Depression among Patients with an Implanted Left Ventricular Assist Device: Uncovering Pathophysiological Mechanisms and Implications for Patient Care.

Depression is a common and devastating mental illness associated with increased morbidity and mortality, partially due to elevated rates of suicidal attempts and death. Select patients with end-stage heart failure on a waiting-list for a donor heart undergo left ventricular assist device (LVAD) implantation. The LVAD provides a circulatory flow of oxygenated blood to the body, mimicking heart functionality by operating on a mechanical technique. LVAD improves functional capacity and survivability among patients with end-stage heart failure. However, accumulating data suggests that LVAD recipients suffer from an increased incidence of depression and suicide attempts. There is scarce knowledge regarding the pathological mechanism and appropriate treatment approach for depressed LVAD patients. This article summarizes the current evidence on the association between LVAD implantation and occurrence of depression, suggesting possible pathological mechanisms underlying the device-associated depression and reviewing the current treatment strategies. The summarized data underscores the need for a rigorous pre-(LVAD)-implantation psychiatric evaluation, continued post-implantation mental health assessment, and administration of antidepressant treatment as necessary.

Revisiting best practice guidelines and patient care workflow for managing the risk of medication-related osteonecrosis of the jaw: comparative summary and case studies.

OBJECTIVE: Patients taking antiresorptive medications in dental clinics are at risk of medication-related osteonecrosis of the jaw (MRONJ), which poses daily challenges for their clinicians. This paper aimed to summarize and revisit the three most recognized practice guidelines for the management and prevention of MRONJ, which were proposed by the American Association of Oral and Maxillofacial Surgeons (AAOMS), and presented by the Journal of Bone and Mineral Research (JBMR) and the Journal of Clinical Oncology (JCO). Results and case studies: The AAOMS position paper focused on risk stratification by different medications, management decision trees, risk factors, pathophysiology, and disease staging. The JBMR international consensus presented eight focused questions, which were addressed by systematic reviews. The JCO clinical practice guideline presented six clinical questions, and each concluded with practical recommendations. Practical information was summarized and converted into an adoptable patient care workflow for clinicians to follow and apply in daily practice. Three case studies presented were treated following these guidelines. Each patient underwent advanced surgeries including alveoloplasty, tooth extraction, implant placement, and particulate bone grafting. Some of the considerations not fully informed were discussed and illustrated in each step of the patient care workflow, which included specifics for risk communication, updates on the use of antibiotics, biomarkers, and drug holidays. CONCLUSION AND PRACTICAL IMPLICATIONS: Structured risk communication with official informed consent documentation should be considered before initiating invasive treatments. Disease control phase with home care therapy should be provided prior to staged reconstructive therapy. Drug holidays and antibiotics coverage can be customized based on individual conditions and related procedures with interprofessional coordination.

Preventive and Therapeutic Aspects of Migraine for Patient Care: An Insight.

BACKGROUND: Migraine is a common neurological condition marked by frequent mild to extreme headaches that last 4 to 72 hours. A migraine headache may cause a pulsing or concentrated throbbing pain in one part of the brain. Nausea, vomiting, excessive sensitivity to light and sound, smell, feeling sick, vomiting, painful headache, and blurred vision are all symptoms of migraine disorder. Females are more affected by migraines in comparison to males. OBJECTIVE: The present review article summarizes preventive and therapeutic measures, including allopathic and herbal remedies for the treatment of migraine. RESULTS: This review highlights the current aspects of migraine pathophysiology and covers an understanding of the complex workings of the migraine state. Therapeutic agents that could provide an effective treatment have also been discussed. CONCLUSION: It can be concluded that different migraines could be treated based on their type and severity.

Strategies for Well-Being in Interventional Radiology.

Interventional radiologists (IRs) have a massive impact on their patients, communities, and healthcare at large. Yet, IRs have physical and emotional challenges that lead to a high rate of burnout compared with other medical specialties. A Medscape survey in 2013 showed a 37% burnout incidence among radiologists, which increased to 49% in 2015. This ranked radiology 7th out of 26 specialties with respect to burnout. Although the survey did not examine IR specifically, with the increasing demands on those in the profession, this number can only be expected to increase. A survey by Bundy et al demonstrated that interventional radiologists are in the upper range of burnout among physicians with 71.9% presenting with at least 1 manifestation of burnout. This is higher than that reported among surgeons or diagnostic radiologists. We must be proactive in addressing wellness in IR if we are to flourish both individually and as a group. The impact of suboptimal well-being in an IR goes beyond that of the individual, influencing patient care with ripple effects to society at large. At worst, severe burnout can lead to an early exit from medicine, with the cost of recruiting a replacement IR estimated at two to three times an annual physician salary. This is to say nothing of the experience, wisdom, and leadership that are lost when physicians burn out and drop out. Particularly in IR, where the work performed often improves the cost-effectiveness and quality of care, burnout is a threat to the physician workforce and healthcare at large. In this article, our goal is to share some elements of physician well-being and highlight opportunities to support well-being in IR.

Dietary and nutrition considerations in caring for patients with nonalcoholic fatty liver disease: Updates for the practicing clinician.

Nonalcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease worldwide, affecting up to one-third of the global population. The disease is defined by excess fat deposition in the liver and has a strong correlation with metabolic syndrome, which, in turn, is also a risk factor for disease progression, including the development of steatohepatitis, advanced fibrosis, cirrhosis, and hepatocellular carcinoma. Although a number of medications are being explored for disease mitigation, nothing is currently approved, and the mainstay of therapy remains dietary and lifestyle intervention that promotes weight loss as well as management of comorbid conditions. The landscape that guides care for patients with NAFLD continues to evolve. Clinicians caring for these patients need to consider underlying disease state and nutrition risk in addition to concurrent related diagnoses, such as insulin resistance and hyperlipidemia, when formulating treatment plans. The following is a comprehensive review of the current dietary and nutrition considerations in the management of patients with NAFLD, with a special emphasis on implications for the practicing clinician.

Uso de precauciones estándar durante la atención de pacientes en un programa de especialización / Application of standard precautions during patient care in a specialization program

Introducción: Con el aumento de las enfermedades infectocontagiosas durante la atención en salud, la aplicación de normas de bioseguridad es fundamental para evitar contaminación cruzada. Los estudiantes de programas de Especialización Profesional durante la atención de pacientes deben cumplir una serie de normas denominadas precauciones estándar. Objetivo: Determinar el grado de uso de las precauciones estándar por estudiantes de un programa de especialización durante la atención de pacientes. Materiales y métodos: Se realizó un estudio observacional descriptivo. El tamaño de la muestra fue de 15 estudiantes del Programa de Especialización Profesional en Endodoncia de la Facultad de Odontología de la Universidad de Chile, divididos en dos grupos, diurno (8-17 h) y vespertino (18-22 h), que firmaron un consentimiento informado para participar. Fueron evaluados en 4 dimensiones: "lavado de manos", "barreras de protección" (guantes, mascarilla, gorro, lentes protectores, pechera), "control de riesgos de accidentes cortopunzantes y salpicaduras", y "manejo de materiales y superficies". Se estableció un 60 por ciento para determinar cumplimiento mínimo de la norma comparando ambos grupos. Resultados: En el lavado de manos ambos grupos no alcanzaron el cumplimiento mínimo de la norma, con un promedio de 12 por ciento. Para "barreras de protección" ambos grupos lograron el cumplimiento mínimo, con un promedio de 63 por ciento. En "control de riesgos de accidentes cortopunzantes y salpicaduras" y "manejo de superficies", ninguno de los grupos alcanzó el cumplimiento mínimo en estas dimensiones, con un porcentaje de cumplimiento de 50 % y 43 por ciento respectivamente. Conclusiones: La mayoría de los estudiantes del Programa de Especialización Profesional en Endodoncia no aplican correctamente todas las precauciones estándar durante la atención. Es necesario reforzar en los estudiantes los contenidos relacionados con la bioseguridad y aumentar la supervisión y exigencia en su cumplimiento por parte de los docentes(AU)

Introduction: With the increase in infectious diseases during health care, the application of biosecurity standards is essential to avoid cross-contamination. Students in Professional Specialization programs must adhere to a set of standards called standard precautions during patient care. Objective: Determine the degree of application of standard precautions by students of a specialization program during patient care. Materials and methods: A descriptive observational study was conducted. The sample size was 15 students from the Professional Specialization Program in Endodontics of the Faculty of Dentistry of the University of Chile, divided into two groups, day (8-17 h) and evening (18-22 h), who signed an informed consent to participate. They were evaluated in 4 dimensions: "hand washing", "protective barriers" (gloves, mask, hat, protective lenses, breastplate), "risks control of sharp accidents and splashes", and "handling of materials and surfaces". A 60 percent was established to determine minimum compliance with the standard by comparing both groups. Results: In handwashing, both groups did not reach the minimum compliance with the standard, with an average of 12 percent. For "protective barriers" both groups achieved minimum compliance, with an average of 63 percent. In "risk control of sharp accidents and splashes" and "surface handling", none of the groups reached the minimum compliance in these dimensions, with a compliance percentage of 50 percent and 43 percent respectively. Conclusions: Most students in the Professional Specialization Program in Endodontics do not correctly apply all standard precautions during care. It is necessary to reinforce in the students the contents related to biosecurity and to increase the supervision and demand in its fulfillment by the teachers(AU)

Age-dependent assessment thresholds to optimize patient care in a resource-limited setting: an analysis based on the Sri Lankan FRAX model.

Age-dependent upper and lower assessment thresholds help categorizing women aged 40 years or more according to their fracture risk, independent of BMD information. INTRODUCTION: Age-dependent assessment thresholds of the FRAX algorithm help stratifying men and women aged 40 years or more according to their fracture risk. This allows clinicians to decide on those who require interventions without BMD assessment and those who require BMD input for further assessment. METHODS: Intervention thresholds were defined by 10-year probabilities of a major osteoporotic fracture (MOF) and hip fracture (HF) considering a woman with a BMI of 25.0 kg/m2 having a prior fragility fracture but no other clinical risk factors. The lower assessment thresholds (LAT) were set at 0.8 times the 10-year probabilities of a MOF and HF in a woman with a BMI of 25.0 kg/m2, without previous fracture or other clinical risk factors. The upper assessment thresholds (UAT) were set at 1.2 times the intervention thresholds of MOF and HF. Fracture probabilities were estimated for the age range of 40-80 years, without BMD input. These values were applied to a group of women who underwent DXA for clinical reasons in a single center. RESULTS: The LATs of MOF and HF varied from 0.7 to 8.8% and 0.1 to 3.7%, from 40 to 80 years, respectively. The corresponding values for UATs were 2.5 to 21.6% and 0.3 to 8.4%. ITs of MOF and HF varied from 2.1 to 18% and 0.2 to 7%, respectively. When applied to a group of 315 postmenopausal women who underwent DXA for clinical indications, 22.9% of women were above the UATs (high-risk category) while 8.6% were below the LATs (low-risk category). The proportion of women in the intermediate category who require BMD for further assessment was 68.6% (95% CI 59.7 to 77.5%). CONCLUSIONS: In nearly one-third of women aged 40 years or more, the decision to treat or not to treat can be achieved without BMD estimation. The remaining two-thirds will require a BMD assessment for further evaluation.

Caring for patients with cognitive dysfunction, fluctuations and dementia caused by Parkinson's disease.

Cognitive dysfunction is one of the most prevalent non-motor symptoms in patients with Parkinson's disease (PD). While it tends to worsen in the later stages of disease, it can occur at any time, with 15-20% of patients exhibiting cognitive deficits at diagnosis (Aarsland et al., 2010; Goldman and Sieg, 2020). The characteristic features of cognitive dysfunction include impairment in executive function, visuospatial abilities, and attention, which vary in severity from subtle impairment to overt dementia (Martinez-Horta and Kulisevsky, 2019). To complicate matters, cognitive dysfunction is prone to fluctuate in PD patients, impacting diagnosis and the ability to assess progression and decision-making capacity. The diagnosis of cognitive impairment or dementia has a huge impact on patient independence, quality of life, life expectancy and caregiver burden (Corallo et al., 2017; Lawson et al., 2016; Leroi et al., 2012). It is therefore essential that physicians caring for patients with PD provide education, screening and treatment for this aspect of the disease. In this chapter, we provide a practical guide for the assessment and management of various degrees of cognitive dysfunction in patients with PD by approaching the disease at different stages. We address risk factors for cognitive dysfunction, prevention strategies prior to making the diagnosis, available tools for screening. Lastly, we review aspects of care, management and considerations, including decision-making capacity, that occur after the patient has been diagnosed with cognitive dysfunction or dementia.

Relationship Between Quality of Care and Patient Care Outcomes for Postoperative Pain in Major Orthopedic Surgery: Analytical and Cross-Sectional Study.

The quality of care provided for the management of postoperative pain and patient outcomes are key criteria for healthcare institutions. This study aimed to determine the relationship between the quality of care provided for the alleviation of postoperative pain experienced among patients undergoing major orthopedic surgery and the patient care outcomes. The study was designed as an analytical and cross-sectional study. The rates of pain severity and sleep interference, activity interference, affective experiences, and adverse effects due to postoperative pain were higher in female patients than in male patients. A significant positive correlation was identified between the quality of postoperative pain care and the perception of care (p < .05). Implementing nursing interventions to improve pain management and increase the quality of care appears to be vital elements for reducing adverse effects caused by pain and increasing the satisfaction with postoperative pain care.

Protocolo para realizar la traqueostomía en pacientes con COVID-19 / A Protocol for Performing Tracheostomy in Patients with COVID-19

Introducción: Los cirujanos pueden desempeñar un papel valioso en la realización de traqueostomía para apoyar a los equipos de cuidados críticos durante la pandemia global de la COVID-19. Objetivo: Diseñar un protocolo para realizar la traqueostomía en pacientes con la COVID-19. Métodos: Se realizó un estudio descriptivo durante el periodo de marzo a diciembre del año 2020 en el Hospital "Comandante Manuel Fajardo Rivero", de Santa Clara, Villa Clara. Se emplearon como métodos teóricos: el análisis-síntesis e inductivo-deductivo; y como empíricos: análisis documental, grupo nominal y el criterio de especialistas para la valoración del producto diseñado. Resultados: El protocolo fue estructurado en: título, propósito, normas organizativas institucionales, indicaciones, procedimiento de actuación y evaluación. Según el criterio de los especialistas consultados el protocolo diseñado, es pertinente, factible y válido. Conclusiones: Para el diseño del protocolo fue fundamental aplicar y adaptar cuidadosamente la mejor evidencia existente sobre la realización de la traqueostomía. Su estructura permite brindar la mejor atención al paciente con la COVID-19 al tiempo que protege al equipo quirúrgico(AU)

Introduction: Surgeons can play a valuable role in performing tracheostomy, as a support for critical care teams during the global COVID-19 pandemic. Objective: To design a protocol for performing the tracheostomy in patients with COVID-19. Methods: A descriptive study was carried out, during the period from March to December 2020, at Comandante Manuel Fajardo Rivero Hospital, in Santa Clara City, Villa Clara Province. The following theoretical methods were used: analysis-synthesis and inductive-deductive; as well as empirical ones: documentary analysis, nominal group and criteria of specialists for the evaluation of the designed product. Results: The protocol was structured into title, purpose, institutional organizational norms, indications, procedure of action and evaluation. According to the criteria of the specialists consulted, the designed protocol is pertinent, feasible and valid. Conclusions: For the design of the protocol, it was essential to apply and adapt, carefully, the best existing evidence on tracheostomy performance. Its structure allows to provide the best care to the patient with COVID-19 while protecting the surgical team(AU)

Os significados atribuídos à segurança do paciente pelos enfermeiros da unidade de terapia intensiva / The meanings attributed to patient safety by intensive care unit nurses

O objetivo geral do estudo foi propor uma teoria substantiva associando a segurança do paciente ao cuidado de enfermagem e o cuidado em saúde na unidade de terapia intensiva (UTI). Os objetivos específicos foram: compreender os significados atribuídos pelos enfermeiros que atuam na unidade de terapia intensiva à segurança do paciente e relacioná-los com as metas internacionais de segurança do paciente. Esta tese teve como referencial teórico o Interacionismo Simbólico. Realizou-se uma pesquisa qualitativa pautada na Teoria Fundamentada nos Dados (TFD) Straussiana. O estudo aconteceu em unidades de terapia intensiva de dois hospitais públicos de Porto Velho, Rondônia. Foram participantes da pesquisa 20 enfermeiros assistenciais. Coletou-se os dados mediante roteiro de entrevista semiestruturada, formulário de caracterização e roteiro de observação não participante. A análise dos dados seguiu os procedimentos da TFD: codificação aberta, codificação axial e integração dos dados. Da análise emergiram os fenômenos: sendo a estrutura, os insumos, os recursos humanos e os processos de trabalho desafiantes para a segurança do paciente na UTI; interagindo na perspectiva da segurança do paciente na UTI: entre o desejado cuidado e o temido descuido; repercutindo os desfechos antagônicos sobre a segurança do paciente na UTI: implicações da promoção ao agravo em saúde. Da articulação das condições, das ações-interações e das consequências das ações desvelou-se a matriz teórica: "SENDO O ENFERMEIRO PROTAGONISTA NA UTI, CONSIDERANDO A LUTA DIÁRIA EM BUSCA DE ASSEGURAR A SEGURANÇA DO PACIENTE QUE, ANTES DE TUDO, É UM EIXO FUNDAMENTAL DA PROFISSÃO ENFERMAGEM". Assim, a segurança do paciente compreende uma multiplicidade de faces, um universo de valores e significados, precisando ser descoberta e redescoberta continuamente, por vezes, modificando ou aprimorando o "como fazer" precedido pela reflexão, pela preocupação, pelo zelo e pela inteireza que o cuidado abrange e que a enfermagem faz acontecer.

The general objective of the study was to propose a substantive theory associating patient safety with nursing care and health care in the intensive care unit (ICU). The specific objectives were: to understand the meanings attributed by nurses working in the intensive care unit to patient safety and to relate them to international patient safety goals. This thesis had as theoretical reference the Symbolic Interactionism. A qualitative research was carried out based on the Straussian Grounded Theory (GT). The study took place in intensive care units of two public hospitals in Porto Velho, Rondônia. Twenty nurses participated in the research. Data were collected using a semi-structured interview script, characterization form and non-participant observation script. Data analysis followed GT procedures: open coding, axial coding and data integration. The following phenomena emerged from the analysis: the structure, inputs, human resources and work processes were challenging for patient safety in the ICU; interacting from the perspective of patient safety in the ICU: between the desired care and the feared carelessness; impacting antagonistic outcomes on patient safety in the ICU: implications of promoting health problems. From the articulation of conditions, actions-interactions and consequences of actions, the theoretical matrix was revealed: "BEING THE NURSE PROTAGONIST IN THE ICU, CONSIDERING THE DAILY STRUGGLE IN SEARCH TO ENSURE PATIENT SAFETY, WHICH, FIRST, IS AN AXIS ESSENTIAL OF THE NURSING PROFESSION". Thus, patient safety comprises a multiplicity of faces, a universe of values and meanings, needing to be discovered and rediscovered continuously, sometimes modifying or improving the "how to do it" preceded by reflection, concern, zeal and the wholeness that care encompasses and what nursing makes happen.

El objetivo general del estudio fue proponer una teoría sustantiva que asocie la seguridad del paciente al cuidado de enfermería y al cuidado de la salud en la unidad de cuidados intensivos (UCI). Los objetivos específicos fueron: comprender los significados atribuidos por los enfermeros que actúan en la unidad de cuidados intensivos a la seguridad del paciente y relacionarlos con las metas internacionales de seguridad del paciente. Esta tesis tuvo como referente teórico el Interaccionismo Simbólico. Se realizó una investigación cualitativa basada en la Grounded Theory (GT) de Strauss. El estudio se llevó a cabo en unidades de cuidados intensivos de dos hospitales públicos en Porto Velho, Rondônia. Veinte enfermeros participaron de la investigación. Los datos fueron recolectados mediante guión de entrevista semiestructurada, ficha de caracterización y guión de observación no participante. El análisis de datos siguió los procedimientos de GT: codificación abierta, codificación axial e integración de datos. Del análisis surgieron los siguientes fenómenos: la estructura, los insumos, los recursos humanos y los procesos de trabajo fueron desafíos para la seguridad del paciente en la UTI; interactuando desde la perspectiva de la seguridad del paciente en la UCI: entre el cuidado deseado y el descuido temido; impactando resultados antagónicos en la seguridad del paciente en la UCI: implicaciones de promover problemas de salud. A partir de la articulación de condiciones, acciones-interacciones y consecuencias de las acciones, se reveló la matriz teórica: "SER EL ENFERMERO PROTAGONISTA EN LA UTI, CONSIDERANDO LA LUCHA DIARIA EN BUSCA DE GARANTIZAR LA SEGURIDAD DEL PACIENTE, QUE, PRIMERO, ES UN EJE ESENCIAL DE LA PROFESIÓN DE ENFERMERÍA". Así, la seguridad del paciente comprende una multiplicidad de rostros, un universo de valores y significados, que necesita ser descubierta y redescubierta continuamente, a veces modificando o mejorando el "cómo hacerlo" precedido por la reflexión, la preocupación, el celo y la totalidad que cuida. abarca y lo que la enfermería hace que suceda.

Cultura de segurança do paciente na perspectiva da equipe multiprofissional: uma revisão integrativa / Patient safety culture from the perspective of the multiprofessional team: an integrative review / Cultura de seguridad del paciente en la perspectiva del equipo multiprofesional: uma revision integrativa

Objective:To identify the scientific production on patient safety culture in a hospital setting from the perspective of the multiprofessional team. Method: review of the literature, in the LILACS, PubMed, WoS and Scopus databases, in Portuguese, English and Spanish. Results: twelve publications were found, which were concentrated between the years 2004 and 2016. The analysis of the studies allowed to identify that the security climate is still fragile in most of the evaluated institutions. Among the strategies to generate improvements in safety culture, training programs, open communication in the work environment, notification of adverse events and non-punitive response to the error were highlighted. The organizational learning dimensions for continuous improvement and teamwork within the units were evidenced as potentialities. Conclusion: incipient scientific production was observed. Few studies have included all professionals to perform the analysis of patient safety culture in the hospital setting, despite their relevance to the promotion of safe care

Objetivo: Identificar a produção científica sobre cultura de segurança do paciente em âmbito hospitalar na perspectiva da equipe multiprofissional. Método: revisão integrativa, realizada nas bases de dados LILACS, PubMed, WoS e Scopus, em português, inglês e espanhol. Resultados: foram localizadas 12 publicações, que concentraram-se entre os anos de 2004 e 2016. A análise dos estudos permitiu identificar que o clima de segurança ainda é frágil na maioria das instituições avaliadas. Dentre as estratégias para gerar melhorias na cultura de segurança, destacaram-se os programas de treinamento, comunicação aberta no ambiente de trabalho, notificação de eventos adversos e resposta não punitiva ao erro. Evidenciaram-se como potencialidades as dimensões aprendizado organizacional para a melhoria contínua e trabalho em equipe dentro das unidades. Conclusão: poucos estudos incluíram todos os profissionais para realizar a análise da cultura de segurança do paciente em âmbito hospitalar, apesar da sua relevância para a promoção do cuidado seguro

Objetivo: Identificar la producción científica sobre cultura de seguridad del paciente en ámbito hospitalario en la perspectiva del equipo multiprofesional. Método: revisión integradora, llevado a cabo en las bases de datos LILACS, PubMed, Scopus y WoS en portugués, Inglés y Español. Resultados: se localizaron 12 publicaciones, que se concentraron entre los años 2004 y 2016. El análisis de los estudios permitió identificar que el clima de seguridad aún es fragil en la mayoría de las instituciones evaluadas. Entre las estrategias para generar mejoras en la cultura de seguridad, se destacaron los programas de entrenamiento, comunicación abierta en el ambiente de trabajo, notificación de eventos adversos y respuesta no punitiva al error. Se evidenció como potencialidades las dimensiones aprendizaje organizacional para la mejora continua y trabajo en equipo dentro de las unidades. Conclusión: pocos estudios incluyeron a todos los profesionales para realizar el análisis de la cultura de seguridad del paciente en el ámbito hospitalario, a pesar de su relevancia para la promoción del cuidado seguro

Caregiver burden among informal caregivers in the largest specialized palliative care unit in Malaysia: a cross sectional study.

BACKGROUND: Informal caregivers (IC) are often overshadowed by the attention required by the terminally ill. This study aims to reveal the estimated proportion of caregiver burden, psychological manifestations and factors associated with caregiver burden among IC in the largest specialized Palliative Care Unit (PCU) in Malaysia. METHODS: This was a cross-sectional study involving IC attending a PCU. Caregiver burden and psychological manifestations were measured using previously translated and validated Zarit Burden Interview and DASS-21 questionnaires respectively. Two hundred forty-nine samples were selected for analysis. RESULT: The mean ZBI score was 23.33 ± 13.7. About half of the population 118(47.4%) was found to experienced caregiver burden whereby majority have mild to moderate burden 90(36.1%). The most common psychological manifestation among IC is anxiety 74(29.7%) followed by depression 51(20.4%) and stress 46(18.5%). Multiple logistic regression demonstrated that women who are IC to patients with non-malignancy were less likely to experience caregiver burden. IC who were highly educated and spent more than 14 h per day caregiving were at least twice likely to experience caregiver burden. Finally, those with symptoms of depression and anxiety were three times more likely to suffer from caregiver burden. CONCLUSION: Caregiver burden among IC to palliative patients is prevalent in this population. IC who are men, educated, caregiving for patients with malignancy, long hours of caregiving and have symptoms of depression and anxiety are at risk of developing caregiver burden. Targeted screening should be implemented and IC well-being should be given more emphasis in local policies.

Caregiver Burden and Associated Factors Among Informal Caregivers of Stroke Survivors.

BACKGROUND: Informal caregiving of stroke survivors often begins with intensity compared with the linear caregiving trajectories in progressive conditions. Informal caregivers of stroke survivors are often inadequately prepared for their caregiving role, which can have detrimental effects on their well-being. A greater depth of understanding about caregiving burden is needed to identify caregivers in most need of intervention. The purpose of this study was to examine caregiver burden and associated factors among a cohort of informal caregivers of stroke survivors. METHODS: A cross-sectional study of 88 informal caregivers of stroke survivors was completed. Caregiver burden was determined with the Zarit Burden Interview, caregiver depressive symptoms were measured with the Patient Health Questionnaire-9, and stroke survivor functional disability was assessed with the Barthel Index. Ordinal logistic regression was used to identify independent factors associated with caregiver burden. RESULTS: Forty-three informal caregivers (49%) reported minimal or no caregiver burden, 30 (34%) reported mild to moderate caregiver burden, and 15 (17%) reported moderate to severe caregiver burden. Stroke survivor functional disability was associated with informal caregiver burden (P = .0387). The odds of having mild to moderate caregiver burden were 3.7 times higher for informal caregivers of stroke survivors with moderate to severe functional disability than for caregivers of stroke survivors with no functional disability. The presence of caregiver depressive symptoms was highly correlated with caregiver burden (P < .001). CONCLUSION: Caregivers of stroke survivors with functional disabilities and caregivers experiencing depressive symptoms may have severer caregiver burden. Trials of interventions aimed at decreasing informal caregiver burden should consider the potential impact of stroke survivors' functional disability and the presence of depressive symptoms.

Unwitting Accomplices: Endocrine Disruptors Confounding Clinical Care.

Burgeoning evidence over the last 25 years has identified myriad synthetic chemicals with the capacity to alter various aspects of hormone synthesis and action. These endocrine-disrupting chemicals (EDCs) have been linked to various diseases, including reproductive disorders, metabolic diseases, and developmental abnormalities, among others. Exposure to EDCs arises from industrial activity, use of personal and home care products, and consumption of contaminated food and water; however, the role of healthcare in exposing individuals to EDCs is grossly underappreciated. Indeed, through the use of medications as well as medical equipment and devices, healthcare providers are unknowing mediators of exposure to EDCs, chemicals that might not only promote disease but that may also antagonize the efficacy of treatments. The ethical implications of provider-dependent exposure are profound. A failure to disclose the endocrine-disrupting properties of medical interventions violates core principles of nonmaleficence, patient autonomy, and justice as well as the practice of informed consent. Furthermore, physicians' lack of knowledge regarding EDCs in medical practice artificially skews risk-benefit calculations that are fundamental to informed medical decision-making. To combat this underappreciated ethical challenge, urgent action is required. Healthcare providers must be educated about endocrine disruption. Known EDCs, defined by endocrinologists, should be clearly labeled on all medical products, and all medication components and devices should be screened for endocrine-disrupting properties. Finally, communication strategies must be devised to empower patients with knowledge about these risks. Providing ethically competent care requires an open acknowledgment of endocrine risks imposed by the medical community that have heretofore been ignored.

Impact of informal cancer caregiving across the cancer experience: A systematic literature review of quality of life.

OBJECTIVE: Informal caregiving may likely increase as the number of cancer survivors grows. Caregiving responsibilities can impact caregivers' quality of life (QOL). Understanding the current state of the science regarding caregiving QOL could help inform future research and intervention development. METHODS: A systematic literature review in PubMed/Medline examined research on QOL among informal cancer caregivers and related psychosocial health outcomes. Original research articles in English, published between 2007 and 2017 about caregivers (aged >18 years) of adult cancer patients in the United States were included. Abstracted articles were categorized according to caregiving recipient's phase of survivorship (acute, middle to long-term, end of life/bereavement). RESULTS: Of 920 articles abstracted, 60 met inclusion criteria. Mean caregiver age ranged from 37 to 68 with the majority being female, non-Hispanic white, with at least a high school degree, and middle income. Almost half of the studies focused on caregivers who provided care for survivors from diagnosis through the end of active treatment. Studies examined physical health, spirituality, psychological distress, and social support. Differences in QOL were noted by caregiver age, sex, and employment status. SIGNIFICANCE OF RESULTS: Additional research includes the examination of the needs of diverse cancer caregivers and determines how additional caregiver characteristics (e.g., physical functioning, financial burden, etc.) affect QOL. This includes studies examining caregiver QOL in the phases following the cessation of active treatment and assessments of health systems, support services, and insurance to determine barriers and facilitators needed to meet the immediate and long-term needs of cancer caregivers.

Proposta de um protótipo de aplicativo Android para diagnósticos de enfermagem utilizando redes neurais artificiais / Propuesta de un protótipo de aplicativo Androide para diagnósticos de enfermería utilizando redes neuronales artificiales / A Proposal of an Android Application Prototype for Nursing Diagnoses Using Artificial Neural Networks

Introdução: A Sistematização da Assistência de Enfermagem deve ser implementada, principalmente nos quais há um nível de cuidado mais avançado com os pacientes, a exemplo das Unidades de Terapia Intensiva que são reconhecidamente locais nos quais se concentram grande especialização e tecnologias. Objetivo: Propor um modelo de um Sistema de Apoio à Decisão utilizando Redes Neurais Artificiais para a elaboração de Diagnósticos de Enfermagem através de um aplicativo para Android. Métodos: O presente estudo se caracteriza como metodológico e tecnológico do tipo prototipagem, no qual onde serão analisados os sinais vitais de pacientes internados em uma Unidade de Terapia Intensiva. Os dados serão obtidos a partir do banco de dados Monitoramento Inteligente Multiparâmetro em Terapia Intensiva que contém sinais fisiológicos e séries de sinais vitais capturados de monitores de pacientes, obtidos de sistemas de informações médicas hospitalares de milhares de pacientes em unidades de terapia intensiva. Resultados: O aplicativo, em fase final de implementação, está projetado com telas ativas trabalhadas junto com corpo de profissionais de enfermagem que opinaram sobre utilidades desejadas e primeiras impressões. Conclusões: No presente momento, os testes para o treinamento da Rede Neural Artificial estão acontecendo, e espera-se o uso de um aplicativo para a promoção dos diagnósticos de enfermagem advindo dos sinais vitais de pacientes, das avaliações sobre o estado geral, e informações do prontuário eletrônico do paciente, juntamente com o julgamento clínico e crítico do profissional enfermeiro(AU)

Introducción: La sistematización de la atención de enfermería debe ser implementada, especialmente en el caso de que haya un nivel más avanzado de atención con pacientes, como en las unidades de cuidados intensivos, que son lugares reconocidos donde se concentran gran experiencia y tecnologías. Objetivo: Proponer un modelo de un Sistema de Apoyo a la Decisión utilizando redes neuronales artificiales para la elaboración de diagnósticos de enfermería a través de una aplicación de Androide. Métodos: Este estudio se caracteriza por ser un tipo de prototipo metodológico y tecnológico en el que se analizarán los signos vitales de los pacientes ingresados en una unidad de cuidados intensivos. Los datos se obtendrán de la base de datos de Monitoreo Inteligente de Parámetros Intensivos de Cuidados Intensivos, que contiene señales fisiológicas y series de signos vitales capturados de monitores de pacientes, obtenidos de los sistemas de información médica hospitalaria de miles de pacientes en unidades de cuidados intensivos. Resultados: La aplicación, en su fase final de implementación, está diseñada con pantallas activas trabajadas junto con un cuerpo de profesionales de enfermería que dieron su opinión sobre las utilidades deseadas y las primeras impresiones. Conclusiones: En este momento, se están realizando pruebas para la capacitación de la Red Neural Artificial, y se espera utilizar una aplicación para promover diagnósticos de enfermería a partir de signos vitales del paciente, evaluaciones generales de salud e información del historial médico electrónico del paciente, junto con el juicio clínico y crítico de la enfermera profesional(AU)

Introduction: Systematization of nursing care must be implemented, especially in the case that there is a more advanced level of patient care, such as in intensive care units, which are recognized places where great experience and technologies are concentrated. Objective: To propose a model of a decision support system using artificial neural networks for the elaboration of nursing diagnoses through an Android application. Methods: This study is characterized by being a type of methodological and technological prototype in which the vital signs of patients admitted to an intensive care unit will be analyzed. The data will be obtained from the database of Smart Monitoring of Intensive Care Parameters, which contains physiological signals and vital sign series captured from patient monitors, and which are obtained from hospital medical information systems of thousands of patients in intensive care units. Results: The application, in its final phase of implementation, is designed with active screens worked together by a body of nursing professionals who gave their opinion on the desired benefits and first impressions. Conclusions: At this time, tests are being carried out to train the artificial neural network, and an application is expected to be used for promoting nursing diagnoses based on the patient's vital signs, general health evaluations, and information on the patient's electronic medical history, together with the clinical and critical judgment of the professional nurse(AU)

Cascades of Care After Incidental Findings in a US National Survey of Physicians.

Importance: Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. Objective: To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. Design, Setting, and Participants: Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. Main Outcomes and Measures: Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. Results: This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. Conclusions and Relevance: The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

Patient Safety Room Assessing Orthopedic Surgery Interns' Abilities to Identify Patient Safety Hazards.

OBJECTIVE: An important part of clinical training is learning how to identify and prevent hospital-acquired conditions or injuries. Despite this, there are few standardized methods in graduate medical education (GME) for teaching and assessing resident patient safety skills. Residents often do not report safety events, and increasing resident engagement can positively impact patient safety. In the current study, we sought to apply such a tool in gauging the capacity of orthopedic surgery interns at a large academic medical center to identify patient safety hazards and begin a discussion regarding the management of potential patient safety issues. METHODS: A total of 27 orthopedic surgery interns at a single large academic medical center participated in the current observational study divided into two distinct groups in the summers of 2016 and 2017. A patient room was simulated with a training mannequin lying supine in a hospital bed. A mock patient chart and handoff were created in the electronic medical record (EMR) on the bedside computer. Patient safety hazards and errors of care were placed around the room and in the EMR, including several derived from the Joint Commission's National Patient Safety Goals. Each intern was given a maximum of 20 minutes to identify as many of the simulated patient safety hazards as possible. A debrief was conducted at the end of the exercise to discuss their responsibility to speak up when hazards are identified in a non-simulated patient room. For analysis, the hazards were distributed into four categories: room organization, EMR, patient care, and white board. Each intern's individual score (number of complete identifications/total number of hazards) and the group's performance as a whole in each category were calculated. RESULTS: The mean individual score was 51.54% (26.67% to 70.00%) in group A and 40.41% (25.71% to 54.29%) in group B. In group A, room organization hazards were identified more than any other category (74.62%), followed by patient care errors (40.38%), EMR hazards (40.17%), and white board errors (38.46%). In group B, room organization was identified the most (57.74%), followed by EMR (50%), and patient care and white board hazards (28.57% each). Certain critical safety hazards were identified by a small number of interns. For example, the inadequate handoff was only identified by four interns in each group. CONCLUSIONS: Hazards related to room cleanliness were easier to identify than hazards related to specific errors in patient care. A wide variation in the identification of critical safety issues was observed among the trainees assessed. This type of simulated educational experience provides important opportunities for resident-specific education in the realm of patient safety and health care quality.