Consequences For Patient Outcomes Research Articles

Crisis of Medical Humanity: It Is the Time for a Real Consideration

The medical humanity issue presents a significant obstacle to the healthcare profession, raising concerns about the ethical standards, compassion, and empathy that are vital aspects of patient-centered care. Amidst the prevalence of technological progress and a focus on measurable results, there is a rising apprehension that healthcare providers are becoming increasingly detached from their patients, viewing them as just medical cases rather than individuals who deserve comprehensive care. The erosion of medical humanity not only weakens the bond between patients and healthcare providers but also has consequences for patient outcomes and the overall quality of service. Healthcare organizations must prioritize activities focused on cultivating a culture of empathy, providing training in communication skills, and promoting mindfulness practices among healthcare staff. To tackle this problem and guarantee the provision of compassionate care that respects the dignity and well-being of every patient, we need to shift our attention towards humanistic ideals and recognize the significance of emotional intelligence in medical practice.

A growing battlefield in the war against biofilm-induced antimicrobial resistance: insights from reviews on antibiotic resistance.

Biofilms are a common survival strategy employed by bacteria in healthcare settings, which enhances their resistance to antimicrobial and biocidal agents making infections difficult to treat. Mechanisms of biofilm-induced antimicrobial resistance involve reduced penetration of antimicrobial agents, increased expression of efflux pumps, altered microbial physiology, and genetic changes in the bacterial population. Factors contributing to the formation of biofilms include nutrient availability, temperature, pH, surface properties, and microbial interactions. Biofilm-associated infections can have serious consequences for patient outcomes, and standard antimicrobial therapies are often ineffective against biofilm-associated bacteria, making diagnosis and treatment challenging. Novel strategies, including antibiotics combination therapies (such as daptomycin and vancomycin, colistin and azithromycin), biofilm-targeted agents (such as small molecules (LP3134, LP3145, LP4010, LP1062) target c-di-GMP), and immunomodulatory therapies (such as the anti-PcrV IgY antibodies which target Type IIIsecretion system), are being developed to combat biofilm-induced antimicrobial resistance. A multifaceted approach to diagnosis, treatment, and prevention is necessary to address this emerging problem in healthcare settings.

Need for Treatment, A Less Restrictive Alternative to Hospitalization, and Treatment Provision: The Utility of Community Treatment Orders.

Provision of involuntary care is an abridgment of civil rights and a source of controversy. Its circumstances require continued monitoring. This study asks 4 questions: Whether, in an era, focused on allowing patients with capacity to refuse community-treatment-order (CTO)-assignments, CTO use decreased. And whether CTOs fulfilled 3 statute mandates: Were CTO-assigned patients in greater need of treatment than other psychiatric inpatients? Was CTO assignment a less-restrictive alternative to psychiatric hospitalization? and Did CTO assignment provide needed treatment at internationally recommended levels with consequences for patient outcomes? All 214 388 Victoria, Australia mental health admissions between 2000- 2017 were reviewed. Two cohort samples were drawn and followed through 2019-ie, all 7826 hospitalized patients who were first placed on CTOs from 2010 to 2017 and 13 896 hospitalized patients without CTO placement. Logistic Regression was used to specify determinants of CTO assignment from the psychiatric inpatient population. OLS Regression with propensity score control to evaluate study questions. In the 2010-2017 decade, initial CTO assignments decreased by 3.5%, and initial hospitalizations increased by 5.9% compared to the 2000-2009 period. At hospital admission and discharge, based on Health of the Nations Score ratings, the CTO-cohort's need for treatment exceeded that of non-CTO patients. CTO patients had 3.75 fewer days in average inpatient episode duration than other inpatients, when adjusted for CTO-assignment determinants, the ratio of patients to community case managers, and patient housing status. CTO patients needing rehospitalization spent 112.68 more days in the community than re-hospitalized non-CTO patients. Patient to case-manager ratios falling above recommended levels and the patient marginal housing status contributed to longer hospital stays and reduced community tenure. Victoria relied less on CTOs as an LRA, consequently, experiencing increased initial hospitalizations. CTO patients were in greater need of treatment than non-CTO patients, yet, with required oversite had shorter hospitalizations and more time out of hospital prior to rehospitalization than the less severely ill non-CTO group. Patient LRA outcomes were adversely affected by higher than recommended community patient to case-manager ratios limiting needed treatment provision to hospital.

Association of Incident Delirium With Short-term Mortality in Adults With Critical Illness Receiving Mechanical Ventilation

Intensive care unit (ICU)-acquired delirium and/or coma have consequences for patient outcomes. However, contradictory findings exist, especially when considering short-term (ie, in-hospital) mortality and length of stay (LOS). To assess whether incident delirium, days of delirium, days of coma, and delirium- and coma-free days (DCFDs) are associated with 14-day mortality, in-hospital mortality, and hospital LOS among patients with critical illness receiving mechanical ventilation. This single-center prospective cohort study was conducted in 6 ICUs of a university-affiliated tertiary hospital in Taiwan. A total of 267 delirium-free patients (aged ≥20 years) with critical illness receiving mechanical ventilation were consecutively enrolled from August 14, 2018, to October 1, 2020. Participants were assessed daily for the development of delirium and coma status over 14 days (or until death or ICU discharge) using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively. Mortality rates (14-day and in-hospital) and hospital LOS using electronic health records. Of 267 participants (median [IQR] age, 65.9 [57.4-75.1] years; 171 men [64.0%]; all of Taiwanese ethnicity), 149 patients (55.8%) developed delirium for a median (IQR) of 3.0 (1.0-5.0) days at some point during their first 14 days of ICU stay, and 105 patients (39.3%) had coma episodes also lasting for a median (IQR) of 3.0 (1.0-5.0) days. The 14-day and in-hospital mortality rates were 18.0% (48 patients) and 42.1% (112 of 266 patients [1 patient withdrew from the study]), respectively. The incidence and days of delirium were not associated with either 14-day mortality (incident delirium: adjusted hazard ratio [aHR], 1.37; 95% CI, 0.69-2.72; delirium by day: aHR, 1.00; 95% CI, 0.91-1.10) or in-hospital mortality (incident delirium: aHR, 1.00; 95% CI, 0.64-1.55; delirium by day: aHR, 1.02; 95% CI, 0.97-1.07), whereas days spent in coma were associated with an increased hazard of dying during a given 14-day period (aHR, 1.16; 95% CI, 1.10-1.22) and during hospitalization (aHR, 1.10; 95% CI, 1.06-1.14). The number of DCFDs was a protective factor; for each additional DCFD, the risk of dying during the 14-day period was reduced by 11% (aHR, 0.89; 95% CI, 0.84-0.94), and the risk of dying during hospitalization was reduced by 7% (aHR, 0.93; 95% CI, 0.90-0.97). Incident delirium was associated with longer hospital stays (adjusted β = 10.80; 95% CI, 0.53-21.08) when compared with no incident delirium. In this study, despite prolonged LOS, ICU delirium was not associated with short-term mortality. However, DCFDs were associated with a lower risk of dying, suggesting that future research and intervention implementation should refocus on maximizing DCFDs to potentially improve the survival of patients receiving mechanical ventilation.

Commentary: Can Automated Blood Culture Systems Be Both New and Improved?

Automated continuous monitoring blood culture (CMBC) systems are a cornerstone of the clinical microbiology laboratory. Despite the critical role of these systems in diagnosing life-threatening bloodstream infections, their core technologies and performance characteristics have remained largely unchanged since their introduction in the 1990s. This stability and uniformity have enabled the development of quality benchmarks, such as percent positivity and contamination rate; downstream diagnostics, such as direct identification and susceptibility testing of microorganisms in positive cultures; and clinical guidelines based on time to positivity or duration of bacteriemia. In this issue of the Journal of Clinical Microbiology, Chavez et al. (J Clin Microbiol 60:e02261-21. 2021, https://doi.org/10.1128/JCM.02261-21) built on a prior study to examine clinical impacts following the introduction of a new blood culture system which boasts enhanced organism recovery and more rapid time to detection of positive blood cultures. While one might assume that these "improvements" would result in clinical benefits, the authors uncovered some unexpected consequences associated with altering long-accepted performance characteristics. Their central finding was that implementation of the new CMBC system did result in alterations to the management of patients with S. aureus bacteremia; however, this did not have any overall consequences for patient outcomes.

Risk Factors for TB/HIV Coinfection and Consequences for Patient Outcomes: Evidence from 241 Clinics in the Democratic Republic of Congo.

(1) Background: In resource-limited countries, patients with tuberculosis (TB)/HIV coinfection commonly face economic, sociocultural, and behavioral barriers to effective treatment. These barriers manifest from low treatment literacy, poverty, gender inequality, malnutrition, societal stigmas regarding HIV, and an absence of available care. It is critical for intervention programs to understand and assist in overcoming these barriers and any additional risks encountered by patients with TB/HIV coinfection. This study analyzes variation in TB/HIV coinfection and risks of negative outcomes among patients with TB/HIV coinfection compared to those without coinfection. (2) Methods: This quantitative study used data from 49,460 patients receiving ART from 241 HIV/AIDS clinics in Haut-Katanga and Kinshasa, two provinces in the Democratic Republic of Congo. Chi-square and logistic regression analysis were performed. (3) Results: Significantly higher proportions of patients with TB/HIV coinfection were men (4.5%; women, 3.3%), were new patients (3.7%; transferred-in, 1.6%), resided in the Kinshasa province (4.0%; Haut-Katanga, 2.7%), and were in an urban health zone (3.9%) or semi-rural health zone (3.1%; rural, 1.2%). Logistic regression analysis showed that after controlling for demographic and clinical variables, TB/HIV coinfection increased the risk of death (adjusted odds ratio (AOR), 2.26 (95% confidence interval (CI): 1.94–2.64)) and LTFU (AOR, 2.06 (95% CI: 1.82–2.34)). TB/HIV coinfection decreased the odds of viral load suppression (AOR, 0.58 (95% CI: 0.46–0.74)). (4) Conclusions: TB/HIV coinfection raises the risk of negative outcomes such as death, LTFU, and lack of viral load suppression. Our findings can help HIV clinics in Democratic Republic of Congo and other African countries to customize their interventions to improve HIV care and reduce care disparities among patients.

Chronic hospital nurse understaffing meets COVID-19: an observational study

IntroductionEfforts to enact nurse staffing legislation often lack timely, local evidence about how specific policies could directly impact the public’s health. Despite numerous studies indicating better staffing is associated with...

The EGFR Exon 19 Mutant L747-A750>P Exhibits Distinct Sensitivity to Tyrosine Kinase Inhibitors in Lung Adenocarcinoma.

EGFR exon 19 deletion (Ex19Del) mutations account for approximately 60% of lung cancer-associated EGFR mutations and include a heterogeneous group of mutations. Although they are associated with benefit from tyrosine kinase inhibitors (TKI), the relative inhibitor sensitivity of individual Ex19Del mutations is unknown.Experimental Design: We studied the TKI sensitivity and structural features of common Ex19Del mutations and the consequences for patient outcomes on TKI treatment. We found that the L747-A750>P mutation, which represents about 4% of all Ex19Del mutations, displays unique inhibitor selectivity. L747-A750>P differs from other Ex19Del mutations in not being suppressed completely by erlotinib or osimertinib, yet is completely inhibited by low doses of afatinib. The HCC4006 cell line (with the L747-A750>P mutation) exhibited increased sensitivity to afatinib over erlotinib and osimertinib, and computational modeling suggests explanations for this sensitivity pattern. Clinically, patients with EGFR L747-A750>P mutant tumors showed inferior outcomes when treated with erlotinib than patients with E746-A750 mutant tumors. These results highlight important differences between specific Ex19Del mutations that may be relevant for optimizing TKI choice for patients.

South African clinical practice guidelines: A landscape analysis.

South Africa (SA) is in the process of implementing National Health Insurance (NHI), which will require co-ordination of health provision across sectors and levels of care. Clinical practice guidelines (CPGs) are tools for standardising and implementing care, and are intended to influence clinical decision-making with consequences for patient outcomes, health system costs and resource use. Under NHI, CPGs will be used to guide the provision of healthcare for South Africans. It is therefore important to explore the current landscape of CPG developers and development. To identify and describe all CPGs available in the public domain produced by SA developers for the SA context. We conducted a cross-sectional evaluation using a two-part search process: an iterative, electronic search of grey literature and relevant websites (161 websites searched), and a systematic search for peer-reviewed literature (PubMed) after publication year 2000. CPGs were identified, and data were extracted and categorised by two independent reviewers. Any discrepancies were referred to a third reviewer. Data extracted included a description of the developer, condition, and reporting of items associated with CPG quality. A search conducted in May 2017 identified 285 CPGs published after January 2000. Of those, 171 had been developed in the past 5 years. Developers included the national and provincial departments of health (DoH), professional societies and associations, ad hoc collaborations of clinicians, and the Council for Medical Schemes. Topics varied by developer; DoH CPGs focused on high-burden conditions (HIV/AIDS, tuberculosis and malaria), and other developers focused on non-communicable diseases. A conflict of interest statement was included in 23% of CPGs developed by societies or clinicians, compared with 4% of DoH CPGs. Accessing CPGs was challenging and required extensive searching. SA has many contributors to CPG development from the public and private sectors and across disciplines, but there is no formal co-ordination or prioritisation of topics for CPG development. Different versions of the CPGs were identified and key quality items were poorly reported, potentially affecting the usability and credibility of those available. There was substantial variation in CPG comprehensiveness and methodological approach. Establishing a national CPG co-ordinating unit responsible for developing standards for CPG development along with clinical quality standards, and supporting high-quality CPG development, is one essential step for moving forward with NHI.

Health locus of control in patients undergoing coronary artery surgery - changes and associated outcomes: a seven-year cohort study.

Health locus of control is a measure of an individual's beliefs in factors that are thought to determine health experiences. Scores are generated and form a graduated linear scale from external to internal control, with respect to their views on health causality. Health locus of control has been considered to be a relatively stable entity. However, it is not clear if this status changes in the advent of serious health challenges, such as coronary artery bypass graft surgery. The aim of this study is to explore the variability of health locus of control and its association with postoperative health in this context. In a longitudinal cohort study of patients undergoing coronary artery bypass graft surgery, a purposive sample ( n=215) were recruited from the waiting list and followed up postoperatively, at approximately one year and seven years later. Patients undergoing coronary artery bypass graft surgery demonstrated marked fluctuations in health locus of control in their peri-operative and rehabilitative phases. Mean health locus of control became more external (often associated with poorer outcomes) peri-operatively, and more internal (generally associated with better health outcomes) in the rehabilitative period. Health locus of control scores were shown to be changeable during a major health care intervention, with possible consequences for patient outcomes and care needs. The significant health belief upheaval demonstrated in this cohort should be considered in assessing patients preoperatively, and managed as part of the patients' clinical journey by both acute and rehabilitation staff. It is likely to have particular importance in individualised assessment and management of future prevention advice for patients.

Uso de tecnologia leve-dura nas práticas de enfermagem: análise de conceito

Objetivo: establecer el concepto de tecnología blanda-dura en las prácticas de enfermería. Materiales y métodos: estudio reflexivo, con aplicación del método de análisis conceptual de Walker e Avant, que utiliza los siguientes pasos: selección de un concepto; determinación de los objetivos de análisis, de los atributos definidores; identificación de un caso modelo y contrario, e identificación de los antecedentes y las consecuencias. El estudio se llevó a cabo desde la búsqueda en bases de datos de las producciones científicas disponibles en ambiente virtual, en el periodo de abril y mayo de 2014. Resultados y discusión: inicialmente, el concepto de tecnología estaba relacionado al de técnica; con el del tiempo, sufrió cambios y pasó a relacionarse con los aspectos subjetivos y objetivos del cuidador. La tecnología blanda-dura sobrepasa los conocimientos tecnológicos estructurados y presenta libertad que les permite a los profesionales diversas posibilidades de acción. El uso de tecnologías en el cuidado de la enfermería es capaz de promover la salud e intensificar el vínculo entre profesional y cliente. Conclusión: el método de Walker e Avant posibilita demarcar los aspectos y la formación de un concepto desde atributos, antecedentes y consecuentes, además de analizar la utilización de los términos en la práctica.

A prospective analysis of pain experience, beliefs and attitudes, and pain management of a cohort of Danish surgical patients

Adequacy of pain management is a process indicator of health care quality with consequences for patient outcomes and satisfaction. The reported incidence of moderate to severe postoperative pain worldwide is between 20% and 80%. The purpose was to assess the quality of pain management in a cohort of Danish postoperative patients by examining their pain experience, beliefs about pain and pain treatment, and relationships between pain intensity, its effect on function, and pharmacological pain management. The American Pain Society's Patient Outcome Questionnaire was administered to a consecutive cohort of Danish patients who had undergone gastrointestinal, gynaecological, orthopaedic or urological surgery within 24 and 72 h of surgery. Findings indicated uncontrolled pain in 45.5% of patients. These patients reported moderate to severe intensity average pain in the previous 24 h, however, 88.4% of the cohort overall stated they were satisfied or very satisfied with pain treatment. Patients who experienced severe pain only received 50% of available strong opioids, 73.3% of available weak opioids, 100% of available non-steroidal antiinflammatory drugs (NSAIDS) and paracetamol. Further, analgesics prescribed to be administered at fixed intervals were administered 99% of the time; in contrast, all Pro Re Nata (PRN) orders irrespective of analgesic categories, were administered only 25% of the time. A number of patients experienced significant pain postoperatively. Although multi-modal analgesics were available, analgesic administration practices did not consistently reflect management responsive to patient needs. Despite this, patients were largely satisfied with the care received suggesting the need for further research to understand how patients perceive the efficacy of pain management.