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Preexisting diabetes (PDM) increases the risk of maternal and perinatal mortality and morbidity. Reduction of maternal hyperglycemia prior to and during pregnancy can reduce these risks. Despite compelling evidence that preconception care (PCC), which includes achieving strict glycemic goals, reduces the risk of congenital malformations and other adverse pregnancy outcomes, only a minority of individuals receive PCC. Suboptimal pregnancy outcomes demonstrated in real-world data highlight the need to further optimize prenatal glycemia. New evolving technology shows promise in helping to achieve that goal. Dysglycemia is not the only driver of poor pregnancy outcomes in PDM. The increasing impact of obesity on pregnancy outcomes underscores the importance of optimal nutrition and management of insulin sensitizing medications during prenatal care for PDM. To provide recommendations for the care of individuals with PDM that lead to a reduction in maternal and neonatal adverse outcomes. The Guideline Development Panel (GDP) composed of a multidisciplinary panel of clinical experts, along with experts in guideline methodology and systematic literature review, identified and prioritized 10 clinically relevant questions related to the care of individuals with diabetes before, during and after pregnancy. The GDP prioritized randomized controlled trials (RCTs) evaluating the effects of different interventions (eg, PCC, nutrition, treatment options, delivery) during the reproductive life cycle of individuals with diabetes, including type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). Systematic reviews queried electronic databases for publications related to these 10 clinical questions. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology was used to assess the certainty of evidence and develop recommendations. The approach incorporated perspectives from 2 patient representatives and considered patient values, costs and resources required, acceptability and feasibility, and impact on health equity of the proposed recommendations. In individuals with diabetes mellitus who have the possibility of becoming pregnant, we suggest asking a screening question about pregnancy intention at every reproductive, diabetes, and primary care visit. Screening for pregnancy intent is also suggested at urgent care/emergency room visits when clinically appropriate (2 | ⊕OOO). This was suggested based on indirect evidence demonstrating a strong association between PCC and both reduced glycated hemoglobin (HbA1c) at the first prenatal visit and congenital malformations.In individuals with diabetes mellitus who have the possibility of becoming pregnant, we suggest use of contraception when pregnancy is not desired (2 | ⊕⊕OO). This was suggested based on indirect evidence in women with diabetes, where PCC-including contraception as a key component-showed a clinically significant association with improvements in first-trimester HbA1c and the rate of congenital malformations, together with indirect evidence from the general population regarding the reduction of unplanned pregnancies and pregnancy terminations with the use of contraception.In individuals with T2DM, we suggest discontinuation of glucagon-like peptide-1 receptor agonist (GLP-1RA) before conception rather than discontinuation between the start of pregnancy and the end of the first trimester (2 | ⊕OOO). This was suggested based on limited data on risk of exposure to GLP-1RA receptor agonists during pregnancy.In pregnant individuals with T2DM already on insulin, we suggest against routine addition of metformin (2 | ⊕OOO). This was suggested based on the GDP judgment that the benefit of adding metformin to insulin to achieve decrease in rates of large for gestational age infants did not outweigh the potential harm of increasing the risk of small for gestational age infants or adverse childhood outcomes related to changes in body composition.In individuals with PDM, we suggest either a carbohydrate-restricted diet (<175 g/day) or usual diet (>175 g/day) during pregnancy (2 | ⊕OOO). This was suggested based on the GDP judgment that the available evidence was limited and very indirect, resulting in significant uncertainty about the net benefits or harms. As such, the evidence was insufficient to support a recommendation either for or against a carbohydrate intake cutoff of 175 g/day.In pregnant individuals with T2DM, we suggest either the use of a continuous glucose monitor (CGM) or self-monitoring of blood glucose (SMBG) (2 | ⊕OOO). There is lack of direct evidence supporting superiority of CGM use over SMBG for T2DM during pregnancy. There is indirect evidence supporting improved glucometrics with the use of CGM for individuals with T2DM outside of pregnancy, substantial improvements in neonatal outcomes for individuals with T1DM using CGM during pregnancy and the potential for decreasing adverse pregnancy outcomes with improved glucometrics in individuals with T2DM.In individuals with PDM using a CGM, we suggest against the use of a single 24-hour CGM target <140 mg/dL (7.8 mmol/L) in place of standard-of-care pregnancy glucose targets of fasting <95 mg/dL (5.3 mmol/L), 1-hour postprandial <140 mg/dL (7.8 mmol/L), and 2-hour postprandial < 120 mg/dL (6.7 mmol/L) (2 | ⊕OOO). This was suggested based on indirect evidence that associated adverse pregnancy outcomes with a fasting glucose > 126 mg/dL (7 mmol/L).In individuals with T1DM who are pregnant, we suggest the use of a hybrid closed-loop pump (pump adjusting automatically based on CGM) rather than an insulin pump with CGM (without an algorithm) or multiple daily insulin injections with CGM (2 | ⊕OOO). This was suggested based on a meta-analysis of RCTs which demonstrated improvement in glucometrics with increased time in range (MD +3.81%; CI -4.24 to 11.86) and reduced time below range (MD -0.85%; CI -1.98 to 0.28) with the use of hybrid closed-loop pump technology.In individuals with PDM, we suggest early delivery based on risk assessment rather than expectant management (2 | ⊕OOO). This was suggested based on indirect evidence that risks may outweigh benefits of expectant management beyond 38 weeks gestation and that risk assessment criteria may be useful to inform ideal delivery timing.In individuals with PDM (including those with pregnancy loss or termination), we suggest postpartum endocrine care (diabetes management), in addition to usual obstetric care (2 | ⊕OOO). As the postpartum period frequently overlaps with preconception, this was suggested based on indirect evidence demonstrating a strong association between PCC and both reduced HbA1c at the first prenatal visit and congenital malformations. The data supporting these recommendations were of very low to low certainty, highlighting the urgent need for research designed to provide high certainty evidence to support the care of individuals with diabetes before, during, and after pregnancy. Investment in implementation science for PCC is crucial to prevent significant mortality and morbidity for individuals with PDM and their children. RCTs to further define glycemic targets in pregnancy and refinement of emerging technology to achieve those targets can lead to significant reduction of harm and in the burden of diabetes care. Data on optimal nutrition and obesity management in pregnancy are lacking. More research on timing of delivery in women with PDM is also needed.
The figure of the "medical clown" is a theologically and anthropologically charged vocation necessary for moral critique and healing in contemporary medicine. Drawing on the Oglala Sioux Heyoka and the circus clown, or holy fool, the authors distinguish between external critics-philosophers and theologians who unmask medicine's principalities through folly-and internal actors-clinicians who subvert dehumanizing logics from within. Against corporate, efficiency-driven models that deform the healing vocation, both roles embody prophetic reversal, exposing absurdities and reorienting practice toward possibilities of redemption that could not otherwise be seen from within the logic of medicine's current priorities and principalities. The holy fool destabilizes the status quo through provocative critique; the Heyoka, grounded in communal trust, rouses through loving contrariness. Together, they witness to medicine's eschatological promises: healing as relational and resistant to commodification. By reclaiming the sacred work of "walking backwards," these clowns and fools invite a re-formation of medical imagination, challenging and shaping practitioners who dwell with suffering to resist the seductions of a system that is forgetting its calling.
This article examines the lived reality of schizophrenia and its treatment as portrayed in Clem and Olivier (Liv) Martini's Bitter Medicine: A Graphic Memoir of Mental Illness (2010), with a focus on how graphic medicine can represent the complexities of subjective experience in the psychiatric health-care system. Drawing on Foucault's critique of disciplinary power in psychiatric institutions, the article explores how the memoir reveals tensions between therapeutic care and systemic control, even after deinstitutionalization. Through El Refaie's idea of visual metaphor and embodiment in comics, Liv's illustrations about his psychiatric suffering are read as more than expressive art that challenges dominant clinical narratives. The article investigates the shift in psychiatric health care in Canada from institutional care to community-based care and the impact of psychopharmaceutical drugs, highlighting the embodied cost of psychiatric treatment. By revealing the social exclusion and economic vulnerability produced by gaps in the implementation of health-care policies, Bitter Medicine critiques the promises of deinstitutionalization. The article illustrates how visual narrative forms can foreground subjective experiences of schizophrenia, while interrogating broader systemic failures in mental health care.
In the 21st century, cancer remains shrouded in complex ways, imbued with sociocultural meanings that extend far beyond its clinical and biological aspects. The fear and anxiety surrounding cancer often prompt family and friends to respond with either excessive protection or emotional detachment, leaving patients feeling isolated and unsupported. This article challenges entrenched stereotypes, particularly cultural tendencies in India to conceal cancer diagnoses, associate the disease with karmic retribution, and view it through fatalistic and death-centered perspectives. Drawing on theories of pathography and restitution narratives, it offers an alternative perspective to the bleak and fatalistic portrayals of cancer commonly found in Indian cinema and popular culture. The article primarily focuses on Neelam Kumar's graphic memoir, To Cancer, with Love: A Graphic Novel (2017), while also engaging with its prose counterpart, To Cancer, with Love: My Journey of Joy (2015). The article investigates Kumar's subversion of conventional narratives of illness and powerful counter-narrative to the dominant discourse on cancer in India. As one of the pioneering graphic pathographies from India, Kumar's memoir presents a transformative and empowering perspective on the experience of cancer, challenging the societal norms that often stigmatize the disease.
Washington state's plans for a public health response to a pandemic or natural disaster were largely untested prior to the COVID-19 pandemic. Individual institutions were unprepared for a crisis of the scale and severity of the pandemic, and they faced a myriad of ethical questions that required expertise and experience. The pandemic also revealed the fundamental need for local, state, and regional collaboration during times of resource scarcity. As individual institutions scrambled to organize and implement strategies for dealing with scarcity in a way that was both effective and fair, the lack of a regional or national system to organize those efforts impaired a timely response and resulted in duplicated efforts and differing approaches. This article describes the authors' pediatric institutional response to the pandemic within the context of a broader cooperative statewide approach. The authors explain the rationale for starting with a utilitarian framework and the ways in which its shortcomings were addressed. The structures and approaches described continue to be utilized and modified for other situations that lead to resource scarcity of all kinds. Although changes at the national level to create a national response would be ideal, collaboration and investment at the state and regional level is both critical and pragmatic in ensuring that all patients can access the health care they need.
This article examines the lived experiences of ADHDers with respect to time perception, through the lens of a neuroqueer temporality framework and its representation in graphic medicine. By close-reading autobiographical comics digitally posted by Pina Varnel (ADHD Alien), Dani Donovan, Heidi Burton, and Cecil, the article studies key elements of ADHD time perception, including time blindness, the now/not now dichotomy, the waiting mode, and the state of hyperfocus. ADHDers' perception of time is nonlinear and present-oriented, diverging from neuronormative temporal expectations. In visualizing the nuanced differences in temporal perception and their impact on ADHD self, the article contributes to the discussion of diverse ways of perceiving and interacting with the world. By recognizing these differences, the article aligns with the neurodiversity paradigm and calls for understanding ADHD as a way of being, breaking the vicious cycle of moral judgments and assumptions of intentionality on the basis of invisible but legitimate differences in temporal perception.
This essay examines the rural mental health crisis through the stories of the author's father, an Iraqi immigrant and sole private psychiatric provider in a rural Michigan town. Moving his clinic in 2023 revealed the strain of practicing where demand far exceeds supply and capacity: long days split between a small hospital and an understaffed clinic, chronic underpayment from Medicaid, and a constant backlog of care. These lived experiences are contextualized through the historic failure of US mental health reform after the 1963 Community Mental Health Act, which has left Community Mental Health Centers (CMHCs) under-resourced and, in many rural counties, the only option. Demographic data on psychiatrist shortages, high suicide and illness burdens, and reimbursement disparities are paired with a patient vignette to illustrate how poverty and insurance work together to hinder treatment and precipitate recurrent crises. The essay argues that incremental workforce expansion alone cannot close rural gaps without such structural fixes as raising Medicaid reimbursement, stabilizing and expanding CMHC financing, aligning residency expansion with rural service incentives, and investing in rural infrastructure that addresses social determinants.
Jeremy Howick's The Power of Placebos (2023) invites readers to reconsider what counts as "real" effects in clinical medicine. The book resists the temptation to delve into the causal interpretation problem and instead asks an interesting question: how should clinicians act, given what's known about mind-body connections and increasing evidence of the importance of patients' beliefs and expectations? Howick argues that rituals, empathy, and meaning can exert biological force and therefore deserve to be studied, taught, and practiced with the same seriousness as drugs and devices. The pragmatic challenge is to design and test multicomponent interventions that harness placebo benefits while minimizing nocebo harm. If realized, the task for modern medicine would be to find new ways of ethically and transparently integrating effective care packages into practice. Doing so could not only help restore trust in medicine but also reclaim space that is too often ceded to unregulated actors and online influencers. While paradoxes and ethical quandaries remain, Howick's proposal merits serious consideration. It may help clinicians fulfill a deeper role in society as empathetic guides who foster healing by helping patients make meaning amid existential uncertainty.
Death certificates act as verified records concluding the administrative aspects of a person's life. In the US, the death certificate includes essential biographical information about the decedent, including the manner and cause of death. To some, the cause of death may be a procedural step necessary to obtain a death certificate, and where there is not an ensuing forensic investigation, the cause of death may even seem immaterial. But specificity in determining the cause of death is crucial to epidemiological and public health initiatives and for the maintenance of accurate mortality records. This article argues that inaccuracies in cause of death determinations are harmful: they are detrimental to the professional commitments physicians owe their patients and distort the lived experiences of the deceased. Inaccuracy in vital statistics affects individuals and families by misrepresenting the physiological and biological processes leading to death and potentially altering the deceased person's life story. While there is extensive literature exploring the challenges faced by clinicians in determining the cause of death, this article focuses on modifications made to the cause of death-whether consciously through deliberate intent to conceal, or unconsciously through error or omission-where the death may be socially stigmatizing.
Parkinson's disease (PD) is the fastest-growing neurodegenerative disease in the world and appears to be an emerging epidemic in Africa, where counteractive measures have become necessary. Previous reports have highlighted the limited epidemiological and clinical PD research in Africa but overlooked the poor preclinical PD research output of the continent. Because preclinical research is a bedrock for translating basic scientific research into clinical practice, a weak preclinical research foundation can hamper advancement in epidemiological and clinical investigations. The sparsity and low impact of preclinical PD research output in African countries compared to high-resource countries underscores the need for pragmatic measures to close the research gap. An improved funding of brain research in African institutions-ensuring provision of facilities and infrastructure for cutting-edge research, adequate remuneration for researchers, and policies to curtail brain drain-will stimulate preclinical PD research in Africa and contribute to stemming the spiraling global PD incidence.
Precision medicine functions by grouping patients along genetic, molecular, and related "-omics" factors. This stratification relies on large, growing databases of patient-volunteered information. Both private companies and government bodies incentivize patients to volunteer this genetic information by appealing to the creation of collaborative "patient partnerships" and the concept of empowerment. This article addresses two related questions: (1) what is the actual nature of patient participation in precision medicine research? and (2) is this participation really that empowering for the average patient? The author contends that the nature of this participation is best conceived of as merely contributory, which falls short of collaboration. Participation in precision medicine research does not entail sharing values, equal say in decisions, or shared benefit. The author also contends that there are important caveats to claims that patient participation in precision medicine is empowering. Empowerment is hindered by the type of participation, the practical use or actionability of genetic data, genetic literacy, the cost of precision drugs for patients that qualify for them, and bioethical considerations of informed consent.
In the 1990s, China experienced an epidemic of HIV/AIDS among poor farmers who sold and were infected by tainted blood and blood product transfusions, not discovered until hundreds of thousands were infected. In 1999, Wuhan University infectious disease physician-scientist Dr. Gui Xi'en visited villages in neighboring Henan province and identified the epidemic. This essay describes how the contributions of one individual-a humble, articulate, and tenacious physician-touched the lives of thousands of patients and health-care providers. His story reveals the virtues of a life that is a compelling call to action in the face of human need and suffering, exemplifying the heart of medicine. Given rampant misinformation and fear surrounding HIV/AIDS, Dr. Gui chose to educate rather than retreat. He welcomed patients whom others turned away, brought real-life cases into classrooms, and trained generations of students to approach medicine with both scientific rigor and human empathy. His work helped shift public understanding and reduce stigma, proving that education is a powerful tool for healing not just bodies, but communities. He is an inspiring figure from whom generations in China and the US could still learn.
This article explores the role in modern medicine for magnanimity, an ancient virtue defined as believing oneself worthy of great things, while being worthy of them. Through analysis of a clinical case involving a seven-month-old infant with congenital heart disease, the authors discuss how hierarchical dynamics in medicine can compromise ethical decision-making and patient care. The case illustrates how some health-care professionals may fail to act in patients' best interests because of an internalized false perception of lower status or authority, a perception that typically emerges in response to domination by others with perceived higher status. The history and concept of magnanimity provides a lens through which to understand what goes wrong in the case and why. The authors suggest how cultivating magnanimity can help health-care professionals meet the ethical challenges of status and hierarchy in medicine more broadly.
Much has been written about how poetry can be of use to medicine and medical education, privileging an instrumental perspective. But what might medicine contribute to poetry, beyond "subject matter"? Through enactive metaphors specific to medicine, medicine can bring body to words, and specific context to abstractions. But medicine and poetry are co-embroiled in life itself. This article first discusses the instrumentalism governing the use of poetry in medical education. Then it uses metaphor theory and the Kristevan concept of translationality to consider what medicine can do for poetry. Finally, the article considers the complex exchange between poetry and medicine in professional and educative contexts, illustrating these ideas through an examination of the uses of poetry in the first year of publication of the Canadian Medical Association Journal.
This essay explores ethical challenges that frequently arise during discharge planning in acute-care and post-acute settings, often involving older adults with continuing care needs, with attention to organizational duties concerning family caregivers. Drawing on bioethics scholarship, empirical data, and their personal experiences and observations, the authors analyze a common set of burdens that a health-care organization will expect to hand off to a family caregiver as part of the discharge process. These burdens are co-produced by a patient's illness, clinical decision-making processes, the limits of public and private health insurers, and collective failures of imagination concerning how the care needs of aging societies can be met more fairly. The essay aims to be of practical use to professionals involved in discharge planning, in health-care ethics, or in executive-level decisions about organizational investments benefiting communities. It includes a set of recommendations premised on caregiver support as an ethical principle for health-care organizations.
Clinicians often focus on measurable health improvements, while patients may prioritize other values, such as autonomy, comfort, and quality of life. This divergence can generate tension between technical excellence and meaningful care. This article introduces "existential competence" as a professional skill for navigating this tension. Existential competence helps patients align health-care decisions with what gives their lives purpose, recognizing health as only one source of human flourishing. Clinicians cultivate this skill by respecting patient choices-healthy or not-that reflect the patient's core values and remain within legal bounds, assuming stable preferences, decision-making capacity, and understanding of the risks. Implementation of existential competence requires expanding health care from risk management to co-stewardship of patients' life narratives, while maintaining clinical accountability. Two approaches are considered: repositioning health as one value among many, versus redefining health to encompass existential well-being. Ultimately, existential competence reorients health care toward helping patients thrive by integrating biomedical expertise with the pursuit of meaningful living.
Despite growing interest in addressing health disparities in the US and around the world, excellence in US health care is largely defined by research dollars, innovation, and perceived prestige. This essay reimagines "excellence" in health care by exploring two different models that center care for the poor and vulnerable: the ancient example of the first hospital, founded by St. Basil of Caesarea in the fourth century, and the contemporary witness of Paul Farmer's liberation theology-inspired work of accompaniment. This renewed vision invites both social and personal transformation, offering health-care institutions and practitioners new ways of naming and pursuing excellence in academic medicine and surgery.
In recent decades, critiques of scientific universalism have grown among postcolonial scholars and epistemologists, highlighting how modern science has been used to dominate non-Western knowledge systems. The notion of "epistemicide" describes the systematic suppression of diverse epistemologies under a singular scientific worldview. Many movements now challenge science's legitimacy and endorse epistemic relativism. Yet such positions risk conflating science with its historical abuses, neglecting the distinction between robust scientific practice and pseudoscientific distortions. This essay discusses pseudoscience-defined as a discourse that mimics science but lacks rigorous methodology-as a potent tool of social oppression. Examples like eugenics, phrenology, hysteria diagnoses, "conversion therapies," and climate change denial demonstrate how pseudoscientific narratives reinforce sexism, racism, and other structural inequalities. Integrating philosophy of science, critical theory, and historical analyses, the authors argue that abandoning science is not the answer. Instead, science should be strengthened methodologically, ethically, and inclusively. By clarifying science's boundaries and exposing pseudoscience's role in social oppression, this work contributes to current debates on epistemic justice and advocates a model of science that is critically reflexive and socially transformative.
Publication of scientific and biomedical manuscripts in "high impact factor" (IF) journals is important in advancing careers, obtaining funding, and developing a field of research. Rejection by prestigious journals is not infrequent and usually painful, especially to young investigators. Reasons provided by an editor are often confusing. We assess the language of the rejection letter from a specific philosophical stance, originated by Ludwig Wittgenstein. Wittgenstein's late writings on language as usage and as inherent to human activity have profoundly influenced many of the humanities but have been less frequently applied to the sciences. However, Wittgenstein's ideas about language have relevance for understanding editorial correspondence and also, more broadly, for our thinking about scientific work and "science."
The idea that people should have a voice in decisions that affect them is now widely accepted in the US health sector. Practices such as patient and family advisory boards, community-based participatory research, patient-centered research, and public deliberation are becoming commonplace. The appeal of public participation turns on a number of purported benefits, including the potential for more inclusive and transparent decision-making, equitable interventions and outcomes, and public trust in institutions. Considerable conceptual work has refined definitions and frameworks of participatory processes, and ample experimentation is underway. Yet participation remains an ambiguous concept and highly variable in practice. Drawing on the authors' collective experiences in life and work, this article clarifies what participatory processes are, describes how they might support varied goals of justice, and identifies opportunities and considerations for their use in health-care organizations. Although participatory processes alone cannot solve the erosion of trust in American health care or remedy marked US health inequities, they can be an important tool for health-care leaders who wish to work toward building fairer health systems, services, and outcomes.