Cultural differences affecting euthanasia practice in Belgium: one law but different attitudes and practices in Flanders and Wallonia

Since 2002, Belgium has had a national law legalising euthanasia. The law prescribes several substantive due care requirements and two procedural due care requirements, i.e. consultation with an independent physician and reporting of euthanasia to a Federal Control Committee. A large discrepancy in reporting rates between the Dutch-speaking (Flanders) and the French-speaking (Wallonia) parts of Belgium has led to speculation about cultural differences affecting the practice of euthanasia in both regions. Using Belgian data from the European Values Study conducted in 2008 among a representative sample of the general public and data from a large-scale mail questionnaire survey on euthanasia of 480 physicians from Flanders and 305 from Wallonia (conducted in 2009), this study presents empirical evidence of differences between both regions in attitudes towards and practice of euthanasia. Acceptance of euthanasia by the general population was found to be slightly higher in Flanders than in Wallonia. Compared with their Flemish counterparts, Walloon physicians held more negative attitudes towards performing euthanasia and towards the reporting obligation, less often labelled hypothetical cases correctly as euthanasia, and less often defined a case of euthanasia having to be reported. A higher proportion of Flemish physicians had received a euthanasia request since the introduction of the law. In cases of a euthanasia request, Walloon physicians consulted less often with an independent physician. Requests were more often granted in Flanders than in Wallonia (51% vs 38%), and performed euthanasia cases were more often reported (73% vs 58%). The study points out some significant differences between Flanders and Wallonia in practice, knowledge and attitudes regarding euthanasia and its legal requirements which are likely to explain the discrepancy between Wallonia and Flanders in the number of euthanasia cases reported. Cultural factors seem to play an important role in the practice of (legal) euthanasia and the extent to which legal safeguards are followed.     

Temporal trends of hemoglobin A1c testing

Objective

The study of utilization patterns can quantify potential overuse of laboratory tests and find new ways to reduce healthcare costs. We demonstrate the use of distributional analytics for comparing electronic health record (EHR) laboratory test orders across time to diagnose and quantify overutilization.

Materials and methods

We looked at hemoglobin A1c (HbA1c) testing across 119 000 patients and 15 years of hospital records. We examined the patterns of HbA1c ordering before and after the publication of the 2002 American Diabetes Association guidelines for HbA1c testing. We conducted analyses to answer three questions. What are the patterns of HbA1c ordering? Do HbA1c orders follow the guidelines with respect to frequency of measurement? If not, how and why do they depart from the guidelines?

Results

The raw number of HbA1c orderings has steadily increased over time, with a specific increase in low-measurement orderings (<6.5%). There is a change in ordering pattern following the 2002 guideline (p<0.001). However, by comparing ordering distributions, we found that the changes do not reflect the guidelines and rather exhibit a new practice of rapid-repeat testing. The rapid-retesting phenomenon does not follow the 2009 guidelines for diabetes diagnosis either, illustrated by a stratified HbA1c value analysis.

Discussion

Results suggest HbA1c test overutilization, and contributing factors include lack of care coordination, unexpected values prompting retesting, and point-of-care tests followed by confirmatory laboratory tests.

Conclusions

We present a method of comparing ordering distributions in an EHR across time as a useful diagnostic approach for identifying and assessing the trend of inappropriate use over time.     

Dual-Energy CT in Patients Treated with Anti-Angiogenic Agents for Non-Small Cell Lung Cancer: New Method of Monitoring Tumor Response?

Objective

To evaluate tumor responses in patients treated with anti-angiogenic agents for non-small cell lung cancer (NSCLC) by assessing intratumoral changes using a dual-energy CT (DECT) (based on Choi''s criteria) and to compare it to traditional Response Evaluation Criteria in Solid Tumors (RECIST) criteria.

Materials and Methods

Ten NSCLC patients treated with bevacizumab underwent DECT. Tumor responses to anti-angiogenic therapy were assessed and compared with the baseline CT results using both RECIST (size changes only) and Choi''s criteria (reflecting net tumor enhancement). Kappa statistics was used to evaluate agreements between tumor responses assessed by RECIST and Choi''s criteria.

Results

The weighted κ value for the comparison of tumor responses between the RECIST and Choi''s criteria was 0.72. Of 31 target lesions (21 solid nodules, 8 lymph nodes, and two ground-glass opacity nodules [GGNs]), five lesions (16%) showed discordant responses between RECIST and Choi''s criteria. Iodine-enhanced images allowed for a distinction between tumor enhancement and hemorrhagic response (detected in 14% [4 of 29, excluding GGNs] of target lesions on virtual nonenhanced images).

Conclusion

DECT may serve as a useful tool for response evaluation after anti-angiogenic treatment in NSCLC patients by providing information on the net enhancement of target lesions without obtaining non-enhanced images.     

我国新生儿复苏的现状

为指导新生儿复苏,美国心脏病协会和美国儿科协会制订了新生儿复苏指南,并在循证医学研究的基础上每5年修订一次,直到最新的第六版。自上世纪90年代初以来,我国新生儿窒息复苏方案已基本与国际指南接轨,窒息的发生率和死亡率也显著减少,但一些地区依照指南的窒息复苏规范还未落实,存在产儿科制度不全、设备配备不足、“经验性”复苏、培训不能坚持等问题,本文就新版指南主要进展解读与我国目前新生儿复苏现状的差距及改进的可能途径进行探讨。     

A Summary and Critical Assessment of the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults: Filling the Gaps

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines has recently released the new cholesterol treatment guideline. This update was based on a systematic review of the evidence and replaces the previous guidelines from 2002 that were widely accepted and implemented in clinical practice. The new cholesterol treatment guideline emphasizes matching the intensity of statin treatment to the level of atherosclerotic cardiovascular disease (ASCVD) risk and replaces the old paradigm of pursuing low-density lipoprotein cholesterol targets. The new guideline also emphasizes the primacy of the evidence base for statin therapy for ASCVD risk reduction and lists several patient groups that will not benefit from statin treatment despite their high cardiovascular risk, such as those with heart failure (New York Heart Association class II-IV) and patients undergoing hemodialysis. The guideline has been received with mixed reviews and significant controversy. Because of the evidence-based nature of the guideline, there is room for several questions and uncertainties on when and how to use lipid-lowering therapy in clinical practice. The goal of the Mayo Clinic Task Force in the assessment, interpretation, and expansion of the ACC/AHA cholesterol treatment guideline is to address gaps in information and some of the controversial aspects of the newly released cholesterol management guideline using additional sources of evidence and expert opinion as needed to guide clinicians on key aspects of ASCVD risk reduction.     

Interventions to promote oral care regimen adherence in the critical care setting: A systematic review

BackgroundOral care is a fundamental nurse-led intervention in the critical care setting that provides patient comfort and prevents adverse outcomes in critically ill patients. To date, there has been minimal focus on nurse-focused interventions to improve adherence to oral care regimens in the adult intensive care unit setting.ObjectivesThe objectives of this study were to (i) identify types and characteristics of interventions to improve oral care adherence amongst critical care nurses and intervention core components, (ii) evaluate the effectiveness of interventions to improve adherence of oral care regimens, and (iii) identify the types of outcome measures used to assess oral care regimen adherence.DesignThis is a systematic review in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.Data sourcesKey bibliographic databases and platforms, including Scopus, Cochrane, MEDLINE, CINAHL, Embase, PsycINFO, ProQuest, and Web of Science, were searched for studies published before July 2020. The Joanna Briggs Institute's quality appraisal tool was used to assess risk of bias in included studies.Results: A total of 21 original research studies were identified, of which 18 studies used multifaceted interventions. In accordance with the Joanna Briggs Institute's quality appraisal tools, four of the 20 quasi-experimental studies were rated as high quality. The one randomised control trial was of moderate quality. Outcome measures included oral care adherence behaviours, oral care knowledge, self-reported adherence, and documentation. Improved effectiveness in oral care adherence was reported in 20 studies.ConclusionsReview findings confirm interventions to change behaviours improve oral care adherence. The most effective interventional approach could not be determined owing to heterogeneity in intervention design and outcome measures. Oral care in the intensive care unit is a vital, nurse-led activity that reduces the risk of hospital-acquired infection. It is recommended that future research adopt implementation science methods to ensure stakeholder engagement and feasibility.Systematic Review Registration NumberThis review was submitted and subsequently registered on PROSPERO, the International Perspective Register of Systematic Reviews PROSPERO 2019 CRD42019123142.     

Efficacy and validity of guideline-concordant treatment according to the JRS guidelines for the managements of pneumonia in adults updated in 2017 for nursing and healthcare-associated pneumonia. A propensity-matching score analysis

IntroductionPatients with nursing and healthcare-associated pneumonia (NHCAP) commonly receive empiric antibiotic therapy according to the guideline's recommendation corresponding to the patient's deteriorated conditions. However, it is unclear whether guideline-concordant treatment (GCT) could be effective or not.Patients and methodsTo evaluate the efficacy and validity of GCT according to the current guideline for pneumonia, we conducted this retrospective study. NHCAP patients who were admitted to our institute between 2014 and 2017 were enrolled. Based on the initial antibiotic treatment, these patients were divided into two groups, the GCT group (n = 83) and the non-GCT group (n = 146). Propensity score matching (PSM) was used to balance the baseline characteristics and potential confounders between the two groups. After PSM, patients’ characteristics, microbial profiles, and clinical outcomes were evaluated.ResultsBoth groups were well-balanced after PSM, and 78 patients were selected from each group. There were no differences in patients’ characteristics or microbial profiles between the two groups. As for outcomes, there were no differences in 30-day, in-hospital mortality rate, duration of antibiotic treatment, or admission. The severity of pneumonia was more severe in patients with the GCT group than those with the non-GCT group. Anti-pseudomonal agents as initial treatment were more frequently seen in patients with the GCT group than those in the non-GCT group.ConclusionUnlike previous studies, GCT's recommendation for management of pneumonia by the JRS in 2017 would appear to be valid and does not increase the mortality rate.     

肝衰竭诊治指南(2012年版)

肝衰竭是临床常见的严重肝病症候群,病死率极高.多年来,各国学者对肝衰竭的定义、病因、分类、分型、诊断和治疗、预后判断等问题不断进行探索.2005年,美国肝病学会(AASLD)发布了《急性肝衰竭处理》的意见书(position-paper)[1].2006年10月,中华医学会感染病学分会肝衰竭与人工肝学组和中华医学会肝病学分会重型肝病与人工肝学组制订了我国第一部《肝衰竭诊疗指南》[2],从定义、诱因、分类、诊断和治疗等方面对肝衰竭进行了系统而精要的阐述,既与国际接轨,又具中国特色,诊断分型突出了实用性,指导和规范了我国肝衰竭的临床诊疗.2009年,亚太肝脏研究协会(APASL)推出了《慢加急性肝衰竭共识》[3].     

低温核供热堆辐射防护安全准则

作者提出了低温核供热堆辐射防护安全准则的建议，即①要求半径５０ｋｍ范围内加权人口不超过１０６；②禁区半径为２５０ｍ；③限制发展区半径２ｋｍ；④低温核供热堆正常运行期间，由于放射性向环境释放所致公众个人剂量（全身或有效）不应超过０．１ｍＳｖ／ａ，集体剂量不超过１００ｍａｎ·Ｓｖ／ａ；⑤低温核供热堆事故期间，公众个人剂量不超过５ｍＳｖ，集体剂量不超过１０００ｍａｎ·Ｓｖ；⑥低温核供热堆正常运行期间，放射性流出物（气体、液体）的释放量不应超过国标ＧＢ６２４９规定值的２／５；⑦热网水中的放射性活度不应超过０．３７Ｂｑ／Ｌ；⑧建议应急状态分为三级，即应急待命、厂房应急和场区应急。     

循证医学在美国的应用与实践

中国循证医学中心代表团对美国循证医学的现状与发展进行了考察,寻找我国与国际上存在的差距,为进一步促进和规划我国循证医学的发展提供借鉴.