in screening rates and program longevity.

Defining the Treatment Window: Early Versus Late Pulsed Dye Laser Therapy for Posttraumatic and Surgical Scars in Asian Patients

ABSTRACTObjectivesThis retrospective study evaluates the effectiveness of pulsed dye laser (PDL) treatment in early versus late treatment groups for traumatic or postoperative scars. The study aims to determine the threshold between early and late treatment. Additionally, it investigates factors that may influence wound healing outcomes.MethodsThe medical records of 147 patients who underwent PDL treatment at our institution between January 2018 and December 2022 were retrospectively reviewed. Inclusion criteria were patients receiving PDL treatment for traumatic or postoperative scars. Out of these patients, we selected those who were willing to receive telephone interviews or re‐visit at a scheduled time. Eventually, 52 participants were included in our study. A standardized questionnaire was administered to all participants during telephone interviews, encompassing inquiries regarding their medical history, treatment experiences, and the patient component of the Patient and Observer Scar Assessment Scale. Among the enrolled patients, 38 were contacted and interviewed via telephone, while the remaining 14 patients attended follow‐up visits where photographs of their current skin condition were captured. The pretreatment and latest follow‐up photographs obtained from the clinical database were independently scored in a blinded manner by two dermatologist reviewers using both the Vancouver Scar Scale and the Manchester Scar Scale.ResultsAmong the 52 patients, 43 (82.7%) were successfully treated with good response. The correlation coefficients between week‐to‐treatment initiation and posttreatment MSS and VSS among patients with good response were 0.50 (p &lt; 0.001) and 0.46 (p = 0.002), respectively. Given these findings, we established a treatment initiation threshold of 10 weeks, distinguishing patients into early and late treatment groups. The early treatment group showed borderline significantly lower posttreatment MSS and VSS scores than the late treatment group (MSS: 7.5 ± 2.1 vs. 9.3 ± 2.5, p = 0.011; VSS: 2.8 ± 2.0 vs. 4.5 ± 2.3, p = 0.011). Furthermore, both MSS and VSS of posttreatment showed significantly greater improvement in the early treatment group (4.4 ± 1.6 vs. 3.2 ± 1.9; p = 0.03 and 3.8 ± 1.8 vs. 2.8 ± 1.4; p = 0.04).ConclusionsEarly intervention using a PDL within 10 weeks post‐injury achieved better outcomes in treating traumatic and postoperative scars based on both clinical and patient opinions.

Impact of expected blood pressure reduction on patient preferences for pharmaceutical and renal denervation treatment.

Effective patient-centered care requires an adequate understanding of patient preferences for different therapeutic options. We modelled patient preference for blood pressure (BP) management by pharmaceutical or interventional treatments such as renal denervation in patients with different profiles of uncontrolled hypertension. Modeling was based on the findings from a previously conducted quantitative discrete choice experiment (DCE). The likelihood of selecting either an interventional treatment option or additional antihypertensive medication option was calculated for three patient profiles that represent the range of patients with hypertension commonly encountered in clinical practice: treatment-naive, patients with uncontrolled BP while on one to three antihypertensive medications, and patients with drug-resistant hypertension. Variables in the preference model were treatment attributes from the DCE study: expected reduction in office SBP with each treatment, duration of treatment effect, risk of reversible drug side effects from drugs, and risk of temporary pain and/or bruising or vascular injury from interventions. Values of the variables were derived from published clinical studies or expert opinion. The model predicted that the likelihood of choosing renal denervation over initiating pharmacotherapy was 17.2% for previously untreated patients, 23.7% for patients with moderate hypertension currently on pharmacotherapy, and 41.8% for patients with drug-resistant hypertension. The dominant variable driving preference in these models was the expected BP reduction. Patient preferences for intervention are greater when drug nonadherence or increased SBP reduction at 3 vs. 1 year are included in the model. Baseline BP, drug side effects, or risks of the procedure had little influence on decisions. Modeling using patient preference weights predicts that a substantial minority of patients favor an interventional treatment such as renal denervation over initiation or escalation of medications. Awareness of a patient's interest in device-based versus pharmaceutical strategies should inform the shared decision-making process for hypertension treatment.

Identification of High-Risk Lower Extremity Wounds Using Point-of-Care Test for Bacterial Protease Activity; A Single-Centre, Single-Blinded, Prospective Study.

Clinician observation is the mainstay to determine if wound infection is present, and focuses on presence of erythema, purulence, and odour. However, non-visible bacterial protease activity can delay wound healing and lead to complications. In this study, a point-of-care test to detect the presence of bacterial protease activity (BPA, tested with Woundchek Bacterial Status test) was appraised. A total of 130 patients with lower extremity wounds were recruited in vascular and podiatry clinics, and across two time-points 182 BPA tests were conducted subsequent to initial (blinded) clinician's wound appraisal. Clinical opinion ('no infection', 'possible' or 'definite' infection) and BPA result (negative or positive test) had a moderate Kendall's tau-c rank correlation coefficient of 0.32 (P < 0.001). Binary logistic regression analysis and principal component analysis showed that infection determined by clinical opinion was significantly associated with abovementioned clinical signs and a positive BPA test. However, a positive BPA result was also significantly linked with wound severity, such as number of lesions, chronicity and size. Throughout a 12-week follow-up period, median ulcer size was larger for wounds positive for BPA test at baseline (P 0.001) and week-12 (P 0.036; both Mann-Whitney U-test) respectively. As a pilot initiative, clinical staff were allowed to act on the BPA result if they wished; in 11 out of 71 test-positive cases (15%) this happened and antimicrobial dressing was applied instead of planned standard dressing. These results show that protease-releasing bacteria may be active in ulcers that do not (yet) exhibit hallmark signs of infection, and are associated with delayed healing. Targeted point-of-care testing for bacterial protease activity may have the potential to identify and enable pro-active (antimicrobial) management of these high-risk wounds.

Clinical Practices and Opinions toward Gastrostomy Use in Patients with Atypical Parkinsonian Syndromes: A National Survey in the UK.

Severe dysphagia poses a significant challenge for clinicians regarding feeding tube choices, practices, and timing due to a lack of evidence-based guidance. To assess national clinical practices and opinions on gastrostomy use in patients with atypical parkinsonian syndromes (APS) across the UK. Online survey was administered to clinicians and allied health professionals regarding availability of services, current use, perceived advantages, and problems associated with gastrostomy insertion. We received responses from 47 respondents across 12 UK centers, including 44 clinicians specialized in APS. Consensus was observed regarding primary indications for gastrostomy insertion and circumstances justifying avoidance of the procedure. Limitations in recommending gastrostomy due to insufficient evidence on safety and outcomes, survival and quality of life were identified. Widespread agreement on delays in gastrostomy discussions was highlighted as a challenge in optimizing patient care, together with variability in current practices and concerns over the lack of a standardized gastrostomy pathway, emphasizing the need for further research to address existing evidence gaps. This multi-center survey highlights agreement among clinicians on key aspects of indication, challenges, and limitations such as delayed decision-making and the absence of standardized pathways regarding the timing, method, and overall approach to gastrostomy insertion in APS. This study identified next steps to facilitate a more structured approach to future research toward a consensus on best practices for gastrostomy in APS. Addressing these challenges is crucial for enhancing patient outcomes and overall care quality in APS.

Methods to incorporate patient preferences into medical decision algorithms and models and their quantification, balancing and evaluation: a scoping review protocol.

The objective of this scoping review is to identify and map methods used to incorporate patient preferences into medical algorithms and models as well report on their quantification, balancing, and evaluation in the literature. It will focus on computational methods used for incorporating patient preferences into algorithms and models at an individual level as well as the types of medical algorithms and models where these methods have been applied. Medical algorithms and models are increasingly being used to support clinical and shared decision-making; however, their effectiveness, accuracy, acceptance, and comprehension may be limited if patients' preferences are not considered. To address this issue, it is important to explore methods integrating patient preferences. This review will investigate patient preferences and their integration into medical algorithms and models for individual-level clinical decision-making. The scoping review will include diverse sources, such as peer-reviewed articles, clinical practice guidelines, gray literature, government reports, guidelines, and expert opinions for a comprehensive investigation of the subject. This scoping review will follow JBI methodology. A comprehensive search will be conducted in PubMed, Web of Science, ACM Digital Library, IEEE Xplore, the Cochrane Library, OpenGrey, the National Technical Reports Library, and the first 20 pages of Google Scholar. The search strategy will include keywords related to patient preferences, medical algorithms and models, decision-making, and software tools and frameworks. Data extraction and analysis will be guided by the JBI framework, which includes an explorative and qualitative analysis. Open Science Framework https://osf.io/qg3b5.

One More Tool in the Tool Belt: A Qualitative Interview Study Investigating Patient and Clinician Opinions on the Integration of Psychometrics Into Routine Testing for Disorders of Gut-Brain Interaction.

Introduction Disorders of gut-brain interaction (DGBIs) encompass a common group of disorders characterised by chronic gastrointestinal symptoms. Psychological comorbidities are common in patients with DGBIs and are linked with poorer patient outcomes. Consequently, assessing and managing mental wellbeing may lead to improvements in symptoms and quality of life. Methods This study aimed to explore patients' and clinicians' opinions on integrating psychometrics into routine DGBI testing. Semi-structured interviews were conducted with 16 patients with gastroduodenal DGBI and 19 clinicians who see and treat these patients. Interviews were analysed using inductive, reflexive thematic analysis. Results Three key clinician themes were developed: (1) psychology as part of holistic care, emphasising the importance of a multidisciplinary approach; (2) the value of psychometrics in clinical practice, highlighting their potential for screening and expanding management; and (3) navigating barriers to utilising psychometrics, addressing the need for standardisation to maintain the therapeutic relationship. Four key patient themes were developed: (1) the utility of psychometrics in clinical care, reflecting the perceived benefits; (2) openness to psychological management, indicating patients' willingness to explore psychological treatments; (3) concerns with psychological integration, addressing potential stigma and fear of labelling; and (4) the significance of clinician factors, emphasising the importance of clinician bedside manner, knowledgeand collaboration. Conclusions These themes demonstrate that patients and clinicians see value in integrating psychometrics into routine DGBI testing. Despite potential barriers, psychometrics advance patient and clinician understanding and facilitate multidisciplinary management. Recommendations for navigating challenges were provided, and considering these, patients and clinicians supported the use of psychometrics as screening tools for patients with DGBIs.

Clinical Management of Endometriosis in Menopause: A Narrative Review.

Endometriosis, an inflammatory disease primarily affecting the pelvis and peritoneum, manifests with pelvic pain, dysmenorrhea, dyschezia, dyspareunia, and infertility. Despite its ubiquity, the management of endometriosis is challenging due to its heterogeneous presentation, limitations in diagnostic methods, variable therapeutic responses, and personal and socio-cultural impact on quality of life. This review attempts to consolidate the current literature on endometriosis occurring during and beyond menopause, and to present details regarding management strategies that take into account individual outcomes and goals when managing this condition. The topics included in this review are the clinical features and differential diagnosis of pelvic pain in postmenopausal patients, imaging considerations, serum and laboratory biomarkers, indications for surgery, the principles of hormone replacement therapy, the de novo development of endometriosis after menopause, and malignant transformation. Each topic includes a summary of the current literature, utilizing clinical research, case reports, and expert opinion. Despite a better understanding of the impact of endometriosis beyond menopause, there are many limitations to this condition, specifically with regard to cancer risk and indications for surgery. The existing evidence supports the use of shared decision making and the incorporation of patient preferences in guiding clinical management. Future research endeavors must shed light on the natural history of postmenopausal endometriosis through longitudinal studies in order to foster a deeper understanding of its complicated disease course across women's lifespans.

Rapid Assay Diagnostic for Acute Stroke Recognition (RADAR): study protocol for a diagnostic accuracy study

IntroductionLarge-vessel occlusion (LVO) stroke is effectively treated by time-critical thrombectomy, a highly specialised procedure only available in a limited number of centres. Many patients with suspected stroke are admitted to...

2142 Shared decision-making on treatment escalation planning in the acute medical setting for older patients: a qualitative study

Abstract Introduction Shared Decision-Making (SDM) is increasingly expected in most aspects of UK medical practice and can be particularly important for older patients to guide goals of care. Treatment Escalation Plans (TEP) summarise medical intervention to be attempted in the event of acute deterioration. Current guidance advocates SDM in TEP but it is unclear whether this is considered practicable by clinicians. This study aims to understand clinicians’ perspectives on SDM in TEP for older patients in the acute medical setting. Methods This was a qualitative study following a relativist constructivist approach. 26 consultant and registrar doctors were recruited from general internal medicine, intensive care, palliative care and emergency medicine. A clinical doctoral student conducted semi-structured interviews including vignettes of older multi-morbid patients with capacity to discuss treatment escalation. Reflexive thematic analysis was performed. Ethics approvals were obtained from the Health Research Authority 22/HRA/4387. Results Three themes were generated: ‘An unequal partnership’, ‘Options without equipoise’ and ‘Decisions with shared understanding’. SDM incorporating patient preferences with clinical opinion was seldom perceived to be appropriate. Clinical complexity and use of intuition, together with lack of perceived moral equipoise, motivated clinicians to develop medically acceptable TEPs. Shared understanding with the patient and family and avoiding conflict were important. Conclusions Contrary to current guidance, SDM was considered a potential barrier to formulating appropriate TEPs in the acute medical setting. This study suggests potential incompatibility between policies prioritising patient autonomy and the right to make unwise decisions, and those stating clinicians’ prerogative to determine realistic chance of treatment success and not provide intervention considered medically inappropriate.

Investigating current clinical opinions in stereoelectroencephalography-informed epilepsy surgery.

Stereoelectroencephalography (SEEG) is increasingly utilized worldwide in epilepsy surgery planning. International guidelines for SEEG terminology and interpretation are yet to be proposed. There are worldwide differences in SEEG definitions, application of features in epilepsy surgery planning, and interpretation of surgical outcomes. This hinders the clinical interpretation of SEEG findings and collaborative research. We aimed to assess the global perspectives on SEEG terminology, differences in the application of presurgical features, and variability in the interpretation of surgery outcome scores, and analyze how clinical expert demographics influenced these opinions. We assessed the practices and opinions of epileptologists with specialized training in SEEG using a survey. Data were qualitatively analyzed, and subgroups were examined based on geographical regions and years of experience. Primary outcomes included opinions on SEEG terminology, features used for epilepsy surgery, and interpretation of outcome scores. Additionally, we conducted a multilevel regression and poststratification analysis to characterize the nonresponders. A total of 321 expert responses from 39 countries were analyzed. We observed substantial differences in terminology, practices, and use of presurgical features across geographical regions and SEEG expertise levels. The majority of experts (220, 68.5%) favored the Lüders epileptogenic zone definition. Experts were divided regarding the seizure onset zone definition, with 179 (55.8%) favoring onset alone and 135 (42.1%) supporting onset and early propagation. In terms of presurgical SEEG features, a clear preference was found for ictal features over interictal features. Seizure onset patterns were identified as the most important features by 265 experts (82.5%). We found similar trends after correcting for nonresponders using regression analysis. This study underscores the need for standardized terminology, interpretation, and outcome assessment in SEEG-informed epilepsy surgery. By highlighting the diverse perspectives and practices in SEEG, this research lays a solid foundation for developing globally accepted terminology and guidelines, advancing the field toward improved communication and standardization in epilepsy surgery.

NASPAG Clinical Opinion: The Care of Transgender and Gender Nonbinary Adolescents and Young Adults

Transgender and gender nonbinary (TGNB) adolescents and young adults (AYA) may present to clinicians with reproductive health expertise for the spectrum of gynecologic, sexual, and reproductive care. As such, clinicians should be knowledgeable in the many facets of gender-affirming care. This clinical opinion reviews language associated with gender diversity and gender-affirming care; current clinical, social, and political barriers faced by TGNB AYA; and the creation of welcoming and inclusive clinical spaces for TGNB AYA. It discusses social, medical, and surgical affirmation processes, and focuses on gynecologic care topics which may arise in the care of TGNB AYA, including those who undergo medical or surgical therapies. This includes menstrual suppression, breakthrough bleeding on testosterone, sexual health, fertility, and the pelvic care of individuals following gender affirming vulvovaginoplasty.

Placenta accreta spectrum in the second trimester: a clinical conundrum in procedural abortion care

Given the limitations in perioperative management strategies available at freestanding abortion clinics, abortion providers must commonly discern which patients are too complicated for procedural abortions at their center and must be referred for a hospital-based abortion. The need to transition from freestanding clinics to hospital-based abortion care can lead to delays in completing an abortion and significant social, economic, and psychological repercussions for the pregnant individual. One significant clinical problem that exemplifies the issue of who can be safely taken care of at a freestanding abortion clinic is when the placenta accreta spectrum is suspected. Placenta accreta spectrum is one of the major contributors to maternal morbidity and mortality in the United States, requiring coordinated multidisciplinary management to ensure the safest outcome for the pregnant individual. In this Clinical Opinion, we review the literature focused on identifying individuals at risk for placenta accreta spectrum >14+0 weeks gestation, delineate an algorithm to improve the frequency of timely referrals to hospital-based abortion providers, and propose next steps for future training goals and research on placenta accreta spectrum in the second trimester between complex family planning and maternal-fetal medicine subspecialists.