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"Vincent, Andrew"
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Building an implementation framework for directly observed feedback by attending physicians
Effective formative feedback from attending physicians to residents is critical for competency-based medical education. Feedback curricula commonly focus on simulated feedback delivery while actual verbal feedback delivery is unobserved by anyone other than the individuals involved. External observation of feedback has received limited attention as a novel method of improving feedback quality. Despite this, there is no research describing attitudes towards directly observed feedback.
We developed two surveys, one for Internal Medicine residents (IMRs) and one for hospitalists, who specialize in comprehensive care of hospitalized patients, at the University of Washington in Seattle, Washington in 2023. Survey validity evidence was gathered prior to disseminating surveys via a census sampling approach by group email listservs. Quantitative questions were analyzed by dichotomizing Likert responses as neutral/disagree vs. agree. Free text comments were qualitatively analyzed via a general inductive approach until theme sufficiency was reached. Survey development and analysis was conducted using a lens of social cognitive theory.
The response rate was 71% (130/184) and 57% (74/129) for IMRs and hospitalists respectively. Most residents and hospitalists reported feeling comfortable with having a feedback exchange observed (105/129, 81%; 46/72, 64% respectively). Hospitalist and IMR concerns about the implementation of directly observed feedback were categorized into three themes: concerns about the relationship with the faculty observer, negative impact on learning environment, and altered feedback quality. Hospitalist and IMR suggestions for parameters to mitigate the challenges of observed feedback were categorized into three themes: the feedback observer's relational boundaries, empower participant agency, and preserve feedback integrity.
The thematic concerns expressed by both cohorts relate to social monitoring, either of a projected self-image or to the educational safety of a learner. These themes highlight the fundamental importance of psychological safety in developing a program of directly observed feedback for attending physicians and residents.
Journal Article
نظريات الدولة
هذا الكتاب \"نظريات الدولة\" به يحاول أندرو فنسنت أن يحدد مفهوم الدولة وطبيعتها واضعا الفواصل والحدود بين المفاهيم التي تتشابك مع الدولة مثل المجتمع والجماعة والأمة ويرى أن الدولة لايمكن رؤيتها وإنما فقط يمكن تصور مضمونها وطبيعتها ولهذا السبب تعددت مفاهيم عامة ومجردة بعد عرضه للموضوعات التي تساعد على فهم طبيعة الدولة مثل السلطة والالتزام والشرعية وخاصية التنازع الجوهري ونظريات الطبيعة البشرية.
Book
Intermittent fasting plus early time-restricted eating versus calorie restriction and standard care in adults at risk of type 2 diabetes: a randomized controlled trial
Intermittent fasting appears an equivalent alternative to calorie restriction (CR) to improve health in humans. However, few trials have considered applying meal timing during the ‘fasting’ day, which may be a limitation. We developed a novel intermittent fasting plus early time-restricted eating (iTRE) approach. Adults (
N
= 209, 58 ± 10 years, 34.8 ± 4.7 kg m
−
2
) at increased risk of developing type 2 diabetes were randomized to one of three groups (2:2:1): iTRE (30% energy requirements between 0800 and 1200 hours and followed by a 20-h fasting period on three nonconsecutive days per week, and ad libitum eating on other days); CR (70% of energy requirements daily, without time prescription); or standard care (weight loss booklet). This open-label, parallel group, three-arm randomized controlled trial provided nutritional support to participants in the iTRE and CR arms for 6 months, with an additional 12-month follow-up. The primary outcome was change in glucose area under the curve in response to a mixed-meal tolerance test at month 6 in iTRE versus CR. Glucose tolerance was improved to a greater extent in iTRE compared with CR (−10.10 (95% confidence interval −14.08, −6.11) versus −3.57 (95% confidence interval −7.72, 0.57) mg dl
−1
min
−1
;
P
= 0.03) at month 6, but these differences were lost at month 18. Adverse events were transient and generally mild. Reports of fatigue were higher in iTRE versus CR and standard care, whereas reports of constipation and headache were higher in iTRE and CR versus standard care. In conclusion, incorporating advice for meal timing with prolonged fasting led to greater improvements in postprandial glucose metabolism in adults at increased risk of developing type 2 diabetes. ClinicalTrials.gov identifier
NCT03689608
.
Comparison of intermittent fasting plus early time-restricted eating (iTRE) to calorie restriction, as well as standard care, in adults at risk of type 2 diabetes in a three-arm randomized controlled study demonstrated that iTRE was associated with greater improvements in postprandial glucose metabolism at 6 months.
Journal Article
Combined advanced parental age has an additive negative effect on live birth rates—data from 4057 first IVF/ICSI cycles
PurposeThe purpose of this study is to determine if there is an additive effect of combined advanced maternal and paternal age on pregnancy and live birth rates.MethodsRetrospective data analysis of 4057 first cycles at a fertility centre between 2009 and 2013 was compiled. Donor, preimplantation genetic screening and double embryo transfer cycles were excluded. Main outcomes measured were clinical pregnancy, viable pregnancy, live birth and term birth.ResultsLogistic regression indicated strong negative associations for maternal ages exceeding 27 years with clinical pregnancies (p < 0.001), viable pregnancies (p < 0.001), live births (p < 0.001) and term births (p < 0.001). There was evidence of negative associations between paternal age and both viable pregnancies (p = 0.06) and live births (p = 0.04), such that the probability of pregnancy was 10% further reduced for women who were 35 years with a partner over 40 years vs. women aged 35 years with a partner under 30 years. There was evidence of an interaction between maternal age and the paternal age on term births (p = 0.02) such that advanced paternal age’s effect on the probability of a term birth was only evident in couples where the maternal age ranged between ~27 and 35 years.ConclusionsThere is an additive effect to pregnancy and live birth rates when both partners are of an advanced age, thus highlighting the need for pre-conception public health messaging and a combined approach to ART counselling assessing both parental ages in combination.
Journal Article
Cross-sectional and longitudinal determinants of serum sex hormone binding globulin (SHBG) in a cohort of community-dwelling men
Despite its widespread clinical use, there is little data available from population-based studies on the determinants of serum sex hormone binding globulin (SHBG). We aimed to examine multifactorial determinants of circulating SHBG levels in community-dwelling men. Study participants comprised randomly selected 35-80 y.o. men (n = 2563) prospectively-followed for 5 years (n = 2038) in the Men Androgen Inflammation Lifestyle Environment and Stress (MAILES) study. After excluding men with illness or medications known to affect SHBG (n = 172), data from 1786 men were available at baseline, and 1476 at follow-up. The relationship between baseline body composition (DXA), serum glucose, insulin, triglycerides, thyroxine (fT4), sex steroids (total testosterone (TT), oestradiol (E2)), and pro-inflammatory cytokines and serum SHBG level at both baseline & follow-up was determined by linear and penalized logistic regression models adjusting for age, lifestyle & demographic, body composition, metabolic, and hormonal factors. Restricted cubic spline analyses was also conducted to capture possible non-linear relationships. At baseline there were positive cross-sectional associations between age (β = 0.409, p<0.001), TT (β = 0.560, p<0.001), fT4 (β = 0.067, p = 0.019) and SHBG, and negative associations between triglycerides (β = -0.112, p<0.001), abdominal fat mass (β = -0.068, p = 0.032) and E2 (β = -0.058, p = 0.050) and SHBG. In longitudinal analysis the positive determinants of SHBG at 4.9 years were age (β = 0.406, p = <0.001), TT (β = 0.461, p = <0.001), and fT4 (β = 0.040, p = 0.034) and negative determinants were triglycerides (β = -0.065, p = 0.027) and abdominal fat mass (β = -0.078, p = 0.032). Taken together these data suggest low SHBG is a marker of abdominal obesity and increased serum triglycerides, conditions which are known to have been associated with low testosterone and low T4.
Journal Article
The Effects of Using Psychotherapeutic e-Mental Health Interventions on Men’s Depression and Anxiety: Systematic Review and Meta-Analysis
While psychotherapeutic e-mental health interventions may circumvent barriers that many men face in accessing mental health care, the effects of men using these interventions have not been evaluated. We aimed to synthesise the characteristics of psychotherapeutic e-mental health interventions for depression or anxiety that have been trialled and evaluated in men, and synthesise and meta-analyse the effects of these interventions on men’s depression and anxiety, including examining influences of participant, intervention, and study characteristics on outcomes. Seven papers (
N
= 552 participant men) identified from systematic literature searches met inclusion criteria. A total 177 studies were excluded because although they met all other inclusion criteria, they did not present analysable data on participant men. The seven included interventions varied in content, length, and format; only one intervention was gender sensitive, having been designed specifically for men. All three randomised controlled trials detected no post-trial difference in men’s depression symptoms between intervention and control participants. All four treatment studies presenting pre-post data reported post-intervention improvements in depression or social anxiety symptoms; this was supported by our meta-analysis of two studies, which found a medium-sized, positive effect of depression treatment interventions on depression symptoms in pre-post data (
g
= 0.64,
p
< 0.005). Further meta-analyses could not be conducted due to data limitations. Psychotherapeutic e-mental health treatment interventions result in pre- to post-intervention improvements in men’s depression symptoms. There is urgent need for consideration of gender and sex in the development, evaluation, and dissemination of e-mental health interventions for men, and for further information on their effects.
Journal Article
Age-related changes in estradiol and longitudinal associations with fat mass in men
In men, circulating 17β-estradiol originates primarily from peripheral aromatization of testosterone particularly in adipose tissue. The effect of ageing and obesity on circulating estradiol remains unclear.
Determine five-year changes in serum estradiol and the association with testosterone and fat mass in Australian men.
Longitudinal cohort study. At baseline and five-year follow-up, socio-demographic and health-related data including behaviors, chronic conditions, and medication use were collected by questionnaire. Estradiol and testosterone were assayed by liquid chromatography-tandem mass spectrometry and sex hormone-binding globulin by immunochemiluminescent assay. Fat mass was assessed by dual-energy X-ray absorptiometry.
Community-dwelling men aged 35 years and older at enrollment, resident in the northern and western suburbs of Adelaide without established disease of, or medications affecting, the hypothalamus-pituitary-gonadal axis (n = 725).
The dependence of change in serum estradiol over five years on age, testosterone and fat mass after adjustment for multiple confounders.
At baseline, mean age was 53.0 ± 10.8 years. Mean serum estradiol levels at baseline and five-year follow-up were 94.9 ± 34.8 and 89.4 ± 30.4 pmol/L respectively (-1.1 pmol/L/year). On multivariable analyses, estradiol change was associated with changes in testosterone (B-estimate = 2.719, standard error = 0.369, p˂0.001), but not age or total fat mass. Change in testosterone/estradiol ratio was inversely associated with change in fat mass (B = -1.450, SE = 0.575, p = 0.012), and this was consistent across quartiles of fat mass change.
In healthy men, circulating estradiol is primarily dependent on testosterone. With increasing fat mass, estradiol decreases less than testosterone. From a clinical standpoint these data indicate that obesity is associated with a change in the testosterone to estradiol ratio, but a change in estradiol does not occur unless some other pathology is present.
Journal Article
Visceral Adipose Tissue Is Associated With Stricturing Crohn’s Disease Behavior, Fecal Calprotectin, and Quality of Life
Abstract
Background
Visceral adipose tissue (VAT) has been proposed to play a pathogenic role in Crohn’s disease (CD); however, prospective clinical data are lacking. The aim was to evaluate whether VAT, beyond body mass index (BMI), is associated with CD behavior, disease activity, quality of life (QoL), or outcomes.
Methods
Body composition data and clinical, anthropometric, disease activity (fecal calprotectin [FC]), and QoL scores were gathered prospectively on adults with CD at 0, 12, and 24 months. BMI and, VAT metrics (visceral adipose tissue volume [cm3]/height [m2] index and VAT:subcutaneous adipose tissue [SAT] ratio) were calculated. Inflammatory bowel disease–related surgery and hospitalization were recorded over extended follow-up (median, 51 months). Multivariable linear mixed effects and logistic regression analyses were performed.
Results
Ninety-seven participants were assessed at baseline (55% male; median age, 31 years), 84 at 12 months, and 72 at 24 months. VAT:SAT was positively associated with stricturing disease behavior (log odds ratio [OR], 1.7; 95% confidence interval [CI], 0.32 to 3; P = 0.01) and elevated FC in patients with ileocolonic disease (β, 1.3; 95% CI, 0.32 to 2.3; P = 0.01). VAT:SAT was associated with lower QoL, particularly in those with ileal disease (β, –12; 95% CI, –19 to –4.5; P = 0.05). However, no prospective associations were observed between serial VAT measurements and time to surgery or hospitalization. No correlations were found between BMI and disease behavior, activity, or QoL.
Conclusions
VAT:SAT, rather than BMI, is associated with stricturing CD behavior, elevated FC, and reduced QoL in a disease distribution–dependent manner. Further studies are required to substantiate the role of VAT as a useful biomarker in CD.
Journal Article