The use of narratives, including physicians' and patients' stories, literature, and film, is increasingly popular in medical education. There is, however, a need for an overarching conceptual ...framework to guide these efforts, which are often dismissed as "soft" and placed at the margins of medical school curricula. The purpose of this article is to describe the conceptual basis for an approach to patient-centered medical education and narrative medicine initiated at the University of Michigan Medical School in the fall of 2003. This approach, the Family Centered Experience, involves home visits and conversations between beginning medical students and patient volunteers and their families and is aimed at fostering humanism in medicine. The program incorporates developmental and learning theory, longitudinal interactions with individuals with chronic illness, reflective learning, and small-group discussions to explore the experience of illness and its care. The author describes a grounding of this approach in theories of empathy and moral development and clarifies the educational value that narratives bring to medical education. Specific pedagogical considerations, including use of activities to create "cognitive disequilibrium" and the concept of transformative learning, are also discussed and may be applied to narrative medicine, professionalism, multicultural education, medical ethics, and other subject areas in medical education that address individuals and their health care needs in society.
It has not yet been possible to quantify dose‐related health risks attributable to indoor dampness or mold (D/M), to support setting specific health‐related limits for D/M. An overlooked target for ...assessing D/M is moisture in building materials, the critical factor allowing microbial growth. A search for studies of quantified building moisture and occupant health effects identified 3 eligible studies. Two studies assessed associations between measured wall moisture content and respiratory health in the UK. Both reported dose‐related increases in asthma exacerbation with higher measured moisture, with 1 study reporting an adjusted odds ratio of 7.0 for night‐time asthma symptoms with higher bedroom moisture. The third study assessed relationships between infrared camera‐determined wall moisture and atopic dermatitis in South Korea, reporting an adjusted odds ratio of 14.5 for water‐damaged homes and moderate or severe atopic dermatitis. Measuring building moisture has, despite extremely limited available findings, potential promise for detecting unhealthy D/M in homes and merits more research attention. Further research to validate these findings should include measured “water activity,” which directly assesses moisture availability for microbial growth. Ultimately, evidence‐based, health‐related thresholds for building moisture, across specific materials and measurement devices, could better guide assessment and remediation of D/M in buildings.
Background
The long‐term survival benefits of neoadjuvant chemotherapy (NAC) and chemoradiotherapy (NACR) for oesophageal carcinoma are well established. Both are burdened, however, by toxicity that ...could contribute to perioperative morbidity and mortality.
Methods
MEDLINE, the Cochrane Library and Embase were searched to capture the incidence of any postoperative complications, cardiac complications, respiratory complications, anastomotic leakage, postoperative 30‐day mortality, total postoperative mortality and treatment‐related mortality in randomized clinical trials comparing NAC or NACR with surgery alone, or NAC versus NACR. Meta‐analyses comparing NAC and NACR were conducted by using adjusted indirect comparison.
Results
Twenty‐three relevant studies were identified. Comparing NAC or NACR with surgery alone, there was no increase in morbidity or mortality attributable to neoadjuvant therapy. Subgroup analysis of NACR for squamous cell carcinoma (SCC) suggested an increased risk of total postoperative mortality and treatment‐related mortality compared with surgery alone: risk ratio 1·95 (95 per cent confidence interval 1·06 to 3·60; P = 0·032) and 1·97 (1·07 to 3·64; P = 0·030) respectively. A combination of direct comparison and adjusted indirect comparison showed no difference between NACR and NAC regarding morbidity or mortality.
Conclusion
Neither NAC nor NACR for oesophageal carcinoma increases the risk of postoperative morbidity or perioperative mortality compared with surgery alone. There was no clear difference between NAC and NACR. Care should be taken with NACR in oesophageal SCC, where an increased risk of postoperative mortality and treatment‐related mortality was apparent.
Neither approach increases surgical risk
An important proportion of respiratory illness is considered attributable to residential dampness or mold (D/M). Developing health‐protective D/M guidelines has been challenging, in part because ...unhealthy levels of indoor D/M cannot be defined using available microbiological measurements. This review paper explores reported multilevel, observation‐based (eg visual or olfactory) D/M metrics for potential in defining unhealthy levels of residential D/M. For many of the 33 multilevel residential D/M metrics identified, health risks generally increased as observed D/M increased. Although some metrics seemed too complex for practical use, simple metrics had among the strongest associations with health outcomes. Available findings suggest the feasibility of setting observation‐based D/M thresholds to trigger remedial action, using further improved D/M metrics without microbiological measurements (at least until the actual dampness‐related agents that cause illness are better quantified). Additional data would allow setting health‐protective D/M thresholds more precisely. Also, metrics could better reflect hidden D/M by more strongly emphasizing mold odor, which has demonstrated strong associations with health effects.
Background
Preoperative factors, including nutritional status, may have strong correlations with postoperative morbidities. The current study evaluated preoperative prealbumin concentrations as a ...predictor of postoperative complications after gastric surgery.
Methods
A retrospective study of 1798 patients who underwent gastrectomy for gastric adenocarcinoma was performed. Information was collected on basic patient characteristics, preoperative laboratory findings, and 30 day postoperative complications. The patients were divided into three groups based on prealbumin concentrations (≥22 mg/dL, <22 to ≥15 mg/dL, and <15 mg/dL) for analysis.
Results
The overall complication rate was 21.7 %, and the infection rate was 16 %. Subgroup analysis based on prealbumin concentrations showed that complication rates were markedly elevated with decreasing concentrations of prealbumin. Multivariate analysis using a logistic regression model showed that both overall and infectious complications were strongly associated with male gender, elevated C-reactive protein (CRP), and decreased prealbumin levels (
p
< 0.05). Even in patients with a CRP level higher than 0.1 mg/dL, male gender and low prealbumin concentrations (<15 mg/dL) were significantly correlated with overall and infectious morbidities (
p
< 0.05).
Conclusions
Preoperative prealbumin concentrations are useful predictors of short-term postoperative outcomes after gastrectomy.
Between 2003 and 2007, 99 knees in 77 patients underwent opening wedge high tibial osteotomy. We evaluated the effect of initial stable fixation combined with an artificial bone substitute on the ...mid- to long-term outcome after medial opening-wedge high tibial osteotomy (HTO) for medial compartmental osteoarthritis or spontaneous osteonecrosis of the knee in 78 knees in 64 patients available for review at a minimum of five years (mean age 68 years; 49 to 82). The mean follow-up was 6.5 years (5 to 10). The mean Knee Society knee score and function score improved from 49.6 (SD 11.4, 26 to 72) and 56.6 (SD 15.6, 5 to 100) before surgery to 88.1 (SD 12.5, 14 to 100) and 89.4 (SD 15.6, 5 to 100) at final follow-up (p < 0.001) respectively. There were no significant differences between patients aged ≥ 70 and < 70 years. The mean standing femorotibial angle was corrected significantly from 181.7° (SD 2.7°, 175° to 185°) pre-operatively to 169.7° (SD 2.4°, 164° to 175°) at one year's follow-up (p < 0.001) and 169.6° (SD 3.0°, 157° to 179°) at the final follow-up (p = 0.69 vs one year). Opening-wedge HTO using a stable plate fixation system combined with a bone substitute is a reliable procedure that provides excellent results. Although this treatment might seem challenging for older patients, our results strongly suggest that the results are equally good.
Dampness and visible mold in homes are associated with asthma development, but causal mechanisms remain unclear. The goal of this research was to explore associations among measured dampness, fungal ...exposure, and childhood asthma development without the bias of culture‐based microbial analysis. In the low‐income, Latino CHAMACOS birth cohort, house dust was collected at age 12 months, and asthma status was determined at age 7 years. The current analysis included 13 asthma cases and 28 controls. Next‐generation DNA sequencing methods quantified fungal taxa and diversity. Lower fungal diversity (number of fungal operational taxonomic units) was significantly associated with increased risk of asthma development: unadjusted odds ratio (OR) 4.80 (95% confidence interval (CI) 1.04–22.1). Control for potential confounders strengthened this relationship. Decreased diversity within the genus Cryptococcus was significantly associated with increased asthma risk (OR 21.0, 95% CI 2.16–204). No fungal taxon (species, genus, class) was significantly positively associated with asthma development, and one was significantly negatively associated. Elevated moisture was associated with increased fungal diversity, and moisture/mold indicators were associated with four fungal taxa. Next‐generation DNA sequencing provided comprehensive estimates of fungal identity and diversity, demonstrating significant associations between low fungal diversity and childhood asthma development in this community.
The purpose of this study was to evaluate the effects of high tibial osteotomy (HTO) on the biological status of knee osteoarthritis (OA) using joint markers in synovial fluid (SF).
Fifty patients ...with medial compartmental OA of the knee who underwent opening wedge HTO were enrolled. Paired SF samples from the affected knee and arthroscopic evaluation of articular cartilage were collected at the time of HTO surgery and the time of plate removal (postoperative 17 ± 4 months). The concentrations of the following SF biomarkers were measured: interleukin (IL)-1β, IL-6, IL-8, IL-10, tumour necrosis factor-α, matrix metalloproteinase (MMP)-2, MMP-3, MMP-9, MMP-13, vascular endothelial growth factor (VEGF), and cartilage oligomeric matrix protein (COMP). The Knee Society Score (KSS) and hip–knee–ankle (HKA) angle were assessed before and 2 years after HTO.
The KSS knee and function scores were significantly improved after HTO (mean changes of 36.4 and 23.7, respectively). The mean HKA angle was altered from mechanical varus (−8.6°) to valgus (5.2°). Concentrations of IL-6, IL-8, MMP-2, MMP-3, MMP-13, VEGF, and COMP in SF were significantly decreased after HTO (mean changes of −49.1%, −30.2%, −31.1%, −26.3%, −30.8%, −42.5%, and −13.7% from preoperative baseline, respectively). The cartilage status was improved in 19 cases (38%) after HTO. However, changes of all biomarkers were not significantly different between subjects with and without an improved cartilage status.
SF levels of biochemical markers for cartilage degradation and synovial inflammation were altered after HTO, suggesting an improvement in the OA disease state.
It has been recently reported that AF is associated with tissue inflammation. Statins reduce C-reactive protein (CRP) levels. However, the effect of statin on atrial fibrillation (AF) is unclear. The ...purpose of the present study was to evaluate the effect of statin on AF in a canine sterile pericarditis model.
Sterile pericarditis was created in 20 dogs randomly assigned to two groups: a control group (10 dogs) and an atorvastatin treatment group (10 dogs). Atorvastatin was administered orally (2 mg/kg/day) beginning 1 week before the operation until the end of the study. Before and 2 days after the operation, CRP levels, the duration of induced AF, the atrial effective refractory period (AERP), and intra-atrial conduction time were determined.
Before the operation, there were no significant differences in any of the parameters between the two groups. On the second postoperative day, the atorvastatin group had a lower CRP level (7.6+/-0.5 versus 11.7+/-1.3 mg/dl, P<0.0001), a shorter AF duration (177+/-57 versus 534+/-189 s, P<0.0001), a longer AERP (138+/-6 versus 130+/-6 ms, P<0.01), and a shorter intra-atrial conduction time (46+/-3 versus 51+/-5 ms, P<0.01) than the control group.
Atorvastatin can prevent maintenance of AF by inhibiting inflammation in the canine sterile pericarditis model. Atorvastatin may thus be a novel therapeutic agent for AF.
Geologic reservoirs containing gas hydrate occur beneath permafrost environments and within marine continental slope sediments, representing a potentially vast natural gas source. Numerical ...simulators provide scientists and engineers with tools for understanding how production efficiency depends on the numerous, interdependent (coupled) processes associated with potential production strategies for these gas hydrate reservoirs. Confidence in the modeling and forecasting abilities of these gas hydrate reservoir simulators (GHRSs) grows with successful comparisons against laboratory and field test results, but such results are rare, particularly in natural settings. The hydrate community recognized another approach to building confidence in the GHRS: comparing simulation results between independently developed and executed computer codes on structured problems specifically tailored to the interdependent processes relevant for gas hydrate-bearing systems. The United States Department of Energy, National Energy Technology Laboratory, (DOE/NETL), sponsored the first international gas hydrate code comparison study, IGHCCS1, in the early 2000s. IGHCCS1 focused on coupled thermal and hydrologic processes associated with producing gas hydrates from geologic reservoirs via depressurization and thermal stimulation. Subsequently, GHRSs have advanced to model more complex production technologies and incorporate geomechanical processes into the existing framework of coupled thermal and hydrologic modeling.
This paper contributes to the validation of these recent GHRS developments by providing results from a second GHRS code comparison study, IGHCCS2, also sponsored by DOE/NETL. IGHCCS2 includes participants from an international collection of universities, research institutes, industry, national laboratories, and national geologic surveys. Study participants developed a series of five benchmark problems principally involving gas hydrate processes with geomechanical components. The five problems range from simple geometries with analytical solutions to a representation of the world's first offshore production test of methane hydrates, which was conducted with the depressurization method off the coast of Japan. To identify strengths and limitations in the various GHRSs, study participants submitted solutions for the benchmark problems and discussed differing results via teleconferences. The GHRSs evolved over the course of IGHCCS2 as researchers modified their simulators to reflect new insights, lessons learned, and suggested performance enhancements. The five benchmark problems, final sample solutions, and lessons learned that are presented here document the study outcomes and serve as a reference guide for developing and testing gas hydrate reservoir simulators.
•Code comparisons build confidence in simulators to model interdependent processes.•International hydrate reservoir simulators are compared over five complex problems.•Geomechanical processes significantly impact response of gas hydrate reservoirs.•Simulators yielded comparable results, however many differences are noted.•Equivalent constitutive models are required to achieve agreement across simulators.
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