Patients Of Different Backgrounds Research Articles

Long COVID: mechanisms, risk factors and recovery.

What is the topic of this review? The emerging condition of long COVID, its epidemiology, pathophysiological impacts on patients of different backgrounds, physiological mechanisms emerging as explanations of the condition, and treatment strategies being trialled. The review leads from a Physiological Society online conference on this topic. What advances does it highlight? Progress in understanding the pathophysiology and cellular mechanisms underlying Long COVID and potential therapeutic and management strategies. Long COVID, the prolonged illness and fatigue suffered by a small proportion of those infected with SARS-CoV-2, is placing an increasing burden on individuals and society. A Physiological Society virtual meeting in February 2022 brought clinicians and researchers together to discuss the current understanding of long COVID mechanisms, risk factors and recovery. This review highlights the themes arising from that meeting. It considers the nature of long COVID, exploring its links with other post-viral illnesses such as myalgic encephalomyelitis/chronic fatigue syndrome, and highlights how long COVID research can help us better support those suffering from all post-viral syndromes. Long COVID research started particularly swiftly in populations routinely monitoring their physical performance - namely the military and elite athletes. The review highlights how the high degree of diagnosis, intervention and monitoring of success in these active populations can suggest management strategies for the wider population. We then consider how a key component of performance monitoring in active populations, cardiopulmonary exercise training, has revealed long COVID-related changes in physiology - including alterations in peripheral muscle function, ventilatory inefficiency and autonomic dysfunction. The nature and impact of dysautonomia are further discussed in relation to postural orthostatic tachycardia syndrome, fatigue and treatment strategies that aim to combat sympathetic overactivation by stimulating the vagus nerve. We then interrogate the mechanisms that underlie long COVID symptoms, with a focus on impaired oxygen delivery due to micro-clotting and disruption of cellular energy metabolism, before considering treatment strategies that indirectly or directly tackle these mechanisms. These include remote inspiratory muscle training and integrated care pathways that combine rehabilitation and drug interventions with research into long COVID healthcare access across different populations. Overall, this review showcases how physiological research reveals the changes that occur in long COVID and how different therapeutic strategies are being developed and tested to combat this condition.

Assessing medical students’ perception of cross-cultural competence at a private University in Karachi

BackgroundCross-cultural competence is widely regarded to play an important role in being able to deliver appropriate and effective health care to patients with different backgrounds, race, gender orientation and cultural beliefs. This study aims to assess how medical students feel about their comfort, knowledge, and skill level in handling a diverse patient population using a validated questionnaire.MethodsThis study was carried out over a period of three weeks from July 5th to July 26th of 2021, in the Aga Khan University Hospital, Karachi, Pakistan. All medical students who fulfilled the eligibility criteria and gave informed consent were included in the study. A modified version of the Harvard cross-cultural care survey was used to assess the medical students’ comfort, knowledge and skill level in a variety of circumstances related to patients with different backgrounds and cultures. Descriptive statistical analysis of the questionnaire items was carried out. We reported frequencies and percentages for gender and year of study. For the questionnaire items, we reported mean, assuming that our Likert scale had equivariant intervals. Furthermore, multivariate analysis between demographics and themes was carried out. A p-value of < 0.05 was taken as statistically significant.ResultsIt was found that students of year 5 considered themselves more knowledgeable, comfortable and skilled in dealing with patients of different backgrounds, religions and beliefs compared to students of year 1 and had a higher average score in all of these categories which was statistically significant. Additionally, students who believed it is extremely important to practice medicine with a diverse patient population also had the highest averages in perceived knowledge, comfort and skills in dealing with patients of different sociocultural backgrounds compared to students who believed it wasn’t important at all.ConclusionThis is a first of its kind study in a private medical university in Pakistan and highlights the students’ self-assessment of their competence when caring for patients from different backgrounds. This study can be used as a reference study in the region to carry out further studies and to assess and improve the gaps in medical training being provided.

Assessing Clinical Outcomes in Patients Undergoing Splenectomy for Immune Thrombocytopenia: A Real World Perspective

Background:Immune thrombocytopenia (ITP) is an acquired immune-mediated disorder characterized by frequent relapses. Splenectomy was considered an integral part of ITP therapy until the inception of newer agents, namely rituximab and thrombopoietin receptor agonists (TPO-RA) over the last 20 years. Recently the role and timing of splenectomy have become an area of debate. Studies regarding optimal predictors of response have not demonstrated reliable clinical or laboratory factors. We chose to evaluate the most recent practices and outcomes at Montefiore Medical Center to assess the role of splenectomy in ITP treatment in our diverse, real world patient population.Methods:We conducted a retrospective cohort study of patients who had undergone splenectomy for ITP at Montefiore between January 1, 2015 and July 1, 2021. Collected data included demographics, comorbidities, prior lines of treatment, and splenectomy outcomes. Outcome data included mortality and need for post-splenectomy treatment. Response rates were assessed by American Society of Hematology (ASH) guidelines.Results:The study population comprised 29 patients who underwent splenectomy for ITP as primary indication. Patients were 59% (N=17) female, with a median age of 45 years. Our multi-ethnic cohort included 11 (40%) Hispanic, 7 (24%) African American, and 6 (21%) Caucasian patients. Five patients chose not to specify. Significant comorbidities prior to undergoing surgery were present in 79% (N=23) of patients, with the average number being two. Of these, 41% (N=12) had a comorbid autoimmune condition. Two were HIV positive.Initial treatment consisted of steroids, IVIG (or WinRho), or both for all patients. Only four patients failed to respond to these therapies; one of whom experienced remission following splenectomy and one of whom expired within 30 days of surgery. Fourteen patients (48%) continued to receive repeat doses of steroids and/or IVIG until surgery. Time to splenectomy was variable, range 0-9 years. Additional therapy following relapse on initial treatment consisted of TPO-RA (11/29, 38%); rituximab (11/29, 38%); immunosuppressive therapy (1/29, 3%); and danazol (3/29, 10%). Response rates for TPO-RA (8/11, 73%), danazol (2/3, 67%), and immunosuppressive therapy (1/1) were greater than that for rituximab infusion (4/11, 36%). Overall, the average number of unique lines of therapy was 2.8 (median=2) and average years from diagnosis to splenectomy was 2.8 (median=1, range 0-11).At a median time from splenectomy to last follow up (or time of death) of 971 days (median=876 days), 18 patients (62.1%) had remained off medical therapy with complete response (CR) following splenectomy. Three patients (10.3%) transiently required additional therapy but subsequently achieved CR and remained off medical therapy for greater than a year. Six patients (20.7%) continued to rely on medical therapy. Two patients (6.9%) died within 30 days of splenectomy; one of unknown causes and one of pulmonary embolism (despite thromboprophylaxis) in the setting of TPO-RA therapy. There was no difference in continued reliance on medical therapy in patients who underwent splenectomy earlier versus later in their ITP course. No differences in outcomes were noted in patients with underlying comorbidities. No differences in outcome were noted between Hispanic, African American, and Caucasian patients.Conclusion:Our review of ITP splenectomies in a real world patient population revealed significant differences in treatment practices and timing of surgical intervention. We did not note differences in splenectomy outcomes across patients of different backgrounds or with comorbidities, confirming that these should not play a role in treatment decisions. Patients who failed to respond to steroids and/or IVIG had lower response rates to splenectomy as has been previously hypothesized, though these represented a very small subset of our study population. Further evaluation of compliance, tolerance, and social factors (i.e. insurance, etc) may assist with understanding differences in response rates to various second line medical therapies. Splenectomy continues to offer high rates of sustained CR for a variety of patients, though reliable predictors of response remain elusive and should continue to be an area of active research. DisclosuresNo relevant conflicts of interest to declare.

Building capacity in times of crisis: Increasing cultural competence of healthcare professionals in the context of the COVID-19.

Nurses are the frontline healthcare professionals fighting the medical and social effects of the current COVID-19 pandemic. Although they work with diverse populations, there is a lack of literature on culturally competent education during an emergency such as a pandemic. To examine the effectiveness of an online education programme aimed at increasing cultural competence among rescue teams and healthcare professionals facing the challenges of the COVID-19 pandemic. Pre-post-web-based intervention study. Pre-post-intervention surveys were administered to a matched sample of Israeli healthcare and rescue organisation professionals. The initial sample included 303 participants (52% women) who completed the pre-intervention survey. More than half of the sample (56%, n=170) were paid workers or volunteers in health organisations. Of the initial sample, 154 participants completed the post-intervention survey following the online cultural competence education programme. Descriptive statistics and multivariate analysis were used to evaluate participants' gains in culturally competent attitudes, knowledge, skills and encounters. This study followed the STROBE guidelines. Participants found the online programme useful in improving their cultural competence during the COVID-19 pandemic. The highest gains were found in the attitudes domains, whereas the lowest in the knowledge domain. Pre-intervention cultural competence scores and incorporating the programme in the educational curricula predicted increased gains in cultural competence. Online educational interventions showed potential for increasing professionals' awareness of cultural biases, differences and attitudes, leading to more open and accepting attitudes towards patients of different backgrounds. Recognising the need for real-time, low-cost and available training, the World Health Organization recommended using online courses for healthcare professionals struggling in the pandemic frontline. Online education programmes provide a useful platform for training health professionals in times of emergency.

Applying Cultural Humility in Geriatric Psychiatry: A Case of Diagnosis and Treatment for an Indian Patient

<h3>Introduction</h3> Cultural humility in geriatric psychiatry provides clinicians with skills to accurately diagnose and effectively treat patients of different backgrounds. Cultural humility includes 1) lifelong learning and self-reflection, 2) acknowledging and addressing power dynamics within the treatment relationship and 3) institutional accountability and partnerships. This poster discusses cultural humility in the diagnosis and treatment of 71-year-old man from India who spoke limited English. <h3>Methods</h3> A case report is presented with information gathered from clinical documents in our electronic medical records system. A literature review and application of cultural humility principles was performed. <h3>Results</h3> Lifelong learning and self-reflection seeks to further knowledge, training and experience to provide culturally competent care. Self-reflection is a skill that develops with time and can be achieved thought through mindfulness and the humility of acknowledging what we do not know. The patient presented for hospitalization after an extended depressive episode with psychosis, suicidal ideation and homicidal ideation. The diagnosis of major depressive disorder with psychosis during hospitalization was later changed to bipolar disorder at follow-up. The delay to care and initial misdiagnosis is discussed in the concept of lifelong learning and self-reflection. Imbalances of power dynamics may result in suboptimal care for patients and recognition and mitigation of imbalances may be critical for the care of people and developing effective relationships with patients and their families. For our patient, like many geriatric patients, treatment planning occurred with both the patient and his adult daughter. The patient would typically prefer his daughter communicate his symptoms and concerns. The treatment power dynamics between provider, patient and family is explored further. Institutional accountability works to have the structure of institutions operate in the model of cultural humility. The patient presented with cognitive impairments but would not engage in evaluation or cognitive assessment tools. There often appeared to be difficulty with use of phone interpreters and understanding the assessment tools. Institutional accountability may address barriers of communication and engagement in assessment by providing robust services for patients and education for providers. <h3>Conclusions</h3> This case demonstrates how cultural humility can be implemented in meaningful ways to improve patient outcomes. Future direction includes the application of cultural humility in clinical and research settings. Further studies to obtain the experience of cultural humility from patients, families and providers would be beneficial to increase the use of cultural humility in patient care. <h3>Funding</h3> No funding to declare.

Diversity in NAFLD: A Review of Manifestations of Nonalcoholic Fatty Liver Disease in Different Ethnicities Globally.

Globally, the rise in prevalence of obesity and metabolic syndrome as a whole has been linked to increased access to processed foods, such as refined sugars and saturated fats. Consequently, nonalcoholic fatty liver disease (NAFLD) is on the rise in both developed and developing nations. However, much is still unknown on the NAFLD phenotype with regards to the effect of ethnic diversity. Despite similarities in dietary habits, it appears that certain ethnicities are more protected against NAFLD than others. However, manifestations of the same genetic polymorphisms in different groups of people increase those individuals’ predisposition to NAFLD. Diets from different regions have been associated with a lower prevalence of NAFLD and have even been linked to regression of hepatic steatosis. Socioeconomic variations amongst different regions of the world also contribute to NAFLD prevalence and associated complications. Thus, a thorough understanding of ethnic variability in NAFLD is essential to tailoring treatment recommendations to patients of different backgrounds.

Current Status of Adverse Drug Reactions (ADRs) Reporting in India

Adverse drug reaction (ADR) has been reported as one of the top ten leading causes of morbidity and mortality. Adverse drug reactions (ADRs) are unpleasant and noxious drug effects that have considerable economic and clinical burden as they often lead to hospital admission and/or prolongation of hospital stay. Pharmacovigilance is the science and activities related to the detection, assessment, understanding and prevention of adverse effects, particularly for a safer and rational use of medicines. It has been observed that a medication that is proven efficacious in a large patient population often fails to work in some other patients of different backgrounds. Promoting safe use of medicines is a priority of the Indian Pharmacopoeia Commission (IPC) that functions as the National Coordination Center (NCC) for the Pharmacovigilance Program of India (PvPI). The main function of the PvPI is monitoring the ADRs efficiently by setting up of Adverse Drug Reactions Monitoring Centers (AMCs) across India and training personnel who can perform this function. As of 2018, there are more than 250 AMCs that report ADRs to NCC-PvPI. They have played an important role in generating awareness amongst healthcare professionals (HCPs) about the importance and the process of reporting ADRs which has led to a multifold increase in ADR reporting in India.

DDHE Director Speaks About the Importance of Diversity in Psychiatry

DDHE Director Speaks About the Importance of Diversity in Psychiatry

Non-adherence to lipid-lowering therapies: a need for more studies to evaluate reasons for medication non-adherence

Linked Comment: Refiker. Int J Clin Pract 2011; 65: 1321. To the Editor: The letter by Ege et al. (1) has highlighted some of the factors associated with suboptimal adherence to lipid-lowering therapies as found in our recent study (2). Admittedly, although these factors were evaluated from a relatively large Chinese population, their generalisability to other patient groups requires caution as medication adherence is affected by health beliefs and cultural-specific attitudes, as well as its therapeutic-specific features like dosage, frequency and side effect profiles. The use of statins in clinical practice is strongly supported by a substantial body of evidence. A recent review of statin trials has established the efficacy and safety of statins in primary prevention across a wide range of high-risk patients (3). In secondary prevention trials, intensive therapy was shown to be safe and could offer further clinical benefits including reduction in cardiovascular risk and hospitalisation for heart failure patients, as well as clinical events in patients with acute coronary syndrome (3). In clinical practice, physicians play an important role to reduce the impact brought forth by dyslipidaemia. Family physicians are influential on its control – this has been impressively demonstrated by a recent study in a US, community-based, independent family medicine practice, where statin therapeutic substitution could be successfully performed within the context of its typical patient care (4). In addition, there is a modelled annual cost savings associated with medication switching. This shows that changes in the model of care of the healthcare system on drug adherence could positively influence clinical outcomes. However, there are simply so many factors influencing patient adherence and there are still a scarcity of studies evaluating the impact of these factors. Retrospective studies conducted on large database (1) are unlikely to explore the underlying reasons of statin non-adherence. One must bear in mind that medication adherence is affected by: (i) demographic variables like age, gender, race, socioeconomic status, educational levels and areas of residence, (ii) Clinical factors like patients’ knowledge on medications, beliefs about treatment, self-efficacy, the presence of cognitive impairment, the presence of comorbidities, smoking and drinking, (iii) drug-related factors like complexity of medication regimen, adverse drug reactions, initial medication dose, mono- vs. combination therapy and (iv) Physician factors like single vs. multiple medical provider; patient–clinician relationship; shared decision-making approach between physicians and patients on the initiation of drugs and their continuation (5). Nevertheless, more studies on the adherence profiles and identification of the most influential factors leading to poor adherence in different clinic settings among different patient groups are earnestly needed. As one can hardly search a comprehensive list of reasons why patients prescribed lipid-lowering therapies are not medication-adherent, evaluation of the reasons of medication non-adherence in patients of different backgrounds represents an important future research direction. The authors have no conflicts of interests to declare.

Barriers to colorectal cancer screening in community health centers: A qualitative study

BackgroundColorectal cancer screening rates are low among disadvantaged patients; few studies have explored barriers to screening in community health centers. The purpose of this study was to describe barriers to/facilitators of colorectal cancer screening among diverse patients served by community health centers.MethodsWe identified twenty-three outpatients who were eligible for colorectal cancer screening and their 10 primary care physicians. Using in-depth semi-structured interviews, we asked patients to describe factors influencing their screening decisions. For each unscreened patient, we asked his or her physician to describe barriers to screening. We conducted patient interviews in English (n = 8), Spanish (n = 2), Portuguese (n = 5), Portuguese Creole (n = 1), and Haitian Creole (n = 7). We audiotaped and transcribed the interviews, and then identified major themes in the interviews.ResultsFour themes emerged: 1) Unscreened patients cited lack of trust in doctors as a barrier to screening whereas few physicians identified this barrier; 2) Unscreened patients identified lack of symptoms as the reason they had not been screened; 3) A doctor's recommendation, or lack thereof, significantly influenced patients' decisions to be screened; 4) Patients, but not their physicians, cited fatalistic views about cancer as a barrier. Conversely, physicians identified competing priorities, such as psychosocial stressors or comorbid medical illness, as barriers to screening. In this culturally diverse group of patients seen at community health centers, similar barriers to screening were reported by patients of different backgrounds, but physicians perceived other factors as more important.ConclusionFurther study of these barriers is warranted.