Clinical Opinion Research Articles

Measuring attitudes, motivations and barriers to presymptomatic dementia testing

AbstractBackgroundThe increasing biomarkers testing and new methods of presymptomatic screening for dementia have risen questions like: Should people get tested? Would they want to know whether they will get this fatal, untreatable disease? This has picked the demand for a well‐structured counseling program for dementia screening. In this direction, it is important to meet the needs of the target group; however, not much is known about people with a family history of dementia attitudes about testing, the motivations and barriers, and the expectations relevant to future counseling programs about testing for dementiaMethodThis study was comprised of a validation study of a new psychometric tool and a cross‐sectional survey to assess the attitudes, buries and motivations to dementia testing. The content of the questionnaire was based on (1) a literature review, (2) the Perceptions Regarding Investigational Screening for Memory in Primary Care (PRISM‐PC) Questionnaire (M. Boustani et al., 2008), (3) a board of Clinical expert opinions. Two hundred eight (208) people enrolled in this cross sectional study. Participants came from Greece, ages ranged from 18‐70 (M = 35.5, SD = 5.7). and the majority of the sample was female (93.3%). Psychometric properties were assessed through construct validity (principal component analysis) and internal consistency (Cronbach’s alpha).ResultExploratory factor analyses revealed the presence of four factors. The first factor labelled as “Perceived harms of testing”, the second “Acceptance of testing”, the third “Perceived benefits of testing”) and the fourth factor “Need of knowledge”. The reliability of each factor separately was satisfactory to very satisfactory (.70‐.87). Cronbach’s alpha coefficient for all the final 25 items of the initial questionnaire was good (Cronbach’s α = 0.82), suggesting very satisfactory internal consistency.ConclusionThis is the first study that created a questionnaire for measuring the attitudes of Greek people towards dementia and genetic screening. Capturing data via this questionnaire might help clinicians, policymakers, and health services researchers in dementia understand better peoples’ perspectives related to the pros and cons of dementia screening and develop effective counseling programs and prevention strategies.

Emerging concepts since the Chronic Hypertension and Pregnancy trial

The recent publication of the Chronic Hypertension and Pregnancy (CHAP) trial has already changed the management of pregnant people with mild chronic hypertension. However, similar to any new intervention or change in management, we have encountered confusion regarding the management and implementation of the "Treatment for mild chronic hypertension during pregnancy" trial findings. In this clinical opinion, we addressed the aspects relating to the implementation that cannot be gleaned from the manuscript but were part of the trial conduct. Furthermore, we discussed several clinical questions that may affect the management of a patient with chronic hypertension following the "Treatment for mild chronic hypertension during pregnancy" trial and provided suggestions based on our experience and opinion.

An economic evaluation of first-line cryoballoon ablation versus antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation from an English NHS perspective

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): This cost-effectiveness study was funded by Medtronic Background The UK National Institute of Care Excellence (NICE) recommend the use of pulmonary vein isolation (PVI) to treat paroxysmal atrial fibrillation (PAF) in those who have not responded to drug treatment. Recently, three randomized controlled trials have demonstrated that as an initial rhythm control strategy, PVI with cryoballoon ablation, reduces atrial arrhythmia recurrence compared to antiarrhythmic drug (AAD) therapy in patients with symptomatic PAF. Purpose To evaluate the cost-effectiveness of first-line cryoablation versus first-line optimized AADs in an English National Health Service (NHS) setting. Methods Individual patient-level data from 703 participants with untreated PAF recruited into Cryo-FIRST, STOP AF First and EARLY-AF were used to derive equations to predict the following outcomes: rates of ablation, AF recurrence and resolution, AF-related hospital attendance, and health-related quality of life (HRQoL) utilities. Where parameters could not be sourced from the trial data, inputs were taken from the published literature or derived using clinical expert opinion. The cost-effectiveness model (CEM) was a hybrid of a decision tree with a one-year time horizon and a Markov model (three-month cycle length) with a lifetime time horizon and was developed from the perspective of the English NHS. Health benefits were expressed in quality-adjusted life years (QALYs), and all benefits and costs were discounted at 3.5% per year in line with NICE requirements. Uncertainty in the CEM inputs was explored using probabilistic sensitivity analysis. The results include an initial 12-week blanking period for all studies. Results The three-monthly rate of AF recurrence was reduced on average by 46.7% (p<0.001) in those treated with cryoablation. Similarly, the monthly rate of receiving an ablation following initial treatment was reduced by 72.8% (p<0.001) in the cryoablation arm. Furthermore, the average cryoablation patient was associated with a 4.3% (p=0.025) increase in their HRQoL. While the likelihood of failure was greater in the AAD group, in those who failed initial treatment, there was no difference in the rate of AF symptom resolution. The CEM indicates that cryoablation is more effective (+0.17 QALYs) and more costly (+£1,414) over a lifetime compared to optimized AADs. Cryoablation resulted in an Incremental Cost-Effectiveness Ratio of £8,435 with a 78.5% probability of being cost-effective at a willingness-to-pay threshold of £20,000 per QALY gained. Individuals in both treatment arms were predicted to receive ~1.2 ablations over a lifetime regardless of initial treatment. However, there was a 45% relative reduction in the amount of time spent in symptomatic AF states for those initially treated with cryoablation. Conclusions AF rhythm control in drug naïve patients with cryoballoon ablation is cost-effective compared to optimized AADs in an English NHS setting.

Dosing and Therapeutic Conduct in Administration Sessions in Substance-Assisted Psychotherapy: A Systematized Review

While the potential of serotonergic psychedelics and related substances as adjuncts in substance-assisted psychotherapy (SAPT) has been investigated for the treatment of several disorders, evidence for the appropriate therapeutic conduct in administration sessions is sparse. In this article, we discuss the current evidence for best therapeutic practice during administration sessions with serotonergic psychedelics and entactogens as adjuncts to psychotherapy. We conducted a systematized review of the literature following PRISMA guidelines. PsycINFO, MEDLINE, and Cochrane Library databases were searched. Clinical trials, treatment manuals, study protocols, qualitative studies, case studies, descriptive studies, opinion papers, reviews, book chapters, and conference proceedings published until February 1, 2022 were retrieved. The final synthesis included k = 82 sources. Information about substances, dosages, number of administration sessions, issues that are common for clients, different types of experiences, music, and therapeutic conduct was summarized, compared, and critically discussed. The effects different therapeutic models, methods, techniques, and more complex interventions each have on the therapeutic outcome have not been investigated by means of rigorous research. Most of the available evidence we retrieved was anecdotal limiting any conclusive statements regarding appropriate therapeutic conduct during administration sessions. Consequently, essential components of therapeutic interventions remain largely tentative, necessitating systematic investigation.

Oral Azacitidine for Maintenance Treatment of Acute Myeloid Leukaemia After Induction Therapy: An Evidence Review Group Perspective of a NICE Single Technology Appraisal.

The National Institute for Health and Care Excellence (NICE) invited the manufacturer (Celgene) of oral azacitidine (ONUREG), as part of the Single Technology Appraisal (STA) process, to submit evidence for the clinical effectiveness and cost-effectiveness of oral azacitidine for maintenance treatment of acute myeloid leukaemia (AML) after induction therapy compared with watch-and-wait plus best supportive care (BSC) and midostaurin. Kleijnen Systematic Reviews Ltd, in collaboration with Maastricht University Medical Centre+, was commissioned to act as the independent Evidence Review Group (ERG). This paper summarises the company submission (CS), presents the ERG's critical review on the clinical and cost-effectiveness evidence in the CS, highlights the key methodological considerations and describes the development of the NICE guidance by the Appraisal Committee. In the QUAZAR AML-001 trial, oral azacitidine significantly improved overall survival (OS) versus placebo: median OS gain of 9.9months (24.7months versus 14.8months; hazard ratio (HR) 0.69 (95% CI 0.55-0.86), p < 0.001). The median time to relapse was also better for oral azacitidine, and the incidences of TEAEs were similar for the two arms. The company excluded two of the comparators listed in the scope, low-dose cytarabine and subcutaneous azacitidine, informed only by clinical expert opinion, leaving only best supportive care (BSC) and midostaurin for the FLT3-ITD and/or FLT3-TKD (FLT3 mutation)-positive subgroup. An ITC comparing oral azacitidine to midostaurin as maintenance therapy in the appropriate subgroup demonstrated that the OS and relapse-free survival (RFS) HRs were favourable for oral azacitidine when compared with midostaurin. However, in the only available trial of midostaurin as maintenance treatment in AML that was used for this ITC, subjects were not randomised at the maintenance phase, but at induction, which posed a substantial risk of bias. The revised and final probabilistic incremental cost-effectiveness ratio (ICER) presented by the company, including a commercial arrangement, was £32,480 per quality-adjusted life year (QALY) gained for oral azacitidine versus watch-and-wait plus BSC. Oral azacitidine was dominant versus midostaurin in the FLT-3 subgroup. The ERG's concerns included the approach of modelling haematopoietic stem cell transplantation (HSCT), the generalisability of the population and the number of cycles of consolidation therapy pre-treatment in the QUAZAR AML-001 trial to UK clinical practice, and uncertainty in the relapse utility. The revised and final ERG base case resulted in a similar probabilistic ICER of £33,830 per QALY gained versus watch-and-wait plus BSC, but with remaining uncertainty. Oral azacitidine remained dominant versus midostaurin in the FLT-3 subgroup. After the second NICE appraisal committee meeting, the NICE Appraisal Committee recommended oral azacitidine (according to the commercial arrangement), within its marketing authorisation, as an option for maintenance treatment for AML in adults who are in complete remission, or complete remission with incomplete blood count recovery, after induction therapy with or without consolidation treatment, and cannot have or do not want HSCT.

Visual Outcomes of Cataract Surgery in Patients With Keratoconus Using Toric and Non-toric Lenses

To compare the accuracy and outcomes of different intraocular lens (IOL) power calculation formulas in eyes with keratoconus undergoing cataract surgery with toric and non-toric IOLs. This was a consecutive retrospective case series study including patients from the Cornea Service at the Department of Ophthalmology and Visual Sciences at the University of British Columbia, Vancouver, Canada, from 2000 to 2020. Keratoconus was diagnosed based on corneal topography and clinician opinion. Patients who underwent topography-guided photorefractive keratectomy, intracorneal ring segments implantation, or corneal transplant were excluded. The manifest spherical equivalent, prediction errors, and median absolute errors were calculated. Descriptive statistics were expressed as mean ± standard deviation. There were 160 eyes from 101 patients; 136 eyes received non-toric lenses and 24 eyes received toric lenses. Most patients had mild disease (< 48.00 diopters [D]) when stratified by steep keratometry values. Patients with severe disease (> 53.00 D) were significantly more hyperopic following surgery (P < .05). The Barrett Universal II (0.26 D, inter-quartile range [IQR] = 0.4), Holladay 2 (0.31, IQR = 1.2), and SRK/T (0.42, IQR = 0.86) formulas had the lowest median absolute error. The postoperative prediction error following toric lens insertion was not significantly different than following non-toric lens insertion, and the mean absolute astigmatism was significantly reduced with toric lenses. The Barrett Universal II, Holladay 2, and SRK/T were the most accurate IOL power calculation formulas in patients with keratoconus undergoing cataract surgery. Hyperopic surprise was increased in severe keratoconus. Toric IOLs may be considered in patients with mild keratoconus. [J Refract Surg. 2023;39(5):319-325.].

A Tale of Two Cases: When to Use PLEX That is The Question (P10-5.025)

<h3>Objective:</h3> NA <h3>Background:</h3> The diagnosis New Onset Status Epilepticus (NORSE) is rare. Autoimmune encephalitis (AIE) is one of the most common causes. Data on timely administration of Plasmapheresis (PLEX) vs IVIG/Solumedrol therapy is lacking. Seizure control can be used as a marker for response to therapy. <h3>Design/Methods:</h3> NA <h3>Results:</h3> In these two cases, we describe NORSE with newly diagnosed Autoimmune encephalitis. The clinical courses for each were different. Case 1, a 30 yo M with no pmh was admitted to Epilepsy Monitoring Unit (EMU). Patient was in focal status with LP CSF findings consistent with AIE. Patient had conventional treatment for AIE: steroids and IVIG. Patient was discharged upon clinical improvement. He was admitted a week later for worsening seizures. Patient’s seizures were treated with 5 PLEX sessions followed by chemotherapy (Actemra and Rituxan) administration in addition to high doses of antiseizure medication. Case 2, 32 yo M with no pmh presents with 11 days of generalized weakness, cognitive slowing/confusion. Patient had 6 generalized tonic clonic seizures. Patient was in the ICU and intubated. Various agents were used for seizure control such as Vimpat, Keppra, Depakote and Ketamine. Day 4, was started on steroids and IVIG. Day 11, started on 5 sessions of PLEX followed by chemotherapy (Actemra and Rituxan) with significant improvement. <h3>Conclusions:</h3> NORSE is a diagnosis with high rate of refractoriness to treatment and severe outcome. Early initiation of immunological therapy provide the most benefit. First line therapy is based on clinical presentation and expert opinion. These two cases illustrate better outcome with early initiation of plasmapheresis in rapidly progressing refractory focal status epilepticus of autoimmune etiology. Its been shown PLEX is better economically and less potential side effects as compared to IVIG. Rapid seizure control with combination of high dose new anti-seizure and immunological treatment in a timely manner are key for better outcomes. <b>Disclosure:</b> Dr. Dalal has nothing to disclose. Dr. Grunstein has nothing to disclose. Dr. Schneider has nothing to disclose. Dr. Proteasa has nothing to disclose.

Diagnosis and Management of Non-Metastatic Upper Tract Urothelial Carcinoma: AUA/SUO Guideline

The purpose of this guideline is to provide a useful reference on the effective evidence-based diagnoses and management of non-metastatic upper tract urothelial carcinoma (UTUC). The Pacific Northwest Evidence-based Practice Center of Oregon Health & Science University (OHSU) team conducted searches in Ovid MEDLINE (1946 to March 3rd, 2022), Cochrane Central Register of Controlled Trials (through January 2022), and Cochrane Database of Systematic Reviews (through January 2022). The searches were updated August 2022. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (Table 1).[Table: see text]Results:This Guideline provides updated, evidence-based recommendations regarding diagnosis and management of non-metastatic UTUC including risk stratification, surveillance and survivorship. Treatments discussed include kidney sparing management, surgical management, lymph node dissection (LND), neoadjuvant/adjuvant chemotherapy and immunotherapy. This standardized guideline seeks to improve clinicians' ability to evaluate and treat patients with UTUC based on available evidence. Future studies will be essential to further support these statements for improving patient care. Updates will occur as the knowledge regarding disease biology, clinical behavior and new therapeutic options develop.

Should artificial intelligence have lower acceptable error rates than humans?

The first patient was misclassified in the diagnostic conclusion according to a local clinical expert opinion in a new clinical implementation of a knee osteoarthritis artificial intelligence (AI) algorithm at Bispebjerg-Frederiksberg University Hospital, Copenhagen, Denmark. In preparation for the evaluation of the AI algorithm, the implementation team collaborated with internal and external partners to plan workflows, and the algorithm was externally validated. After the misclassification, the team was left wondering: what is an acceptable error rate for a low-risk AI diagnostic algorithm? A survey among employees at the Department of Radiology showed significantly lower acceptable error rates for AI (6.8 %) than humans (11.3 %). A general mistrust of AI could cause the discrepancy in acceptable errors. AI may have the disadvantage of limited social capital and likeability compared to human co-workers, and therefore, less potential for forgiveness. Future AI development and implementation require further investigation of the fear of AI's unknown errors to enhance the trustworthiness of perceiving AI as a co-worker. Benchmark tools, transparency, and explainability are also needed to evaluate AI algorithms in clinical implementations to ensure acceptable performance.

5554869 ASSOCIATION BETWEEN HEMOGLOBIN LEVELS AND END-ORGAN DAMAGE IN SICKLE CELL DISEASE: A RETROSPECTIVE LINKED PRIMARY AND SECONDARY CARE DATABASE ANALYSIS IN ENGLAND

Background: Sickle cell disease (SCD) is a chronic, multifaceted blood disorder that affects the oxygen-carrying protein hemoglobin (Hb). Along with chronic hemolysis and vaso-occlusion that often accompanies SCD, low Hb levels may contribute to downstream end-organ damage (EOD). Emerging evidence suggests an association between chronic hemolytic anemia in SCD and both short-term and long-term adverse outcomes, including EOD. Therefore, treatments that directly increase Hb may improve patients’ acute symptoms while reducing the risk for long-term disease-related effects known to contribute to morbidity and mortality. Aims: This study aims to ascertain the association between Hb level variation and EOD and clinical conditions typically associated with SCD (stroke, pulmonary hypertension, chronic kidney disease [CKD], end-stage renal disease [ESRD], leg ulcers, and pneumonia) in a real-world data set. Methods: The Clinical Practice Research Datalink (CPRD) and the Hospital Episode Statistics (HES) databases in England were used to retrospectively identify linked Hb data among patients with SCD (April 1, 2007, to March 31, 2019). Recurring results in any 90-day period were averaged. Logistic regression adjusted with demographic and clinical variables was used to determine odds ratios (ORs) of developing each EOD outcome or clinical complication. ORs, P values, 95% confidence intervals (CIs), and areas under the receiver operating curve (AUC-ROCs) and corresponding 95% CIs were reported. Results: Of 11,936 patients identified, 5379 (45%) had Hb results recorded in the CPRD. The logistic model for risk assessment of all outcomes studied indicated that an increase in Hb among patients with SCD was associated with a statistically significant (P<0.001) decrease in adjusted ORs per 1 g/dL increase in Hb (Table). Except for ESRD, leg ulcers, and pneumonia, the adjusted models showed statistically significant increases in AUC-ROC compared with the unadjusted models, signifying that the adjusted models were more robust and further verified a statistical OR after adjustment. Increased Hb was associated with decreased risk of respiratory-related events. Pulmonary hypertension had the strongest effect with the most robust model (ORadjusted of 0.66). For pneumonia, ORadjusted was 0.77. For renal insufficiency, ORs for developing CKD or ESRD were significantly lower than 1 (ORadjusted=0.73 and ORadjusted=0.75, respectively). After adjusting for clinical and demographic factors, the model predicted a lower risk for stroke (ORadjusted=0.89). The estimated AUC-ROCs suggest that the adjusted model is more robust in stroke, hypertension, and CKD. These findings did not change when testing for other covariates such as deep vein thrombosis. Summary-Conclusion: Among patients with SCD, an increase in Hb of 1 g/dL was associated with a statistically significant reduction in risk for 6 common EOD outcomes and clinical conditions. The results were more pronounced after adjusting for demographic and clinical covariates (based on clinical opinion and literature review) and further assessed with a bivariate analysis. The results were obtained from a representative real-world evidence dataset analyzed over a 12-year period, which was sufficient to observe EOD events, and are generalizable to the UK and similar populations. Our findings support the use of therapeutics that increase Hb in patients with SCD to protect against deleterious organ damage.

A clinical frailty scale obtained from MDT discussion performs poorly in assessing frailty in haemodialysis recipients

BackgroundThe Clinical Frailty Scale (CFS) is a commonly utilised frailty screening tool that has been associated with hospitalisation and mortality in haemodialysis recipients, but is subject to heterogenous methodologies including subjective clinician opinion. The aims of this study were to (i) examine the accuracy of a subjective, multidisciplinary assessment of CFS at haemodialysis Quality Assurance (QA) meetings (CFS-MDT), compared with a standard CFS score via clinical interview, and (ii) ascertain the associations of these scores with hospitalisation and mortality.MethodsWe performed a prospective cohort study of prevalent haemodialysis recipients linked to national datasets for outcomes including mortality and hospitalisation. Frailty was assessed using the CFS after structured clinical interview. The CFS-MDT was derived from consensus at haemodialysis QA meetings, involving dialysis nurses, dietitians, and nephrologists.Results453 participants were followed-up for a median of 685 days (IQR 544–812), during which there were 96 (21.2%) deaths and 1136 hospitalisations shared between 327 (72.1%) participants. Frailty was identified in 246 (54.3%) participants via CFS, but only 120 (26.5%) via CFS-MDT. There was weak correlation (Spearman Rho 0.485, P < 0.001) on raw frailty scores and minimal agreement (Cohen’s κ = 0.274, P < 0.001) on categorisation of frail, vulnerable and robust between the CFS and CFS-MDT. Increasing frailty was associated with higher rates of hospitalisation for the CFS (IRR 1.26, 95% C.I. 1.17–1.36, P = 0.016) and CFS-MDT (IRR 1.10, 1.02–1.19, P = 0.02), but only the CFS-MDT was associated with nights spent in hospital (IRR 1.22, 95% C.I. 1.08–1.38, P = 0.001). Both scores were associated with mortality (CFS HR 1.31, 95% C.I. 1.09–1.57, P = 0.004; CFS-MDT HR 1.36, 95% C.I. 1.16–1.59, P < 0.001).ConclusionsAssessment of CFS is deeply affected by the underlying methodology, with the potential to profoundly affect decision-making. The CFS-MDT appears to be a weak alternative to conventional CFS. Standardisation of CFS use is of paramount importance in clinical and research practice in haemodialysis.Trial registrationClinicaltrials.gov : NCT03071107 registered 06/03/2017.

Mapping the burden of severe forms of epidermolysis bullosa – Implications for patient management

The pathophysiological processes underlying the phenotypic spectrum of severe forms of epidermolysis bullosa (EB) are complex and poorly understood. To use burden mapping to explore relationships between primary pathomechanisms and secondary clinical manifestations in severe forms of EB (junctional and dystrophic EB [JEB/DEB]) and highlight strengths and weaknesses in evidence regarding the contribution of different pathways. Literature searches were performed to identify evidence regarding the pathophysiological and clinical aspects of JEB/DEB. Identified publications and clinical experience were used to construct burden maps to visually communicate plausible connections and their relative importance by subtype. Our findings suggest that most of the clinical consequences of JEB/DEB may result from an abnormal state and/or faulty skin remodeling driven by a vicious cycle of delayed wound healing, predominantly mediated through inflammation. The quantity and quality of evidence varies by individual manifestations and disease subtype. The burden maps are provisional hypotheses requiring further validation and are limited by the published evidence base and subjectivity in clinical opinion. Delayed wound healing appears to be a key driver of the burden of JEB/DEB. Further studies are warranted to understand the role of inflammatory mediators and accelerated wound healing in patient management.

Development of a UK core dataset for geriatric medicine research: a position statement and results from a Delphi consensus process

BackgroundThere is lack of standardisation in assessment tools used in geriatric medicine research, which makes pooling of data and cross-study comparisons difficult.MethodsWe conducted a modified Delphi process to establish measures to be included within core and extended datasets for geriatric medicine research in the United Kingdom (UK). This included three complete questionnaire rounds, and one consensus meeting. Participants were selected from attendance at the NIHR Newcastle Biomedical Research Centre meeting, May 2019, and academic geriatric medicine e-mailing lists. Literature review was used to develop the initial questionnaire, with all responses then included in the second questionnaire. The third questionnaire used refined options from the second questionnaire with response ranking.ResultsNinety-eight responses were obtained across all questionnaire rounds (Initial: 19, Second: 21, Third: 58) from experienced and early career researchers in geriatric medicine. The initial questionnaire included 18 questions with short text responses, including one question for responders to suggest additional items. Twenty-six questions were included in the second questionnaire, with 108 within category options. The third questionnaire included three ranking, seven final agreement, and four binary option questions. Results were discussed at the consensus meeting. In our position statement, the final consensus dataset includes six core domains: demographics (age, gender, ethnicity, socioeconomic status), specified morbidities, functional ability (Barthel and/or Nottingham Extended Activities of Daily Living), Clinical Frailty Scale (CFS), cognition, and patient-reported outcome measures (dependent on research question). We also propose how additional variables should be measured within an extended dataset.ConclusionsOur core and extended datasets represent current consensus opinion of academic geriatric medicine clinicians across the UK. We consider the development and further use of these datasets will strengthen collaboration between researchers and academic institutions.

Decisions and Decisional Needs of Canadians From all Provinces and Territories During the COVID-19 Pandemic: Population-Based Cross-sectional Surveys.

Never before COVID-19 had Canadians faced making health-related decisions in a context of significant uncertainty. However, little is known about which type of decisions and the types of difficulties that they faced. We sought to identify the health-related decisions and decisional needs of Canadians. Our study was codesigned by researchers and knowledge users (eg, patients, clinicians). Informed by the CHERRIES (the Checklist for Reporting Results of Internet E-Surveys) reporting guideline, we conducted 2 online surveys of random samples drawn from the Leger consumer panel of 400,000 Canadians. Eligible participants were adults (≥18 years) who received or were receiving any health services in the past 12 months for themselves (adults) or for their child (parent) or senior with cognitive impairment (caregiver). We assessed decisions and decisional needs using questions informed by the Ottawa Decision Support Framework, including decisional conflict and decision regret using the Decision Conflict Scale (DCS) and the Decision Regret Scale (DRS), respectively. Descriptive statistics were conducted for adults who had decided for themselves or on behalf of someone else. Significant decisional conflict (SDC) was defined as a total DCS score of >37.5 out of 100, and significant decision regret was defined as a total DRS score of >25 out of 100. From May 18 to June 4, 2021, 14,459 adults and 6542 parents/caregivers were invited to participate. The invitation view rate was 15.5% (2236/14,459) and 28.3% (1850/6542); participation rate, 69.3% (1549/2236) and 28.7% (531/1850); and completion rate, 97.3% (1507/1549) and 95.1% (505/531), respectively. The survey was completed by 1454 (97.3%) adults and 438 (95.1%) parents/caregivers in English (1598/1892, 84.5%) or French (294/1892, 15.5%). Respondents from all 10 Canadian provinces and the northern territories represented a range of ages, education levels, civil statuses, ethnicities, and annual household income. Of 1892 respondents, 541 (28.6%) self-identified as members of marginalized groups. The most frequent decisions were (adults vs parents/caregivers) as follows: COVID-19 vaccination (490/1454, 33.7%, vs 87/438, 19.9%), managing a health condition (253/1454, 17.4%, vs 47/438, 10.7%), other COVID-19 decisions (158/1454, 10.9%, vs 85/438, 19.4%), mental health care (128/1454, 8.8%, vs 27/438, 6.2%), and medication treatments (115/1454, 7.9%, vs 23/438, 5.3%). Caregivers also reported decisions about moving family members to/from nursing or retirement homes (48/438, 11.0%). Adults (323/1454, 22.2%) and parents/caregivers (95/438, 21.7%) had SDC. Factors making decisions difficult were worrying about choosing the wrong option (557/1454, 38.3%, vs 184/438, 42.0%), worrying about getting COVID-19 (506/1454, 34.8%, vs 173/438, 39.5%), public health restrictions (427/1454, 29.4%, vs 158/438, 36.1%), information overload (300/1454, 20.6%, vs 77/438, 17.6%), difficulty separating misinformation from scientific evidence (297/1454, 20.4%, vs 77/438, 17.6%), and difficulty discussing decisions with clinicians (224/1454, 15.4%, vs 51/438, 11.6%). For 1318 (90.6%) adults and 366 (83.6%) parents/caregivers who had decided, 353 (26.8%) and 125 (34.2%) had significant decision regret, respectively. In addition, 1028 (50%) respondents made their decision alone without considering the opinions of clinicians. During COVID-19, Canadians who responded to the survey faced several new health-related decisions. Many reported unmet decision-making needs, resulting in SDC and decision regret. Interventions can be designed to address their decisional needs and support patients facing new health-related decisions.

Chat Generative Pre-trained Transformer: why we should embrace this technology

With the advent of artificial intelligence that not only can learn from us but also can communicate with us in plain language, humans are embarking on a brave new future. The interaction between humans and artificial intelligence has never been so widespread. Chat Generative Pre-trained Transformer is an artificial intelligence resource that has potential uses in the practice of medicine. As clinicians, we have the opportunity to help guide and develop new ways to use this powerful tool. Optimal use of any tool requires a certain level of comfort. This is best achieved by appreciating its power and limitations. Being part of the process is crucial in maximizing its use in our field. This clinical opinion demonstrates the potential uses of Chat Generative Pre-trained Transformer for obstetrician-gynecologists and encourages readers to serve as the driving force behind this resource.

The Clinical Attachment Revisited: A Clinical Opinion Introducing the (A-LEVEL), (A-GAIN), and (A-LOSS)

The Clinical Attachment Revisited: A Clinical Opinion Introducing the (A-LEVEL), (A-GAIN), and (A-LOSS)

Towards a clinical consensus on the management of pregnancy and birth after laparoscopic and open myomectomy: A survey of obstetricians and gynaecologists

ObjectivesThe primary aim was to assess if a clinical consensus regarding the management of pregnancy post myomectomy existed amongst consultant obstetricians and gynaecologists. Secondary objectives were to evaluate factors which influence the clinician’s decision making in this group of women. Study designElectronic survey sent to all consultants working in the North Central and East London deanery, Kent Surrey and Sussex deanery and Imperial NHS Trust to assess opinions on mode of birth post myomectomy, intervals advised to pregnancy post myomectomy, factors influencing the management of delivery in the scarred uterus post myomectomy, opinions on induction of labour and questions relating to operative notes. Results209 consultant responses received between 07/03/2022–07/05/2022 (44% response rate); 77% (161/209) practicing obstetricians and gynaecologists, 10% (21/109) pure gynaecologists and 13% (27/209) pure obstetricians.The majority would support a vaginal birth after open myomectomy (75%) and laparoscopic myomectomy (79%). No consensus was found as to the optimal time interval between myomectomy and pregnancy. Higher frequency of performing myomectomy and a greater level of experience were significantly associated with a shorter interval to pregnancy advised.The most important operative factors influencing decision to support trial of labour post myomectomy were breach of uterine cavity; location of fibroids removed and number of incisions on the uterus. 77% believe women should be given a choice regarding mode of delivery post myomectomy in a similar way to previous LSCS. 82.8% would support enrolment of patients into a prospective trial to investigate delivery post myomectomy. ConclusionsWe present a comprehensive survey of clinician opinions on pregnancy post myomectomy demonstrating that the majority of consultant obstetricians and gynaecologists sampled would support vaginal birth post myomectomy; counselling patients in a similar way to VBAC; a standardised myomectomy operation note and enrolment of patients in a future prospective trial. Wide variation in opinion regarding interval to pregnancy post myomectomy has been highlighted. We believe this information will facilitate counselling discussions and empower women with subsequent pregnancies after myomectomy to make an informed decision on mode of birth post myomectomy.

Examining Clinical Opinion and Experience Regarding Utilization of Plain Radiography of the Spine: Evidence from Surveying the Chiropractic Profession.

Plain Radiography of the spine (PROTS) is utilized in many forms of healthcare including the chiropractic profession; however, the literature reflects conflicting opinions regarding utilization and value. Despite being an essential part of Evidence-Based Practice (EBP), few studies assess Doctors of Chiropractic (DCs) clinical opinions and experience regarding the utilization of (PROTS) in practice. In this study, DCs were surveyed regarding utilization of PROTS in practice. The survey was administered to an estimated 50,000 licensed DCs by email. A total of 4301 surveys were completed, of which 3641 were United States (US) DCs. The Clinician Opinion and Experience on Chiropractic Radiography (COECR) scale was designed to analyze survey responses. This valid and reliable scale demonstrated good internal consistency using confirmatory factor analysis and the Rasch model. Survey responses show that 73.3% of respondents utilize PROTS in practice and 26.7% refer patients out for PROTS. Survey responses show that, among US DCs, 91.9% indicate PROTS has value beyond identification of pathology, 86.7% indicate that PROTS is important regarding biomechanical analysis of the spine, 82.9% indicate that PROTS is vital to practice, 67.4% indicate that PROTS aids in measuring outcomes, 98.6% indicate the opinion that PROTS presents very low to no risk to patients, and 93.0% indicate that sharing clinical findings from PROTS studies with patients is beneficial to clinical outcomes. The results of the study indicated that based on clinical experience, the majority of DCs find PROTS to be vital to practice and valuable beyond the identification of red flags.

Understanding the Cures Act Information Blocking Rule in cancer care: a mixed methods exploration of patient and clinician perspectives and recommendations for policy makers

BackgroundThe 21st Century Cures Act Interoperability and Information Blocking Rule was created to increase patient access to health information. This federally mandated policy has been met with praise and concern. However, little is known about patient and clinician opinions of this policy within cancer care.MethodsWe conducted a convergent parallel mixed methods study to understand patient and clinician reactions to the Information Blocking Rule in cancer care and what they would like policy makers to consider. Twenty-nine patients and 29 clinicians completed interviews and surveys. Inductive thematic analysis was used to analyze the interviews. Interview and survey data were analyzed separately, then linked to generate a full interpretation of the results.ResultsOverall, patients felt more positive about the policy than clinicians. Patients wanted policy makers to understand that patients are unique, and they want to individualize their preferences for receiving health information with their clinicians. Clinicians highlighted the uniqueness of cancer care, due to the highly sensitive information that is shared. Both patients and clinicians were concerned about the impact on clinician workload and stress. Both expressed an urgent need for tailoring implementation of the policy to avoid unintended harm and distress for patients.ConclusionsOur findings provide suggestions for optimizing the implementation of this policy in cancer care. Dissemination strategies to better inform the public about the policy and improve clinician understanding and support are recommended. Patients who have serious illness or diagnoses such as cancer and their clinicians should be included when developing and enacting policies that could have a significant impact on their well-being. Patients with cancer and their cancer care teams want the ability to tailor information release based on individual preferences and goals. Understanding how to tailor implementation of the Information Blocking Rule is essential for retaining its benefits and minimizing unintended harm for patients with cancer.

The role of service providers' linguistic backgrounds on assessment of multilingual children.

Cultural and linguistic competencies play a critical role in speech-language pathology services when working with people from diverse linguistic backgrounds with communication disorders (CD; Hopf etal., 2021). The personal experiences of speech-language pathologists (SLPs) influence their cultural and linguistic competence skills. Training programs that consider these personal factors might address the unique needs of the SLPs based on their experiences. The current research explores the connection between the linguistic backgrounds of the SLPs and the challenges and needs they reported while assessing multilingual children with CD. This study uses a survey method for documenting and comparing 105 SLPs with varying linguistic backgrounds - monolingual, bilingual, and multilingual - on their reported challenges and needs associated with evaluating communication abilities in children from multilingual families with CD. Although all the SLPs worked with children from multilingual families, their linguistic backgrounds introduced differences in their clinical assessment opinions. Across all SLPs in the study, common challenges were the limited availability of interpreters, dedicated assessment materials, multilingual clinical supervisors, and pre-professional training opportunities. This study provides valuable information on the effects of linguistic backgrounds on the clinical opinions of SLPs and alludes to the importance of personal experiences on clinical practices. Future research that examines other personal factors and their effects on the SLPs' clinical opinions and practices will help the development of evidence-based cultural and linguistic competence training programs.