The impact of adherence to community-acquired pneumonia (CAP) management guidelines on improving clinical outcomes in hospitalized patients

Objectives: Community-acquired pneumonia (CAP) is linked with high morbidity and mortality, particularly among the elderly. Because of the high incidence and accompanying financial expenses, accurate diagnosis and adequate care of this group hospitalized with CAP are required. The purpose of the study was to assess the level of adherence to CAP national guidelines at a private hospital, as well as the impact of adherence to these national recommendations on clinical outcomes. Methods: Data from electronic medical records of adult patients hospitalized with CAP between 2018 and 2019 were retrieved for a quantitative observational retrospective cohort research. Results: This study comprised 159 patients, with 76 patients (47.8%) receiving therapy according to the recommendations of the guidelines. A total of 75 (98.7%) of those patients were hospitalized across the ICU wards. In contrast, 98.4% (64/65) of patients who had received empiric antibiotic treatment within isolation floors were non-compliant. There was a statistically significant relationship between the level of adherence to CAP clinical guidelines and the following variables: The 72-hour reassessment (P = 0.01), medications altered OR retained when culture findings were revealed (P = 0.01), primary diagnosis (P = 0.028), and total intended period of antibiotic therapy (P = 0.007). Conclusions: According to the findings of this study, higher adherence to the guidelines amongst ICU patients was linked to better outcomes, such as a significant reduction in the overall planned period of antibiotic therapy. (AU)

Decision-Making Preferences among Advanced Cancer Patients in a Palliative Setting in Jordan.

Understanding patients' decision-making preferences is crucial for enhancing patients' outcomes. The current study aims to identify Jordanian advanced cancer patients' preferred decision-making and to explore the associated variables of the passive decision-making preference. We used a cross-sectional survey design. Patients with advanced cancer referred to the palliative care clinic at a tertiary cancer center were recruited. We measured patients' decision-making preferences using the Control Preference Scale. Patients' satisfaction with decision-making was assessed with the Satisfaction with Decision Scale. Cohen's kappa statistic was used to assess the agreement between decision-control preferences and actual decision-making, and the bivariate analysis with 95% CI and the univariate and multivariate logistic regression were used to examine the association and predictors of the demographical and clinical characteristics of the participants and the participants' decision-control preferences, respectively. A total of 200 patients completed the survey. The patients' median age was 49.8 years, and 115 (57.5%) were female. Of them, 81 (40.5%) preferred passive decision control, and 70 (35%) and 49 (24.5%) preferred shared and active decision control, respectively. Less educated participants, females, and Muslim patients were found to have a statistically significant association with passive decision-control preferences. Univariate logistic regression analysis showed that, being a male (p = 0.003), highly educated (p = 0.018), and a Christian (p = 0.006) were statistically significant correlates of active decision-control preferences. Meanwhile, the multivariate logistic regression analysis showed that being a male or a Christian were the only statistically significant predictors of active participants' decision-control preferences. Around 168 (84%) of participants were satisfied with the way decisions were made, 164 (82%) of patients were satisfied with the actual decisions made, and 143 (71.5%) were satisfied with the shared information. The agreement level between decision-making preferences and actual decision practices was significant (ⱪ coefficient = 0.69; 95% CI = 0.59 to 0.79). The study's results demonstrate that a passive decision-control preference was prominent among patients with advanced cancer in Jordan. Further studies are needed to evaluate decision-control preference for additional variables, such as patients' psychosocial and spiritual factors, communication, and information sharing preferences, throughout the cancer trajectory so as to inform policies and improve practice.

Validation of the Arabic Version of the Edmonton Symptom Assessment System.

Quality cancer care is a team effort. In addition, patients' symptoms change over the course of treatment. As such, the Edmonton Symptom Assessment System (ESAS) is a simple tool designed to quickly monitor symptom change. Here, we present the results from a two-phase study aimed at validating the Arabic version of the ESAS (ESAS-A). Phase one involved the creation of two versions of the ESAS with both reverse and forward translations by bilingual, native Arabic speakers as well as evaluation by an expert panel. The reconciled version was then administered to 20 patients as a pilot from which to create the final version, which was then used with 244 patients. Phase two for the ESAS-involved an ESAS-based validation of 244 adults aged 18 years and older who were diagnosed with advanced cancer; then, further validation was completed in conjunction with two other symptom survey tools, the EORTC-Pal 15 and the HADS. The ESAS-A items possessed good internal consistency with an average Cronbach's alpha of 0.84, ranging from 0.82 to 0.85. Moreover, the results of ESAS-A showed good agreement with those of EORTC QLQ- 15 PAL (r = 0.36 to 0.69) and HADS (r = 0.60 and 0.57) regarding anxiety and depression. We found the ESAS-A to be responsive to symptom change and a median time to completion of 3.73 min. The results of our study demonstrate that the ESAS-A is a reliable, valid, and feasible tool for the purposes of monitoring symptom change over the course of cancer treatment.

Religion, Islam, and Compliance with COVID-19 Best Practices.

While many have implemented best practices intended to help stem the spread of COVID-19, there are also a substantial number of citizens, both domestically and abroad, who have resisted these practices. We argue that public health authorities, as well as scientific researchers and funders, should help address this resistance by putting greater effort into ascertaining how existing religious practices and beliefs align with COVID-19 guidelines. In particular, we contend that Euro-American scholars-who have often tended to implicitly favor secular and Christian worldviews-should put added focus on how Islamic commitments may (or may not) support COVID-19 best practices, including practices that extend beyond the domain of support for mental health.

Antimicrobial prescribing and clinical outcomes in patients with COVID-19 infection: Experience of a single center in an upper middle-income country.

Objectives: The aim of this study was to describe antimicrobial prescribing patterns in hospitalized adult patients with confirmed diagnosis of COVID-19 infection, and to determine the relationship between antimicrobial agent used and non-survival amongst the studied COVID-19 patients. Methods: This is an observational, retrospective study. Specialty Clinic Hospital in Jordan is selected as the study setting for this conducted study. The study comprised of all hospitalized adult patients with confirmed diagnosis of COVID-19 infection who were admitted to the hospital between October 2020 and December 2020. Findings: A total of 216 hospitalized patients with confirmed COVID-19 were included in the analysis. The majority of patients were prescribed antibiotic agents (n=149, 69.0%). Almost half of the patients have been prescribed antivirals agent (n=111, 51.4%). Survivals were significantly more likely to have been prescribed third generation cephalosporin (19.8% vs 3.4%, p=0.02). Non-survivals were significantly more likely to be older in age (mean age: 70.5 vs 62.7 years, p=0.009), have higher mean Charleston Comorbidity Index Score (3.7 vs 2.7, p=0.01), have at least one comorbidity (93.1% vs 71.1%, p=0.008), had shortness of breath at admission (72.4% vs 50.8%, p=0.023) and were admitted to the ICU during current admission (96.6% vs 18.7%, p<0.001) compared to survivors. Non-survivals were significantly more likely to had increased levels of WBC count (41.4% vs 19.7%; p=0.034), increased neutrophiles count (72.4% vs 39.4%; p=0.004) and higher mean C-reactive protein (167.2 vs 103.6; p=0.001) at admission. Conclusions: The results of this study demonstrated factors are associated with the non-survival, and additionally benchmarked the mortality rate, amongst the studied COVID 19 patients.

Antimicrobial prescribing and clinical outcomes in patients with COVID-19 infection: Experience of a single center in an upper middle-income country

Objectives: The aim of this study was to describe antimicrobial prescribing patterns in hospitalized adult patients with confirmed diagnosis of COVID-19 infection, and to determine the relationship between antimicrobial agent used and non-survival amongst the studied COVID-19 patients. Methods: This is an observational, retrospective study. Specialty Clinic Hospital in Jordan is selected as the study setting for this conducted study. The study comprised of all hospitalized adult patients with confirmed diagnosis of COVID-19 infection who were admitted to the hospital between October 2020 and December 2020. Findings: A total of 216 hospitalized patients with confirmed COVID-19 were included in the analysis. The majority of patients were prescribed antibiotic agents (n=149, 69.0%). Almost half of the patients have been prescribed antivirals agent (n=111, 51.4%). Survivals were significantly more likely to have been prescribed third generation cephalosporin (19.8% vs 3.4%, p=0.02). Non-survivals were significantly more likely to be older in age (mean age: 70.5 vs 62.7 years, p=0.009), have higher mean Charleston Comorbidity Index Score (3.7 vs 2.7, p=0.01), have at least one comorbidity (93.1% vs 71.1%, p=0.008), had shortness of breath at admission (72.4% vs 50.8%, p=0.023) and were admitted to the ICU during current admission (96.6% vs 18.7%, p<0.001) compared to survivors. Non-survivals were significantly more likely to had increased levels of WBC count (41.4% vs 19.7%; p=0.034), increased neutrophiles count (72.4% vs 39.4%; p=0.004) and higher mean C-reactive protein (167.2 vs 103.6; p=0.001) at admission. Conclusions: The results of this study demonstrated factors are associated with the non-survival, and additionally benchmarked the mortality rate, amongst the studied COVID 19 patients. (AU)

DNR and COVID-19: The Ethical Dilemma and Suggested Solutions.

Ethics are considered a basic aptitude in healthcare, and the capacity to handle ethical dilemmas in tough times calls for an adequate, responsible, and blame-free environment. While do-not-resuscitate (DNR) decisions are made in advance in certain medical situations, in particular in the setting of poor prognosis like in advanced oncology, the discussion of DNR in relation to acute medical conditions, the COVID-19 pandemic in this example, might impose ethical dilemmas to the patient and family, healthcare providers (HCPs) including physicians and nurses, and to the institution. The literature on DNR decisions in the more recent pandemics and outbreaks is scarce. DNR was only discussed amid the H1N1 influenza pandemic in 2009, with clear global recommendations. The unprecedented condition of the COVID-19 pandemic leaves healthcare systems worldwide confronting tough decisions. DNR has been implemented in some countries where the healthcare system is limited in capacity to admit, and thus intubating and resuscitating patients when needed is jeopardized. Some countries were forced to adopt a unilateral DNR policy for certain patient groups. Younger age was used as a discriminator in some, while general medical condition with anticipated good outcome was used in others. The ethical challenge of how to balance patient autonomy vs. beneficence, equality vs. equity, is a pressing concern. In the current difficult situation, when cases top 100 million globally and the death toll surges past 2.7 million, difficult decisions are to be made. Societal rather than individual benefits might prevail. Pre-hospital triaging of cases, engagement of other sectors including mental health specialists and religious scholars to support patients, families, and HCPs in the frontline might help in addressing the psychological stress these groups might encounter in addressing DNR in the current situation.

Ethical Considerations for Treating Cancer Patients During the SARS-CoV-2 Virus Crisis: To Treat or Not to Treat? A Literature Review and Perspective From a Cancer Center in Low-Middle Income Country.

Providing routine healthcare to patients with serious health illnesses represents a challenge to healthcare providers amid the SARS-CoV-2 pandemic. Treating cancer patients during this pandemic is even more complex due to their heightened vulnerability, as both cancer and cancer treatment weaken the immune system leading to a higher risk of both infections and severe complications. In addition to the need to protect cancer patients from unnecessary exposure to SARS-CoV-2 infection during their routine care, interruption, and discontinuation of cancer treatment can result in negative consequences on patients' health, in addition to the ghost of rationing healthcare resources in high demand during a global health crisis. This article aims to explore the ethical dilemmas faced by decision-makers and healthcare providers caring for cancer patients during the SARS-CoV-2 pandemic. This includes setting triage criteria for non-infected cancer patients, fairly allocating limited healthcare resources between cancer patients and SARS-CoV-2 patients, prioritizing SARS-CoV-2 treatment or vaccine, once developed, for cancer patients and non-cancer patients, patient-physician communication on matters such as end-of-life and do-not-resuscitate (DNR), and lastly, shifting physicians' priorities from treating their own cancer patients to treating critically ill SARS-CoV-2 infected patients. Ultimately, no straightforward decision can be easily made at such exceptionally difficult times. Applying different ethical principles can result in very different scenarios and consequences. In the end, we will briefly share the experience of the King Hussein Cancer Center (KHCC), the only standalone comprehensive cancer center in the region.

Stem Cell Statute in Jordan: Leading the Way.

The use of stem cells in research has caused much controversy and ethical dilemma. The primary source of stem cells is human embryos, a source which has been confronted with objections based on ethical, moral, and religious positions. Jordan has passed the first of its-kind Statute in the region, aiming at regulating the use of stem cells both for therapeutic and research purposes. The Statute adopted a regulatory approach between the restrictive and intermediate. The Statute, however, pays more attention to stem cell banking in many of its articles. Many critical aspects in regulating stem cell research activities are overlooked. This is including but not limited to the process of informed consent, protecting privacy, maintaining confidentiality, the need for a national entity responsible for regulating embryonic stem cell (ESC) research, and requirements of monitoring activity. The authors recommend further review of the current Statute in light of the deficiencies discussed so as to develop a more comprehensive and coherent Statute.

Disclosure of medical errors: physicians' knowledge, attitudes and practices (KAP) in an oncology center.

BACKGROUND: Between the need for transparency in healthcare, widely promoted by patient's safety campaigns, and the fear of negative consequences and malpractice threats, physicians face challenging decisions on whether or not disclosing medical errors to patients and families is a valid option. We aim to assess the knowledge, attitudes and practices (KAP) of physicians in our center regarding medical error disclosure. METHODS: This is a cross-sectional self-administered questionnaire study. The questionnaire was piloted and no major modifications were made. A day-long training workshop consisting of didactic lectures, short and long case scenarios with role playing and feedback from the instructors, were conducted. Physicians who attended these training workshops were invited to complete the questionnaire at the end of the training, and physicians who did not attend any training were sent a copy of the questionnaire to their offices to complete. To assure anonymity and transparency of responses, we did not query names or departments. Descriptive statistics were used to present demographics and KAP. The differences between response\s of physicians who received the training and those who did not were analyzed with t-test and descriptive statistics. The 0.05 level of significance was used as a cutoff measure for statistical significance. RESULTS: Eighty-eight physicians completed the questionnaire (55 attended training (62.50%), and 33 did not (37.50%)). Sixty Five percent of physicians were males and the mean number of years of experience was 16.5 years. Eighty-Seven percent (n = 73) of physicians were more likely to report major harm, compared to minor harm or no harm. Physicians who attended the workshop were more knowledgeable of articles of Jordan's Law on Medical and Health Liability (66.7% vs 45.5%, p-value = 0.017) and the Law was more likely to affect their decision on error disclosure (61.8% vs 36.4%, p-value = 0.024). CONCLUSION: Formal training workshops on disclosing medical errors have the power to positively influence physicians' KAP toward disclosing medical errors to patients and possibly promoting a culture of transparency in the health care system.

Intensity of Cancer Care Near the End of Life at a Tertiary Care Cancer Center in Jordan.

CONTEXT: Chemotherapy use in the last month of life is an indicator of poor quality of end-of-life care. OBJECTIVES: We assessed the frequency of chemotherapy use at the end of life at our comprehensive cancer center in Jordan and identified the factors associated with chemotherapy use. METHODS: We conducted a retrospective chart review to examine the use of chemotherapy in the last 30 days and 14 days of life in consecutive adult patients with cancer seen at King Hussein Cancer Center (KHCC) who died between January 1, 2010, and December 31, 2012. We collected data on patient and disease characteristics, palliative care referral, and end-of-life care outcome indicators. RESULTS: Among the 1714 decedents, 310 (18.1%) had chemotherapy use in the last 30 days and 142 (8.3%) in the last 14 days of life. Over half (910; 53.1%) had a palliative care referral. Chemotherapy use in the last 30 and 14 days of life were associated with younger age (odds ratio [OR] 0.99/yr, P = 0.01, and OR 0.99/yr, P = 0.01, respectively) and hematological malignances (OR 1.98, P < 0.001, and OR 2.85, P < 0.001, respectively). Palliative care referral was significantly associated with decreased use of chemotherapy in the last 30 (OR 0.30, P < 0.001) and 14 (OR 0.15, P < 0.001) days of life. CONCLUSIONS: A sizable minority of patients with cancer at KHCC received chemotherapy at the end of life. Younger patients and those with hematological malignancies were more likely to receive chemotherapy, whereas those referred to palliative care were significantly less likely to receive chemotherapy at the end of life.