Direct Clinical Experience Research Articles

Understanding the Sequelae of Invasive Meningococcal Disease in the United States.

Invasive meningococcal disease (IMD) is an uncommon but serious and potentially fatal condition that can result in reduced life expectancy and a broad spectrum of sequelae, many of which may be lifelong and devastating for those who survive the acute disease period. In the United States of America (USA), vaccination is available against the five meningococcal serogroups (A, B, C, W, and Y), but meningococcal vaccination rates among healthy USA adolescents and individuals at high risk because of medical conditions are low, rendering them vulnerable to IMD and its sequelae. Despite the severity of the disease, the clinical impact and rates of IMD sequelae in the USA are poorly understood, as USA-specific data are limited, and the methodology of existing research is heterogenous. This commentary presents clinical experts' perspectives on IMD sequelae based on the available published evidence and direct clinical experience. Among sequelae previously identified in a global systematic literature review, 16 conditions were considered as related to IMD by the present authors. These sequelae include short- and long-term physical, neurological, and emotional consequences that impose a substantial humanistic burden on survivors and their caregivers and result in considerable healthcare and societal costs. This commentary highlights existing knowledge gaps concerning IMD sequelae, including the unclear relationship between IMD and mental health disorders, the contribution of sequelae to the disease burden, prevalence of late-onset sequelae among survivors, and timing of the development of sequelae in different age groups. Addressing these knowledge gaps can inform decisions regarding clinical management in the post-acute period and help quantify the impact of prevention through meningococcal vaccination.

Graduate student perspectives on training and clinical experiences with antagonism treatment.

The objective of this preregistered study was to gather evidence on training and clinical experiences offered by clinical psychology doctoral programs on the treatment of antagonism-a construct from the personality and psychopathology literature that captures individual differences in aggressiveness, callousness, grandiosity, domineering, and manipulativeness. We surveyed current graduate students (N = 376) in APA-accredited clinical psychology doctoral programs (Mage = 28.4; 83.2% female; 65.2% White) about their experiences in training and treatment of antagonistic patients (ANT-patients) as well as experiences with patients with predominant negative affect (NA; e.g., anxious and depressed). Students reported significantly less training to treat antagonism compared to NA (|ds| = 0.43-2.88), as well as lower rates of direct clinical experience, generally poorer treatment experiences, and stronger countertransference reactions (|ds| = 0.53-1.40). These discrepancies were especially large for adult-focused students compared to child/adolescent-focused students. In fact, adult-focused students reported a mean competency rating of M = 1.71, between the scalar points not competent at all (1) and a little bit competent (2). Overall, these results indicate a lack of training and competence to treat antagonism among current graduate students, especially adult-focused students. We believe the crux of this issue is a field-wide lack of robust empirical work on antagonism treatments (for adults). Moving forward, we implore researchers and funding agencies to help address this substantial gap, which is both an ethical and practical imperative. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Impact of the COVID-19 Pandemic on Inpatient Pediatric Medical Student Education in Hawai'i.

The COVID-19 pandemic has had many effects on medical student education, ranging from safety measures limiting patient exposure to changes in patient diagnoses encountered by medical students in their clerkship experience. This study aimed to identify the impact of the pandemic on the inpatient experiences of third- and fourth-year medical students by assessing patient volumes and diagnoses seen by students. Frequency and types of notes written by medical students on hospital-based pediatric rotations at Kapi'olani Medical Center for Women and Children as well as patient diagnoses and ages were compared between 2 time periods: pre-pandemic (July 2018-February 2020) and pandemic (May 2020-September 2021). On average, the number of patients seen by medical students was significantly reduced in the pandemic period from 112 patients/month to 88 patients/month (P=.041). The proportion of patients with bronchiolitis or pneumonia were also significantly reduced in the pandemic period (P<.001). Bronchiolitis was diagnosed in 1.3% of patients seen by medical students during the pandemic period, compared with 5.9% of patients pre-pandemic. Pneumonia was diagnosed in 1.0% of patients seen by medical students in the pandemic period compared with 4.6% pre-pandemic. There was no significant difference in patient age between the 2 groups (P=.092). During the first 18 months of the COVID-19 pandemic, medical students in this institution had a remarkably different inpatient experience from that of their predecessors. They saw fewer patients, and those patients had fewer common pediatric respiratory diseases. These decreases suggest these students may require supplemental education to compensate for these gaps in direct pediatric clinical experience.

Mutual recognition of qualifications, health workforce migration, and graduate outcomes: a comparative mapping study of undergraduate dental education in Europe

BackgroundThe resource needs of health services are served by the recognition of qualifications across borders which allows professionals to migrate between countries. The movement of dentists across the European Union (EU), especially into the United Kingdom (UK), has provided a valuable boost to workforce supply. Recent changes to policy recognising overseas qualifications have brought attention to the equivalence of qualifications awarded in EU countries. Professional regulators need to be confident that dentists who qualified elsewhere have the appropriate knowledge, skills and experience to practise safely and effectively. The aim of this study was to compare UK and EU dental curricula, identify any differences, and compare the extent of pre-qualification clinical experience.MethodsThis was a mixed methods study comprising a questionnaire and website searches to identify information about curricula, competences, and quality assurance arrangements in each country. The questionnaire was sent to organisations responsible for regulating dental education or dental practice in EU member states. This was supplemented with information obtained from website searches of stakeholder organisations for each country including regulators, professional associations, ministries, and providers of dental education. A map of dental training across the EU was created.ResultsNational learning outcomes for dental education were identified for seven countries. No national outcomes were identified 13 countries; therefore, learning outcomes were mapped at institution level only. No information about learning outcomes was available for six countries. In one country, there is no basic dental training. Clinical skills and communication were generally well represented. Management and leadership were less represented. Only eight countries referenced a need for graduates to be aware of their own limitations. In most countries, quality assurance of dental education is not undertaken by dental organisations, but by national quality assurance agencies for higher education. In many cases, it was not possible to ascertain the extent of graduates’ direct clinical experience with patients.ConclusionsThe findings demonstrate considerable variation in learning outcomes for dental education between countries and institutions in Europe. This presents a challenge to decision-makers responsible for national recognition and accreditation of diverse qualifications across Europe to maintain a safe, capable, international workforce; but one that this comparison of programmes helps to address.

Factors Influencing Engagement Across the Motivational PrEP Cascade Among Latino SMM: A Mixed-Methods Analysis from the Perspectives of Community Providers and Latino SMM.

Latino sexual minority men (SMM) are a highly vulnerable population to HIV, and while pre-exposure prophylaxis (PrEP) has emerged as a promising biomedical tool for HIV prevention among them, its utilization remains disproportionately low in this community despite its potential. Understanding the barriers along the PrEP continuum of care, known as the "PrEP cascade," is crucial for effectively implementing PrEP interventions. Therefore, the objective of our study was twofold: first, to explore the stage of Latino SMM in the PrEP cascade by examining disparities in demographics, social factors, and healthcare aspects; second, to gain insights from healthcare providers who have direct clinical experience with our population regarding the challenges faced by Latino SMM in accessing and adhering to PrEP. Based on the study findings, the majority of participants (n = 74; 49%) were in the contemplation stage, and only one in ten Latino SMM (10.6%) were currently adherent to PrEP. Compared to those who were at least second-generation, first-generation status had a positive association (B = 0.699, SE = 0.208, β = 0.351, p < .001) with engagement along the PrEP Contemplation Ladder. Conversely, having at least one parent who did not have legal residency, relative to those whose parents were both U.S. citizens or held legal residency documentation, was found to have a negative association (B = - 0.689, SE = 0.245, β = 0.245, p = .006) with engagement along the PrEP Contemplation Ladder. Additionally, discussing PrEP with a healthcare provider had a positive association (B = 0.374, SE = 0.179, β = 0.185, p = .038) with engagement along the PrEP Contemplation Ladder. Qualitative results from our study suggest that some Latinos who initially agreed to start using PrEP ended up getting lost in the care pipeline and failed to attend their scheduled appointments. Providers also noted that many patients lacked access to a pharmacy where they felt comfortable obtaining their PrEP prescription, leading them to discontinue use after only a few months. These findings emphasize the importance of considering the unique needs, culture, and background of Latinos, including care delivery and provider attitudes that can facilitate progress through the PrEP cascade.

Using the Delphi Process to Prioritize an Agenda for Care Transition Research for Patients With Substance Use Disorders.

Medical hospitalizations are increasingly recognized as important opportunities to engage individuals with substance use disorders (SUD) and offer treatment. While a growing number of hospitals have instituted interventions to support the provision of SUD care during medical admissions, post-hospitalization transitions of care remain a challenge for patients and clinicians and an understudied area of SUD care. Evidence is lacking on the most effective and feasible models of care to improve post-hospitalization care transitions for people with SUD. In the absence of strong empirical evidence to guide practice and policy, consensus-based research methods such as the Delphi process can play an important role in efficiently prioritizing existing models of care for future study and implementation. We conducted a Delphi study that convened a group of 25 national interdisciplinary experts with direct clinical experience facilitating post-hospitalization care transitions for people with SUD. Our panelists rated 10 existing care transition models according to anticipated effectiveness and facility of implementation based on the GRADE Evidence to Decision framework. Qualitative data on each care model were also gathered through comments and an online moderated discussion board. Our results help establish a hierarchy of SUD care transition models to inform future study and program development.

Hematology and Oncology Fellow Education About Sexual and Reproductive Health: A Survey of Program Directors in the United States.

Clinical oncology guidelines recommend addressing sexual and reproductive health (SRH) concerns in routine cancer care. However, limited training often hinders clinicians' ability to do so effectively. The objective of this study was to understand the state of current fellowship education on SRH (ie, sexual health, safe sex practices, and fertility) through conducting a national survey of US hematology/oncology fellowship program directors (PDs). A survey was sent to all PDs of adult hematology/oncology fellowship programs in the United States via online link. PDs who did not complete the survey were sent up to four follow-up emails and a paper mailing. Descriptive statistics and McNemar tests were conducted. One hundred-fourteen PDs responded (65%). Fewer programs offered formal instruction on sexual health (49%) and safe sex practices (37%) compared with fertility (75%). Informal training in SRH relied heavily on direct clinical experience (73%-78% of programs), with other methods (eg, case-based approaches, webinars, and journal clubs) being less common. Lack of experts to provide instruction was the most commonly cited barrier to offering training in SRH, endorsed by 74% for sexual health, 68% for safe sex practices, and 54% for fertility; difficulty finding space within the curriculum (50%; 54%; and 43%, respectively) and a lack of training requirements were also commonly endorsed (57%; 60%; and 35%, respectively). Barriers were endorsed more commonly for sexual health topics than fertility. The results highlight the scarcity of training in SRH, particularly in sexual health, within hematology/oncology fellowship programs. The heavy reliance on informal instruction methods may lead to inconsistent and inadequate education. Efforts to integrate comprehensive training in SRH into fellowship programs are crucial to ensuring that such concerns are included in routine cancer care.

Cross-sectional survey of sexual health professionals’ experiences and perceptions of the 2022 mpox outbreak in the UK

ObjectiveTo understand the experiences and perceptions of sexual health professionals responding to the May 2022 mpox outbreak in the UK.DesignCross-sectional, anonymous, online survey collecting quantitative and qualitative data. Convenience sample...

Statin-induced autoimmune myositis: a proposal of an “experience-based” diagnostic algorithm from the analysis of 69 patients

Statin-induced autoimmune myositis (SIAM) represents a rare clinical entity that can be triggered by prolonged statin treatment. Its pathogenetic substrate consists of an autoimmune-mediated mechanism, evidenced by the detection of antibodies directed against the 3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR Ab), the target enzyme of statin therapies. To facilitate the diagnosis of nuanced SIAM clinical cases, the present study proposes an “experience-based” diagnostic algorithm for SIAM. We have analyzed the clinical data of 69 patients diagnosed with SIAM. Sixty-seven patients have been collected from the 55 available and complete case records regarding SIAM in the literature; the other 2 patients represent our direct clinical experience and their case records have been detailed. From the analysis of the clinical features of 69 patients, we have constructed the diagnostic algorithm, which starts from the recognition of suggestive symptoms of SIAM. Further steps provide for CK values dosage, musculoskeletal MR, EMG/ENG of upper-lower limbs and, Anti-HMGCR Ab testing and, where possible, the muscle biopsy. A global evaluation of the collected clinical features may suggest a more severe disease in female patients. Atorvastatin proved to be the most used hypolipidemic therapy.

Special Report: How to Work With Patients Using Problem-Focused Psychodynamic Psychotherapies

Special Report: How to Work With Patients Using Problem-Focused Psychodynamic Psychotherapies

“Let’s face it… it’s futile”: Experiences of futility among nurses who provide care to patients with borderline personality disorder

IntroductionResearch studies suggest that mental health nurses hold negative attitudes towards patients diagnosed with borderline personality disorder (BPD).ObjectivesThe aim of this study was to explore mental health nurses’ experiences and attitudes towards BPD patients in Greece, using a qualitative approach.MethodsData were collected through two audio-recorded focus group discussions. The participants were twelve nurses who work in two General Hospital Psychiatric Units –one in Athens and one regional– and have direct clinical experience with BPD patients. The audio recordings were transcribed verbatim and analysed using thematic analysis in the context of grounded theory.ResultsOne overarching theme and three main themes were identified. The overarching theme that emerged was: “Futility”, which refers to feelings that the provision of nursing care to BPD patients is devoid of purpose and meaning. The main themes were: “Uncertainty”, which refers to the absence of valid causal explanations for mental disorders and on the perplexity of the BPD psychopathology; “Frustration”, which refers to challenges and barriers to providing care to BPD patients; “Unsupportiveness”, which refers to a complex mental health system, where there is a lack of guidance and goal orientation. Of significance are the nurses’ feelings of frustration and futility creating a sense of being burdened and leading to negative attitudes and behaviours towards BPD patients.ConclusionsUnderstanding treatment goals from the recovery model perspective and developing guidelines to help nurses revisit the concept of medical futility, may improve care to BPD patients.DisclosureNo significant relationships.

Creating a win-win for the health system and health Profession\u2019s education: a direct observation clinical experience with feedback iN real-time (DOCENT) for low acuity patients in the emergency department

BackgroundClinical education across the professions is challenged by a lack of recognition for faculty and pressure for patient throughput and revenue generation. These pressures may reduce direct observation of patient care provided by students, a requirement for both billing student-involved services and assessing competence. These same pressures may also limit opportunities for interprofessional education and collaboration.MethodsAn interprofessional group of faculty collaborated in a sequential quality improvement project to identify the best patients and physical location for a student teaching clinic. Patient chief complaint, use of resources, length of stay, estimated severity of illness and student participation and evaluation of the clinic was tracked.ResultsClinic Optimization and Patient Care: Five hundred and thirty-two emergency department (ED) patients were seen in the first 19 months of the clinic. A clinic located near the ED allowed for patients with higher emergency severity index and greater utilization of imaging. Patients had similar or lower lengths of stay and higher satisfaction than patients who remained in the ED (p < 0.0001). In the second clinic location, from October 2016–June 2019, 644 patients were seen with a total of 667 concerns; the most common concern was musculoskeletal (50.1%).Student Interprofessional Experience: A total of 991 students participated in the clinic: 68.3% (n = 677) medical students, 10.1% (n = 100) physician assistant students, 9.7% (n = 96) undergraduate nursing students, 9.1% (n = 90) physical therapy students, and 2.8% (n = 28) nurse practitioner students. The majority (74.5%, n = 738) of student participants worked with students from other professions. More than 90% of students reported that faculty set a positive learning environment respectful of students. However, 20% of students reported that faculty could improve provision of constructive feedback.Direct Observation: Direct observation of core entrustable professional activities for medical students was possible. Senior medical students were more likely to be observed generating a differential diagnosis or management plan than first year medical students.ConclusionsCreation of a DOCENT clinic in the emergency department provided opportunities for interprofessional education and observation of student clinical skills, enriching student experience without compromising patient care.

Experiences of Futility Among Nurses Providing Care to Patients With Borderline Personality Disorder in the Greek Mental Health System.

The aim of the current study was to explore mental health nurses' experiences and attitudes toward patients with borderline personality disorder (BPD) in Greece using a qualitative approach. Data were collected through two audio-recorded focus group discussions. Participants were 12 nurses who work in two general hospital psychiatric units and have direct clinical experience with patients with BPD. Audio recordings were transcribed verbatim and analyzed using thematic analysis in the context of grounded theory. One overarching theme and three main themes were identified. The overarching theme, Futility, refers to feelings that the provision of nursing care to patients with BPD is devoid of purpose and meaning. The main themes were: Uncertainty, Frustration, and Unsupportiveness. Of significance are nurses' feelings of frustration and futility creating a sense of being burdened and leading to negative attitudes and behaviors toward patients with BPD. Understanding treatment goals from the recovery model perspective and developing guidelines to help nurses revisit the concept of medical futility may improve care to patients with BPD. [Journal of Psychosocial Nursing and Mental Health Services, 60(6), 33-42.].

22.3 SELF-INJURIOUS BEHAVIOR IN CATATONIA IN AUTISM SPECTRUM DISORDER: POINTERS, PEARLS, AND CHALLENGES

The objectives of this presentation are to provide an overview of the current understanding regarding repetitive self-injurious behavior as a symptom of catatonia in autism spectrum disorder (ASD), the paradigms and lessons learned, as well as longstanding and novel challenges. The literature review and direct clinical experience will be discussed. Catatonia is reported to occur in 12% to 20% of youth with ASD, with significant advances in understanding over the past 2 decades. Some youth with ASD experience more “expected” psychomotor-retarded catatonic symptoms, such as slowness, rigidity, getting “stuck,” and posturing, speech abnormalities, or frank mutism, which are often coupled with prominent skill regression. This presentation can lead to massive clinical devastation, as is also the case when psychomotor agitation dominates the catatonic picture, often in the form of intractable self-injury devoid of any operant function, unresponsive to any behavioral intervention, and often requiring the most desperate measures of bodily restraint to prevent catastrophic tissue damage. Three current cases will be reviewed describing catatonia in ASD, where life-threatening self-injurious behavior (SIB) dominated the catatonic clinical picture. One youth had experienced prior catatonic episodes resulting in severe malnutrition and bilateral retinal detachment from head-directed SIB before relative stability was achieved with ECT; maintenance ECT remained de rigueur for months as this patient’s illness course waxed and waned. Another youth spent 9 months restrained in a pediatric unit in a state of chronic agitated catatonia until ECT introduction; despite massive improvement with ECT, this patient exemplified the complexity of such cases in terms of additional behavioral complexities requiring intensive management. A third youth with intractable head-directed SIB experienced prompt relief with ECT introduction; his treatment, however, was inadvertently disrupted by the COVID-19 pandemic, with many lessons learned from his brief relapse and subsequent renewed recovery. Recognition of repetitive SIBs devoid of environmental function as part of the catatonic spectrum in ASD is no longer novel. Much continues to be learned, however, about both the acute and long-term management of such patients, with pearls, new challenges, and vistas for improvement.

Conceptual bases, elements of methodology and narrative aspects resulted from direct clinical experience – afferent to pulmonary rehabilitation in post COVID-19 patients

Conceptual bases, elements of methodology and narrative aspects resulted from direct clinical experience – afferent to pulmonary rehabilitation in post COVID-19 patients

Committing to Continuity: Primary Care Practices During COVID-19 in an Urban Brazilian Neighborhood.

Decreased engagement in preventive services, including vaccination, during the COVID-19 pandemic represents a grave threat to global health. We use the case of the Bom Retiro Public Health Clinic in São Paulo, Brazil, to underscore how continuity of care is not only feasible, but a crucial part of health as a human right. The long-standing relationship between the clinic and neighborhood residents has facilitated ongoing management of physical and mental health conditions. Furthermore, we demonstrate how the clinic’s history of confronting infectious diseases has equipped it to adapt preventive services to meet patients’ needs during the pandemic. Our academic–community partnership used a multidisciplinary approach, relying on analysis of historical data, ethnographic data, and direct clinical experience. We identify specific prevention strategies alongside areas for improvement. We conclude that the clinic serves as a model for continuity of care in urban settings during a pandemic.

SIMULATION ANALYSIS ON COST-EFFECTIVENESS OF SANITARY AND MEDICAL MATERIAL USAGE AT URINARY TRACT INFECTION OUTBREAK CAUSED BY ANTIBIOTIC-RESISTANT BACTERIA IN UROLOGICAL WARD

(Purpose) The purpose of this study is to compare the costs of active surveillance culture (ASC) and of an environmental cleaner and disinfectant, with the medical costs for inhibiting hospitalized urinary tract infection (UTI) outbreaks in a urology ward over a 3 year 8 months period by simulation calculation. (Methods) We previously reported a UTI outbreak via antibiotic resistant bacteria transmission in 9 hospitalized patients, for which we initiated ASC and introduced a potassium peroxymonosulfate-based product (RUBYSTA® (RST)) as a disinfectant environmental cleaner, then prevented recurrence for 3 years and 8 months. This study compared the actual costs of ASC and RST use to the calculated medical expense for an outbreak leading to urosepsis on the same scale caused by transmission of antibiotic resistant bacteria. (Results) Based on our simulation calculation, ASC and disinfectant costs were about 770,000 Japanese yen lower than the medical expense of resolving an outbreak without recurrence for a period of 3 years and 8 months, based on our direct clinical experience. (Conclusion) Even though it is needless to say that education for medical stuffs, patients and their families is the most important as to the measures for prevention of infections, our simulation study suggests that ASC and RST use may reduce medical costs for resolving such outbreaks and preventing their recurrence for an extended period of time.

Machine-Learning Implementation in Clinical Anesthesia: Opportunities and Challenges.

Machine-Learning Implementation in Clinical Anesthesia: Opportunities and Challenges.

Teaching of implant dentistry in dental hygiene and therapy schools in the UK and Ireland.

Objective The aim of this study was to assess the current status of implant teaching within dental hygiene and therapy schools in the UK and Ireland.Methods An online questionnaire relating to current and future possible trends in dental implantology education was developed and distributed to programme directors in each of the 23 dental hygiene and therapy schools in the UK and Ireland.Results All responding schools (response rate of 60%) provided implant training for their students. The teaching is mainly delivered in lecture-based or phantom head room settings. The majority of schools provided direct clinical experience in procedures relating to peri-implant maintenance, although in some schools it was stated that not every student was guaranteed to receive such experience. In 86% of schools, students gained experience in oral hygiene and scaling, while 71% and 64% provided experience of non-surgical management of patients with peri-implant mucositis and peri-implantitis, respectively. The main barrier to developing the implant programme was an insufficient number of suitable cases.Conclusions Although all responding schools provide implant training, the overall findings show that further development and improvement of implant teaching in dental hygiene and therapy schools within the UK and Ireland is required, particularly with respect to direct clinical experience. This will ensure that newly qualified dental hygienists and therapists are sufficiently prepared for managing implant patients in their clinical practice.

Impact of an early clinical exposure project conducted by senior clinical students compared between participating and nonparticipating students

An early clinical exposure project conducted by clinical students aimed to promote direct clinical experience to preclinical students. The aim of this study was to determine the effects of the project on academic achievement and study attitudes and habits between participating and nonparticipating students before ( test 1) and after the project ( test 2) in the second preclinical year and at the end of the first semester of the first clinical year ( test 3), with a subgroup analysis of the first (lowest) to third (highest) tertile of the score. Questionnaires were sent to the first clinical year students at test 3 and asked the information retrospectively at test 1 and test 2 in second year preclinical and currently at test 3, with 83.86% (265/316) being returned. Mean percentile of scores was higher at test 2 compared with test 1 in the first tertile group of participating students. Motivation to study medicine (motivation), realization of application of preclinical knowledge to clinical study (application), understanding of clinical environment (environment), and lesson review after class (review) were higher for participating than nonparticipating students at test 2 and/or test 3. Searching additional study information was higher at test 2 compared with test 1 only for participating students. This project could effectively promote application, motivation, environment, and review for participating vs. nonparticipating students at test 2 and/or test 3. Effortless, intimate, and effective communication between clinical and preclinical students and a direct experience in early clinical exposure might be key success factors.