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1.
J Am Geriatr Soc ; 70(11): 3070-3079, 2022 11.
Article in English | MEDLINE | ID: covidwho-2136977

ABSTRACT

Guardianship may pose an ethical dilemma for physicians, who must balance protecting vulnerable patients from potential safety concerns with respecting their autonomy. Older adults with dementia are particularly susceptible to loss of independence and the ability to participate in medical decision making. To have the capacity for medical decision making, individuals must understand relevant information, appreciate their circumstances, demonstrate reasoning, and express a consistent choice free from coercion. Although capacity assessments are usually task-specific, geriatricians and other specialists may be asked to comment on capacity more globally. These determinations may be used to support a Petition for the Appointment of a Guardian of a Legally Incapacitated Adult, the legal process of pursuing guardianship in probate court. Assigned guardians may be known to the incapacitated individual (e.g., a family member or friend) or may be professional guardians with no prior relationship to the ward. Guardians are encouraged to use substituted decision-making, taking into account the ward's previously expressed values and preferences. Although a number of viable alternatives to guardianship exist, numerous systemic barriers may prevent these from being fully explored. The ongoing need for guardianship should be periodically revisited and reassessed. Data about guardians and wards is shockingly sparse, as there are no centralized databases. Laws and regulations for guardianships vary significantly between states. Physicians can serve as important allies and advocates for patients with cognitive impairment at risk of incapacity, can help preserve their autonomy for as long as possible, and ensure appropriate protections are in place if the patient does lose their decision-making ability.


Subject(s)
Decision Making , Legal Guardians , Humans , Aged , Clinical Decision-Making
2.
Lancet Oncol ; 23(2): 270-278, 2022 02.
Article in English | MEDLINE | ID: covidwho-2115061

ABSTRACT

BACKGROUND: Endoscopic surveillance is recommended for patients with Barrett's oesophagus because, although the progression risk is low, endoscopic intervention is highly effective for high-grade dysplasia and cancer. However, repeated endoscopy has associated harms and access has been limited during the COVID-19 pandemic. We aimed to evaluate the role of a non-endoscopic device (Cytosponge) coupled with laboratory biomarkers and clinical factors to prioritise endoscopy for Barrett's oesophagus. METHODS: We first conducted a retrospective, multicentre, cross-sectional study in patients older than 18 years who were having endoscopic surveillance for Barrett's oesophagus (with intestinal metaplasia confirmed by TFF3 and a minimum Barrett's segment length of 1 cm [circumferential or tongues by the Prague C and M criteria]). All patients had received the Cytosponge and confirmatory endoscopy during the BEST2 (ISRCTN12730505) and BEST3 (ISRCTN68382401) clinical trials, from July 7, 2011, to April 1, 2019 (UK Clinical Research Network Study Portfolio 9461). Participants were divided into training (n=557) and validation (n=334) cohorts to identify optimal risk groups. The biomarkers evaluated were overexpression of p53, cellular atypia, and 17 clinical demographic variables. Endoscopic biopsy diagnosis of high-grade dysplasia or cancer was the primary endpoint. Clinical feasibility of a decision tree for Cytosponge triage was evaluated in a real-world prospective cohort from Aug 27, 2020 (DELTA; ISRCTN91655550; n=223), in response to COVID-19 and the need to provide an alternative to endoscopic surveillance. FINDINGS: The prevalence of high-grade dysplasia or cancer determined by the current gold standard of endoscopic biopsy was 17% (92 of 557 patients) in the training cohort and 10% (35 of 344) in the validation cohort. From the new biomarker analysis, three risk groups were identified: high risk, defined as atypia or p53 overexpression or both on Cytosponge; moderate risk, defined by the presence of a clinical risk factor (age, sex, and segment length); and low risk, defined as Cytosponge-negative and no clinical risk factors. The risk of high-grade dysplasia or intramucosal cancer in the high-risk group was 52% (68 of 132 patients) in the training cohort and 41% (31 of 75) in the validation cohort, compared with 2% (five of 210) and 1% (two of 185) in the low-risk group, respectively. In the real-world setting, Cytosponge results prospectively identified 39 (17%) of 223 patients as high risk (atypia or p53 overexpression, or both) requiring endoscopy, among whom the positive predictive value was 31% (12 of 39 patients) for high-grade dysplasia or intramucosal cancer and 44% (17 of 39) for any grade of dysplasia. INTERPRETATION: Cytosponge atypia, p53 overexpression, and clinical risk factors (age, sex, and segment length) could be used to prioritise patients for endoscopy. Further investigation could validate their use in clinical practice and lead to a substantial reduction in endoscopy procedures compared with current surveillance pathways. FUNDING: Medical Research Council, Cancer Research UK, Innovate UK.


Subject(s)
Adenocarcinoma/pathology , Barrett Esophagus/pathology , COVID-19 , Esophageal Neoplasms/pathology , Patient Selection , Watchful Waiting/methods , Adenocarcinoma/diagnostic imaging , Adenocarcinoma/metabolism , Aged , Barrett Esophagus/diagnostic imaging , Barrett Esophagus/metabolism , Barrett Esophagus/therapy , Biomarkers/metabolism , COVID-19/prevention & control , Clinical Decision-Making , Clinical Trials as Topic , Cross-Sectional Studies , Decision Trees , Disease Progression , Esophageal Neoplasms/diagnostic imaging , Esophageal Neoplasms/metabolism , Esophagoscopy , Feasibility Studies , Female , Humans , Male , Middle Aged , Pilot Projects , Prospective Studies , Retrospective Studies , Risk Assessment , Risk Factors , SARS-CoV-2 , Trefoil Factor-3/metabolism , Tumor Suppressor Protein p53/metabolism
4.
JAMA Netw Open ; 5(11): e2240332, 2022 Nov 01.
Article in English | MEDLINE | ID: covidwho-2094125

ABSTRACT

Importance: There is increasing recognition of the long-term health effects of SARS-CoV-2 infection (sometimes called long COVID). However, little is yet known about the clinical diagnosis and management of long COVID within health systems. Objective: To describe dominant themes pertaining to the clinical diagnosis and management of long COVID in the electronic health records (EHRs) of patients with a diagnostic code for this condition (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] code U09.9). Design, Setting, and Participants: This qualitative analysis used data from EHRs of a national random sample of 200 patients receiving care in the Department of Veterans Affairs (VA) with documentation of a positive result on a polymerase chain reaction (PCR) test for SARS-CoV-2 between February 27, 2020, and December 31, 2021, and an ICD-10 diagnostic code for long COVID between October 1, 2021, when the code was implemented, and March 1, 2022. Data were analyzed from February 5 to May 31, 2022. Main Outcomes and Measures: A text word search and qualitative analysis of patients' VA-wide EHRs was performed to identify dominant themes pertaining to the clinical diagnosis and management of long COVID. Results: In this qualitative analysis of documentation in the VA-wide EHR, the mean (SD) age of the 200 sampled patients at the time of their first positive PCR test result for SARS-CoV-2 in VA records was 60 (14.5) years. The sample included 173 (86.5%) men; 45 individuals (22.5%) were identified as Black and 136 individuals (68.0%) were identified as White. In qualitative analysis of documentation pertaining to long COVID in patients' EHRs 2 dominant themes were identified: (1) clinical uncertainty, in that it was often unclear whether particular symptoms could be attributed to long COVID, given the medical complexity and functional limitations of many patients and absence of specific markers for this condition, which could lead to ongoing monitoring, diagnostic testing, and specialist referral; and (2) care fragmentation, describing how post-COVID-19 care processes were often siloed from and poorly coordinated with other aspects of care and could be burdensome to patients. Conclusions and Relevance: This qualitative study of documentation in the VA EHR highlights the complexity of diagnosing long COVID in clinical settings and the challenges of caring for patients who have or are suspected of having this condition.


Subject(s)
COVID-19 , Male , Humans , Middle Aged , Female , COVID-19/diagnosis , COVID-19/epidemiology , SARS-CoV-2 , Clinical Decision-Making , Uncertainty
5.
J Am Assoc Nurse Pract ; 34(11): 1235-1241, 2022 Nov 01.
Article in English | MEDLINE | ID: covidwho-2077949

ABSTRACT

ABSTRACT: Nurse practitioners (NPs) are often responsible for coding patient encounters for reimbursement. Students should learn the basics of this skill during their educational preparation. On January 1, 2021, the American Medical Association and the Centers for Medicare & Medicaid Services implemented new guidelines to the evaluation and management office appointment documentation and coding. The new medical decision-making (MDM) guidelines created a learning curve for NP students, faculty, and preceptors. An additional obstacle was encountered when on-campus preclinical intensives, which included a coding practice session, were canceled due to the COVID-19 pandemic. The faculty of an NP program identified MDM coding as a difficult concept to teach in an asynchronous learning environment. In response, the faculty developed and implemented synchronous online case study sessions that incorporated active student participation and real-time feedback, thus increasing engagement with peers, faculty, and the MDM concepts. The purpose of this article was to present a synchronous method for teaching MDM coding to NP students, and the outcomes, lessons learned, and implications for nursing education and practice.


Subject(s)
COVID-19 , Nurse Practitioners , Students, Medical , Students, Nursing , Aged , Humans , United States , Pandemics , Medicare , Nurse Practitioners/education , Students , Clinical Decision-Making
7.
Appl Health Econ Health Policy ; 20(5): 693-706, 2022 09.
Article in English | MEDLINE | ID: covidwho-2000146

ABSTRACT

BACKGROUND: Information asymmetries and the agency relationship are two defining features of the healthcare system. These market failures are often used as a rationale for government intervention. Many countries have government financing and provision of healthcare in order to correct for this, while health technology agencies also exist to improve efficiency. However, informational asymmetries and the resulting principal-agent problem still persist, and one example is the lack of cost awareness amongst clinicians. This study explores the cost awareness of clinicians across different settings. METHODS: We targeted four clinical cohorts: medical students, Senior House Officers/Interns, Mid-grade Senior Registrar/Residents, and Consultant/Attending Physicians, in six hospitals in the United Kingdom, the United States, Australia, New Zealand and Spain. The survey asked respondents to report the cost (as they recalled) of different types of scans, visits, medications and tests. Our analysis focused on the differential between the perceived/recalled cost and the actual cost. We explored variation across speciality, country and other potential confounders. Cost-awareness levels were estimated based on the cost estimates within 25% of the actual cost. RESULTS: We received 705 complete responses from six sites across five countries. Our analysis found that respondents often overestimated the cost of common tests while underestimating high-cost tests. The mean cost-awareness levels varied between 4 and 23% for different items. Respondents acknowledged that they did not feel they had received adequate training in cost awareness. DISCUSSION: The current financial climate means that cost awareness and the appropriate use of scarce healthcare resources is more paramount than perhaps ever before. Much of the focus of health economics research is on high-cost innovative technologies, yet there is considerable waste in the system with respect to overtreatment and overdiagnosis. Common reasons put forward for this include defensive medicine, poor education, clinical uncertainty and the institution of protocols. CONCLUSION: Given the role of clinicians in the healthcare system, as agents both for patients and for providers, more needs to be done to remove informational asymmetries and improve clinician cost awareness.


Subject(s)
Clinical Decision-Making , Hospitals , Australia , Humans , Surveys and Questionnaires , Uncertainty , United States
9.
J Plast Reconstr Aesthet Surg ; 75(7): 2387-2440, 2022 07.
Article in English | MEDLINE | ID: covidwho-1956092

ABSTRACT

Flap monitoring charts and escalation protocols are ubiquitous amongst microsurgical departments and can facilitate converting flap observations into flap monitoring decisions. However, human factors in the recognition-communication process of decision-making still pose a threat to timely intervention and thus are a key determinant of success in microvascular surgery. Digitally transforming paper-based pathways may facilitate early recognition and escalation to potentially salvage a free flap with compromised vascularity. We describe the early adoption and use case of a ChatBot to support clinical decision-making support for free flap monitoring - the 'FlapBot'.


Subject(s)
Free Tissue Flaps , Reconstructive Surgical Procedures , Clinical Decision-Making , Free Tissue Flaps/blood supply , Humans , Reconstructive Surgical Procedures/methods , Retrospective Studies , Salvage Therapy
10.
Braz J Infect Dis ; 26(4): 102389, 2022.
Article in English | MEDLINE | ID: covidwho-1956091

ABSTRACT

The performance of a test can be suboptimal, but in appropriate setting such a test is still useful for clinical decision making. We investigated the role of Antigen Rapid Diagnostic Test (Ag-RDT) for clinical decision making in an Emergency Department (ED) in Curacao during peak of COVID-19 pandemic. Ag-RDT was performed in the naso- and oropharynx-swabs from patients with respiratory insufficiency presented to the ED. Ag-RDT was performed in 153 patients, of which 64 (41.8%) showed positive results. Comparing Ag-RDT results with molecular tests, its sensitivity was 68.8% (95% CI 57.4 to 78.7), and specificity of 94.6% (95% CI 84.9 to 98.9). The positive and negative predictive value were 95.1% (95% CI 86.5 to 98.3) and 66.3 (95% CI 58.6 to 73.3), respectively. All patients with Ag-RDT positive test were admitted to the cohorted COVD-19 department of the hospital. By using Ag-RDT, 35.9% of rapid PCR tests (that are more costly and laborious to perform) could be avoided at cost of 5.8% patients with false positive result. In conclusion, in real practice, disease prevalence is as important as test's performance for clinical decision making. The conclusion may also be applicable for other diagnostic tests than COVID-19 diagnostic.


Subject(s)
COVID-19 Testing , COVID-19 , Clinical Decision-Making , Prevalence , COVID-19/diagnosis , COVID-19 Testing/statistics & numerical data , Curacao/epidemiology , Humans , Pandemics , Sensitivity and Specificity
11.
BMJ Open Respir Res ; 9(1)2022 07.
Article in English | MEDLINE | ID: covidwho-1950207

ABSTRACT

INTRODUCTION: Malignant pleural mesothelioma is a rare, incurable cancer arising from previous asbestos exposure; patients have a poor prognosis, with a median survival rate of 8-14 months. Variation in mesothelioma clinical decision-making remains common with a lack of multidisciplinary knowledge sharing, leading to inconsistencies in treatment decisions. The study aimed to explore which factors impacted on clinicians' decision-making in mesothelioma care, with a view to optimising the mesothelioma care pathway. METHODS: This mixed methods study consisted of documentary analysis of local and national guidelines, policies or documents pertaining to mesothelioma care pathways, secondary analysis of mesothelioma patient data, and interviews with clinicians attending lung cancer and/or mesothelioma-specific multidisciplinary team meetings. The study took place at three National Health Service trusts in England. Documentations relating to patients' treatment pathways were collated and reviewed qualitatively. Records of patients with mesothelioma were extracted from hospital patient records and data collected on diagnosis date, treatment, mortality rates, survival postdiagnosis, age and clinical care team. Data were statistically analysed. Interviews with clinicians explored influences on clinical decision-making, including challenges or barriers involved. Data were thematically analysed. The Strengthening the Reporting of Observational Studies in Epidemiology reporting checklist was used. RESULTS: There were differences in the structure and delivery of mesothelioma treatment and care between trusts. Four main themes were identified: 'collaboration and communication', 'evidence base and knowledge', 'role of the clinician' and 'role of the patient'. Two cross-cutting themes relating to the role of the mesothelioma nurse specialist and the impact of COVID-19 were identified. DISCUSSION: There is a need to review the structure of mesothelioma multidisciplinary team meetings to ensure patients are reviewed by clinicians with appropriate knowledge, expertise and understanding of how, why and when decisions should be made. There is a need for expert clinicians in mesothelioma care to promote an up-to-date evidence and knowledge base within the wider multidisciplinary team.


Subject(s)
COVID-19 , Mesothelioma, Malignant , Mesothelioma , Clinical Decision-Making , Humans , Mesothelioma/diagnosis , State Medicine
12.
Med Decis Making ; 42(6): 741-754, 2022 Aug.
Article in English | MEDLINE | ID: covidwho-1909954

ABSTRACT

HIGHLIGHTS: Fuzzy-trace theory (FTT) supports practical approaches to improving health and medicine.FTT differs in important respects from other theories of decision making, which has implications for how to help patients, providers, and health communicators.Gist mental representations emphasize categorical distinctions, reflect understanding in context, and help cue values relevant to health and patient care.Understanding the science behind theory is crucial for evidence-based medicine.


Subject(s)
Decision Making , Problem Solving , Clinical Decision-Making , Humans
13.
Hastings Cent Rep ; 52(3): 4-5, 2022 May.
Article in English | MEDLINE | ID: covidwho-1905851

ABSTRACT

Kensey Dishman was unvaccinated when she contracted Covid-19 at thirteen years old. She also had asthma and is now dead. Her divorced parents disagreed about whether Kensey should be vaccinated, and her father suggested that it was Kensey's own choice to refuse vaccination. This situation is as complicated as it is tragic, and it raises a number of legal and ethical issues regarding medical decision-making for minors, parental rights, vaccination mandates, and individual freedom versus government interests in protecting minors as well as public health. This commentary explores these issues and highlights potential sources of liability for those involved in Kensey's treatment decisions given her high-risk for complications from Covid-19.


Subject(s)
COVID-19 , Adolescent , Clinical Decision-Making , Female , Humans , Minors , Public Health , Vaccination
15.
Int J Mol Sci ; 23(2)2022 Jan 13.
Article in English | MEDLINE | ID: covidwho-1884201

ABSTRACT

Colorectal cancer (CRC) is still a leading cause of cancer death worldwide. Less than half of cases are diagnosed when the cancer is locally advanced. CRC is a heterogenous disease associated with a number of genetic or somatic mutations. Diagnostic markers are used for risk stratification and early detection, which might prolong overall survival. Nowadays, the widespread use of semi-invasive endoscopic methods and feacal blood tests characterised by suboptimal accuracy of diagnostic results has led to the detection of cases at later stages. New molecular noninvasive tests based on the detection of CRC alterations seem to be more sensitive and specific then the current methods. Therefore, research aiming at identifying molecular markers, such as DNA, RNA and proteins, would improve survival rates and contribute to the development of personalized medicine. The identification of "ideal" diagnostic biomarkers, having high sensitivity and specificity, being safe, cheap and easy to measure, remains a challenge. The purpose of this review is to discuss recent advances in novel diagnostic biomarkers for tumor tissue, blood and stool samples in CRC patients.


Subject(s)
Biomarkers, Tumor , Colorectal Neoplasms/diagnosis , Colorectal Neoplasms/etiology , Early Detection of Cancer/methods , Clinical Decision-Making , Colorectal Neoplasms/metabolism , Disease Management , Disease Susceptibility , Feces/chemistry , Humans , Liquid Biopsy/methods , Precision Medicine/methods , Volatile Organic Compounds
16.
Circulation ; 144(6): e123-e135, 2021 08 10.
Article in English | MEDLINE | ID: covidwho-1883361

ABSTRACT

Myocarditis remains a clinical challenge in pediatrics. Originally, it was recognized at autopsy before the application of endomyocardial biopsy, which led to a histopathology-based diagnosis such as in the Dallas criteria. Given the invasive and low-sensitivity nature of endomyocardial biopsy, its diagnostic focus shifted to a reliance on clinical suspicion. With the advances of cardiac magnetic resonance, an examination of the whole heart in vivo has gained acceptance in the pursuit of a diagnosis of myocarditis. The presentation may vary from minimal symptoms to heart failure, life-threatening arrhythmias, or cardiogenic shock. Outcomes span full resolution to chronic heart failure and the need for heart transplantation with inadequate clues to predict the disease trajectory. The American Heart Association commissioned this writing group to explore the current knowledge and management within the field of pediatric myocarditis. This statement highlights advances in our understanding of the immunopathogenesis, new and shifting dominant pathogeneses, modern laboratory testing, and use of mechanical circulatory support, with a special emphasis on innovations in cardiac magnetic resonance imaging. Despite these strides forward, we struggle without a universally accepted definition of myocarditis, which impedes progress in disease-targeted therapy.


Subject(s)
Myocarditis/diagnosis , Myocarditis/therapy , Animals , Biopsy , Child , Clinical Decision-Making , Combined Modality Therapy , Disease Management , Disease Models, Animal , Disease Susceptibility/immunology , Humans , Multimodal Imaging , Myocarditis/etiology , Myocarditis/mortality , Prognosis , Symptom Assessment , Treatment Outcome
17.
Rev Bras Enferm ; 75(5): e20210586, 2022.
Article in English, Portuguese | MEDLINE | ID: covidwho-1855075

ABSTRACT

OBJECTIVE: To analyze the critical alarms predictors of clinical deterioration/sepsis for clinical decision making in patients admitted to a reference hospital complex. METHODS: An observational retrospective cohort study. The Machine Learning (ML) tool, Robot Laura®, scores changes in vital parameters and lab tests, classifying them by severity. Inpatients and patients over 18 years of age were included. RESULTS: A total of 122,703 alarms were extracted from the platform, classified as 2 to 9. The pre-selection of critical alarms (6 to 9) indicated 263 urgent alerts (0.2%), from which, after filtering exclusion criteria, 254 alerts were delimited for 61 inpatients. Patient mortality from sepsis was 75%, of which 52% was due to sepsis related to the new coronavirus. After the alarms were answered, 82% of the patients remained in the sectors. CONCLUSIONS: Far beyond technology, ML models can speed up assertive clinical decisions by nurses, optimizing time and specialized human resources.


Subject(s)
Artificial Intelligence , Sepsis , Adolescent , Adult , Clinical Decision-Making , Humans , Machine Learning , Retrospective Studies , Sepsis/diagnosis
18.
Br J Health Psychol ; 27(4): 1275-1295, 2022 11.
Article in English | MEDLINE | ID: covidwho-1799275

ABSTRACT

OBJECTIVES: This study aimed to (1) examine barriers and enablers to General Practitioners' (GP) use of National Institute for Health and Care Excellence (NICE) guidelines for self-harm and (2) recommend potential intervention strategies to improve implementation of them in primary care. DESIGN: Qualitative interview study. METHODS: Twenty-one telephone interviews, semi-structured around the capabilities, opportunities and motivations model of behaviour change (COM-B), were conducted with GPs in the United Kingdom. The Theoretical Domains Framework was employed as an analytical framework. Using the Behaviour Change Wheel, Behaviour Change Techniques (BCTs), intervention functions and exemplar interventions were identified. RESULTS: GPs valued additional knowledge about self-harm risk assessments (knowledge), and communication skills were considered to be fundamental to high-pressure consultations (cognitive and interpersonal skills). GPs did not engage with the guidelines due to concerns that they would be a distraction from patient cues about risk during consultations (memory, attention and decision processes), and perceptions that following the guidance is difficult due to time pressures and lack of access to mental health referrals (environmental context and resources). Clinical uncertainty surrounding longer term care for people that self-harm, particularly patients that are waiting for or cannot access a referral, drives GPs to rely on their professional judgement over the guidance (beliefs about capabilities). CONCLUSIONS: Three key drivers related to information and skill needs, guideline engagement and clinical uncertainty need to be addressed to support GPs to be able to assess and manage self-harm. Five intervention functions and ten BCT groups were identified as potential avenues for intervention design.


Subject(s)
General Practitioners , Self-Injurious Behavior , Clinical Decision-Making , General Practitioners/psychology , Humans , Qualitative Research , Self-Injurious Behavior/prevention & control , Uncertainty
19.
Transpl Infect Dis ; 24(1): e13725, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1794555

ABSTRACT

BACKGROUND: Lower respiratory tract infections (LRTIs) are a significant cause of morbidity and mortality in lung transplant (LTx) recipients. Timely and precise pathogen detection is vital to successful treatment. Multiplex PCR kits with short turnover times like the BioFire Pneumonia Plus (BFPPp) (manufactured by bioMérieux) may be a valuable addition to conventional tests. METHODS: We performed a prospective observational cohort study in 60 LTx recipients with suspected LRTI. All patients received BFPPp testing of bronchoalveolar lavage fluid in addition to conventional tests including microbiological cultures and conventional diagnostics for respiratory viruses. Primary outcome was time-to-test-result; secondary outcomes included time-to-clinical-decision and BFPPp test accuracy compared to conventional tests. RESULTS: BFPPp provided results faster than conventional tests (2.3 h [2-2.8] vs. 23.4 h [21-62], p < 0.001), allowing for faster clinical decisions (2.8 [2.2-44] vs. virology 28.1 h [23.1-70.6] and microbiology 32.6 h [4.6-70.9], both p < 0.001). Based on all available diagnostic modalities, 26 (43%) patients were diagnosed with viral LRTI, nine (15 %) with non-viral LRTI, and five (8 %) with combined viral and non-viral LRTI. These diagnoses were established by BFPPp in 92%, 78%, and 100%, respectively. The remaining 20 patients (33 %) received a diagnosis other than LRTI. Preliminary therapies based on BFPPp results were upheld in 90% of cases. There were six treatment modifications based on pathogen-isolation by conventional testing missed by BFPPp, including three due to fungal pathogens not covered by the BFPPp. CONCLUSION: BFPPp offered faster test results compared to conventional tests with good concordance. The absence of fungal pathogens from the panel is a potential weakness in a severely immunosuppressed population.


Subject(s)
Lung Transplantation , Pneumonia , Respiratory Tract Infections , Clinical Decision-Making , Humans , Lung Transplantation/adverse effects , Prospective Studies , Respiratory Tract Infections/diagnosis
20.
J AAPOS ; 26(3): 113.e1-113.e6, 2022 06.
Article in English | MEDLINE | ID: covidwho-1783440

ABSTRACT

BACKGROUND: Acute infectious conjunctivitis is a common childhood illness, and the role of antibiotic treatment remains unclear. The purpose of this study was to describe the decision-making process providers use when managing infectious conjunctivitis, to identify factors that reduce unnecessary antibiotic prescribing, and to evaluate how the COVID-19 pandemic influenced prescribing behavior. METHODS: We conducted semi-structured interviews with 20 providers caring for children in primary care, urgent cares, and emergency departments in Denver, Colorado. Interviews were evaluated for major themes using deductive and inductive content analysis methods. RESULTS: Significant drivers for deciding to treat infectious conjunctivitis with antibiotics included patient's clinical presentation, family expectations, antibiotic stewardship concerns, etiological diagnostic uncertainty, and school/daycare policies. High variability existed in approaches used to distinguish viral from bacterial conjunctivitis. No providers were aware of pediatric treatment guidelines or standardized recommendations for return to school or daycare. Providers reported higher antibiotic prescribing during the COVID-19 pandemic. Factors identified that could reduce unnecessary antibiotic prescribing included family education, a reliable diagnostic test to decrease diagnostic uncertainty, pediatric clinical guidelines, and standardizing exclusion policies for school/daycare. CONCLUSIONS: Management of pediatric infectious conjunctivitis is inconsistent. Creation of guidelines for the evaluation and management of infectious conjunctivitis in children could help reduce unnecessary prescribing and the burden for families and the health care system. In addition, updated guidelines for school/daycare exclusion may be important to establish streamlined and evidence-based exclusion practices.


Subject(s)
COVID-19 , Conjunctivitis , Anti-Bacterial Agents/therapeutic use , COVID-19/epidemiology , Child , Clinical Decision-Making , Humans , Pandemics , Practice Patterns, Physicians'
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