Diagnosis - the limiting focus of taxonomy

Global Mental Health and Nutrition: Moving Toward a Convergent Research Agenda

Both malnutrition and poor mental health are leading sources of global mortality, disease, and disability. The fields of global food security and nutrition (FSN) and mental health have historically been seen as separate fields of research. Each have undergone substantial transformation, especially from clinical, primary care orientations to wider, sociopolitical approaches to achieve Sustainable Development Goals. In recent years, the trajectories of research on mental health and FSN are further evolving into an intersection of evidence. FSN impacts mental health through various pathways such as food insecurity and nutrients important for neurotransmission. Mental health drives FSN outcomes, for example through loss of motivation and caregiving capacities. They are also linked through a complex and interrelated set of determinants. However, the heterogeneity of the evidence base limits inferences about these important dynamics. Furthermore, interdisciplinary projects and programmes are gaining ground in methodology and impact, but further guidance in integration is much needed. An evidence-driven conceptual framework should inform hypothesis testing and programme implementation. The intersection of mental health and FSN can be an opportunity to invest holistically in advancing thinking in both fields.

Stigmatize the use, not the user? Attitudes on opioid use, drug injection, treatment, and overdose prevention in rural communities

Stigma is a known barrier to treating substance use disorders and dramatically diminishes the quality of life of people who use drugs (PWUD) nonmedically. Stigma against PWUD may be especially pronounced in rural areas due to their decreased anonymity and residents' limited access, or resistance, to "neutralizing" information on factors associated with drug use. Stigma often manifests in the attitudes of professionals whom stigmatized individuals regularly interact with and often materially impact. We analyzed interviews conducted between July 2018 and February 2019 with professional stakeholders in rural southern Illinois who interact with PWUD, specifically those who use opioids nonmedically or who inject drugs (n = 30). We further analyzed interview data from a complementary PWUD sample (n = 22). Interviews addressed perspectives around nonmedical drug use and treatment/harm reduction, with analysis centered around the Framework Integrating Normative Influences on Stigma and its focus on micro, meso and macro level stigmatization processes. Stakeholder participants included professionals from local law enforcement, courts, healthcare organizations, emergency management services, and faith-based and social services organizations. Most stakeholders, particularly law enforcement, negatively perceived PWUD and nonmedical drug use in general, questioned the character, agency and extrinsic value of PWUD, and used labels (e.g. "addict," "abuser," etc.) that may be regarded as stigmatizing. Further, most respondents, including PWUD, characterized their communities as largely unaware or dismissive of the bio-medical and sociocultural explanations for opioid use, drug injection and towards harm reduction services (e.g., syringe exchanges) and naloxone, which were frequently framed as undeserved usages of taxpayer funds. In conclusion, rural stigma against PWUD manifested and was framed as a substantial issue, notably activating at micro, meso and macro levels. Stigma prevention efforts in these communities should aim to improve public knowledge on the intricate factors contributing to opioid use and drug injection and harm reduction programming's moral and fiscal value.

Application of Disease Etiology and Natural History to Prevention in Primary Health Care: A Discourse

The principles of etiology and natural history of disease are essential to recognizing opportunities for prevention across the illness spectrum. They have a bearing on how illness is experienced, how differently it can be perceived at the time of first contact with the health system, and how it may appear at later stages. Opportunities for prevention arise at every stage in the process, and three main levels are described: primary, secondary, and tertiary. Prevention strategies include health promotion focused on determinants, clinical prevention to reduce modifiable risk factors, case finding, screening, and addressing functional outcomes relevant to quality of life; the importance of preventing errors is also recognized. The distinction between incidence effects and treatment effects of prevention is explored. This review also examines the differing roles of language in health science and public communication, aspects of disease classification, related issues in patient-centered care, the prevention paradox, and integrated models of disease prevention.

[]"Sacred encounters" in primary care: What do they mean for family physicians?]

OBJECTIVE

To determine the perceptions and attitudes of the general practitioners (GP) towards consultations with great emotional component, initially called "sacred encounters", and to identify areas of improvement.

DESIGN

A qualitative methodology based on a socio-subjective approach and focused on health services research. Descriptive-interpretative study.

LOCATION

Health Centres of Alava and Biscay.

PARTICIPANTS

Selection of 23 GP from 23 urban and rural Health Centres.

METHOD

Intentional sampling aimed at looking for discursive diversity. Data generated in 2016 by means of 3 discussion groups and 3 individual interviews recorded and transcribed after informed consent. Presentation to the ethics committee of the Basque Country. Thematic analysis with the aid of conceptual maps and MaxQDA program. Triangulation of the results between researchers and verification by the participants.

RESULTS AND DISCUSSION

The findings were clustered into overlapping thematic areas related to the meaning of these encounters, attitudes of GP, health context, and patients. The importance of the emotions in primary care encounters and their invisibility is underlined, but the adequacy of the term "sacred" is questioned. This expression is built into the GP-patient relationship, if GP favours it and the patient also allows it, discussing the main circumstances that intervene in an essential dimension of integral care.

CONCLUSIONS

The attention to the emotional dimension in the encounters has deficiencies that need to be corrected. In addition to its recognition and evaluation, it would be necessary to modify the organisational, training and professional factors that determine the involvement of the GPs in their good health care.

Evidence-based medicine-Not a panacea for the problems of a complex adaptive world

The recent sacking of Peter Gøtzsche from the Cochrane Collaboration Board raised strong responses and highlights the neglected issue about priorities-maintaining the reputation of the organization or vigorously debating the merits of scientific approaches to find answers to complex problems? The Cochrane approach hales the randomized trial (RCT) as the gold standard research approach and affirms that meta-analysis provides the ultimate proof (or platinum standard) to settle contentious issues confronting the clinician. However, most published medical research is wrong, and critics coined the acronym GIGO (garbage in, garbage out) as a meme to highlight the risks of blind faith in the hyped-up procedures of the EBM movement. This paper firstly explores the differences between the prevailing scientific method arising from the linear cause-and-effect assumption and the complex adaptive systems science methods arising from observations that most phenomena emerge from nonlinearity in networked systems. Most medical conditions are characterized by necessary features that by themselves are not sufficient to explain their nature and behaviour. Such nonlinear phenomena require modelling approaches rather than linear statistical and/or meta-analysis approaches to be understood. These considerations also highlight that research is largely stuck at the data and information levels of understanding which fails clinicians who depend on knowledge-the synthesis of information-to apply in an adaptive way in the clinical encounter. Clinicians are constantly confronted with the linked challenges of doing things right and doing the right thing for their patients. EBM and Cochrane with their restrictive approaches are the antithesis to a practice of medicine that is responsive to constantly changing patient needs. As such, the EBM/Cochrane crisis opens a window of opportunity to re-examine the nature of health, illness and disease, and the nature of health care and its systems for the benefits of its professionals and their patients. We are at the cusp of a paradigmatic shift towards an understanding a praxis of health care that takes account of its complexities.

Resilience and health (care): A dynamic adaptive perspective

This special forum on resilience explores particular worldviews of resilience-clinical, psychosocial, sociological, complexity science, organizational, and political economy through eight papers. This forum aims to open up the wealth of understandings and implications in health care by taking a transdisciplinary overview.

The key-features approach to assess clinical decisions: validity evidence to date

The key-features (KFs) approach to assessment was initially proposed during the First Cambridge Conference on Medical Education in 1984 as a more efficient and effective means of assessing clinical decision-making skills. Over three decades later, we conducted a comprehensive, systematic review of the validity evidence gathered since then. The evidence was compiled according to the Standards for Educational and Psychological Testing's five sources of validity evidence, namely, Content, Response process, Internal structure, Relations to other variables, and Consequences, to which we added two other types related to Cost-feasibility and Acceptability. Of the 457 publications that referred to the KFs approach between 1984 and October 2017, 164 are cited here; the remaining 293 were either redundant or the authors simply mentioned the KFs concept in relation to their work. While one set of articles reported meeting the validity standards, another set examined KFs test development choices and score interpretation. The accumulated validity evidence for the KFs approach since its inception supports the decision-making construct measured and its use to assess clinical decision-making skills at all levels of training and practice and with various types of exam formats. Recognizing that gathering validity evidence is an ongoing process, areas with limited evidence, such as item factor analyses or consequences of testing, are identified as well as new topics needing further clarification, such as the use of the KFs approach for formative assessment and its place within a program of assessment.

Inflammation-Nature's Way to Efficiently Respond to All Types of Challenges: Implications for Understanding and Managing "the Epidemic" of Chronic Diseases

Siloed or singular system approach to disease management is common practice, developing out of traditional medical school education. Textbooks of medicine describe a huge number of discrete diseases, usually in a systematic fashion following headings like etiology, pathology, investigations, differential diagnoses, and management. This approach suggests that the body has a multitude of ways to respond to harmful incidences. However, physiology and systems biology provide evidence that there is a simple mechanism behind this phenotypical variability. Regardless if an injury or change was caused by trauma, infection, non-communicable disease, autoimmune disorders, or stress, the typical physiological response is: an increase in blood supply to the area, an increase in white cells into the affected tissue, an increase in phagocytic activity to remove the offending agent, followed by a down-regulation of these mechanisms resulting in healing. The cascade of inflammation is the body's unique mechanism to maintain its integrity in response to macroscopic as well as microscopic injuries. We hypothesize that chronic disease development and progression are linked to uncontrolled or dysfunctional inflammation to injuries regardless of their nature, physical, environmental, or psychological. Thus, we aim to reframe the prevailing approach of management of individual diseases into a more integrated systemic approach of treating the "person as a whole," enhancing the patient experience, ability to a make necessary changes, and maximize overall health and well-being. The first part of the paper reviews the local immune cascades of pro- and anti-inflammatory regulation and the interconnected feedback loops with neural and psychological pathways. The second part emphasizes one of nature's principles at work-system design and efficiency. Continually overwhelming this finely tuned system will result in systemic inflammation allowing chronic diseases to emerge; the pathways of several common conditions are described in detail. The final part of the paper considers the implications of these understandings for clinical care and explore how this lens could shape the physician-patient encounter and health system redesign. We conclude that healthcare professionals must advocate for an anti-inflammatory lifestyle at the patient level as well as at the local and national levels to enhance population health and well-being.

General Practitioners Records Are Epidemiological Predictors of Comorbidities: An Analytical Cross-Sectional 10-Year Retrospective Study

Background. Comorbidity represents the co-occurrence of pathological conditions in the same individual, and presents with very complex patterns. In most cases, reference data for the study of various types of comorbidities linked to complex diseases are those of hospitalized patients. Such patients may likely require cure due to acute conditions. We consider the emerging role of EHR (Electronic Healthcare Records), and study comorbidity patterns in a general population, focusing on diabetic and non-diabetic patients. Methods. We propose a cross-sectional 10-year retrospective study of 14,958 patients and 1,728,736 prescriptions obtained from family doctors, and thus refer to these data as General Practitioner Records (GPR). We then choose networks as the tools to analyze the diabetes comorbidity patterns, distinguished by both prescription type and main patient characteristics (age, gender). Results. As expected, comorbidity increases with patients’ age, and the network representations allow the assessment of associations between morbidity groups. The specific morbidities present in the diabetic population justify the higher comorbidity patterns observed in the target group compared to the non-diabetic population. Conclusions. GPR are usually combined with other data types in EHR studies, but we have shown that prescription data have value as standalone predictive tools, useful to anticipate trends observed at epidemiological level on large populations. This study is thus relevant to policy makers seeking inference tools for an efficient use of massive administrative database resources, and suggests a strategy for detecting comorbidities and investigating their evolution.

Diagnostic protocols-A consultation tool still to be discovered

RATIONALE

Experienced primary care physicians handle most illnesses to everyone's satisfaction despite limited resources of time and means. However, cases can be multifaceted in that harmless-presenting symptoms may also be warning signals or an indicator of a health disorder that too infrequently presents in family practice to be diagnosed correctly. On the basis of these observations, RN Braun developed 82 diagnostic protocols for a structured recording of various complaints.

METHOD

All consultations during the years 2001 to 2014, in which 1 author (WF) had used diagnostic protocols in her single-handed practice, were analyzed retrospectively regarding reasons for encounter, diagnostic classification, and long-term outcome.

RESULTS

During the period, a diagnostic protocol was used 1686 times. It was applied at a rate of approximately 5% of 2500 new complaints annually, most often (1366 times) for febrile conditions. In 320 consultations for other complaints, 43 different diagnostic protocols were applied. Among them, the "tabula diagnostica" for various undifferentiated symptoms was used most frequently (n = 54), followed by diagnostic protocols for headache (n = 45), dizziness (n = 36), precordial pain (n = 20), nonspecific abdominal pain (n = 15), low back pain (n = 14), hypertension (n = 12), diarrhea > 1 week (n = 12), epigastralgia (n = 11), depression (n = 10), polyarthralgia (n = 8), cough, and lower abdominal pain (each n = 7). A final diagnosis was established in less than 20% of cases.

CONCLUSIONS

This observational study from routine practice gives an insight how diagnostic protocols helped to manage complex patient presentations. A broader use of diagnostic protocols could investigate the potential of this consultation tool to handle the complexity of primary health care. The use of a standardized diagnostic approach could stimulate research, in particular on managing common complaints/undifferentiated illness and their inherent diagnostic uncertainty.

'Multimorbidity' as the manifestation of network disturbances

We argue that 'multimorbidity' is the manifestation of interconnected physiological network processes within an individual in his or her socio-cultural environment. Networks include genomic, metabolomic, proteomic, neuroendocrine, immune and mitochondrial bioenergetic elements, as well as social, environmental and health care networks. Stress systems and other physiological mechanisms create feedback loops that integrate and regulate internal networks within the individual. Minor (e.g. daily hassles) and major (e.g. trauma) stressful life experiences perturb internal and social networks resulting in physiological instability with changes ranging from improved resilience to unhealthy adaptation and 'clinical disease'. Understanding 'multimorbidity' as a complex adaptive systems response to biobehavioural and socio-environmental networks is essential. Thus, designing integrative care delivery approaches that more adequately address the underlying disease processes as the manifestation of a state of physiological dysregulation is essential. This framework can shape care delivery approaches to meet the individual's care needs in the context of his or her underlying illness experience. It recognizes 'multimorbidity' and its symptoms as the end product of complex physiological processes, namely, stress activation and mitochondrial energetics, and suggests new opportunities for treatment and prevention. The future of 'multimorbidity' management might become much more discerning by combining the balancing of physiological dysregulation with targeted personalized biotechnology interventions such as small molecule therapeutics targeting specific cellular components of the stress response, with community-embedded interventions that involve addressing psycho-socio-cultural impediments that would aim to strengthen personal/social resilience and enhance social capital.

Assessment and Classification of Tongue-Tie

Tongue-tie can cause many serious breastfeeding problems and even lead to breastfeeding cessation. As the mothers’ stories listed in “When Tongue-Ties Were Missed: Mothers’ Stories” attest, healthcare providers often do not correctly identify when a baby has a tongue-tie. Assessing tongue-tie is essential. What should clinicians look for? Which professionals should be the ones identifying and identifying tongue-tie? Assessing tongue-tie is the focus of this article.

Applying a complex adaptive system's understanding of health to primary care

This paper explores the diagnostic and therapeutic potential of a new concept of health. Investigations into the nature of health have led to a new definition that explains health as a complex adaptive system (CAS) and is based on five components (a-e). Humans like all biological creatures must satisfactorily respond to (a) the demands of life. For this purpose they need (b) a biologically given potential (BGP) and (c) a personally acquired potential (PAP). These properties of individuals are embedded within (d) social and (e) environmental determinants of health. Between these five components of health there are 10 complex interactions that justify viewing health as a CAS. In each patient, the current state of health as a CAS evolved from the past, will move forward to a new future, and has to be analyzed and treated as an autonomous whole. A diagnostic procedure is suggested as follows: together with the patient, the five components and 10 complex interactions are assessed. This may help patients to better understand their situations and to recognize possible next steps that may be useful in order to evolve toward better health by themselves. In this process mutual trust in the patient-physician interaction is critical. The described approach offers new possibilities for helping patients improve their health prospects.

Intimate Partner Violence and Its Resolution Among African American Women

Intimate partner violence (IPV) is a significant problem that is difficult to overcome within African American communities. Thus, the purpose of this qualitative systematic review was to synthesize isolated qualitative findings relating to IPV among African American women to make them more meaningful and generalizable. A framework of IPV among African American women resulted from this work, and key elements include the following: ubiquitous and perpetual oppression and abuse contribute to the emergence of IPV, and personal and interpersonal forms of inspiration and support are generally inadequate to prevent or resolve it. Moreover, ambivalence of others, fear, mental health problems, and negative perceptions of helping services are barriers to change. Resolution of IPV is an emergent process that is enhanced by holistic Afrocentric services. Outcomes are safety with strings attached and personal growth for mothers and children. Research hypotheses are inferred from this framework along with implications for clinical practice.