1,099 research outputs found
Impact of the implementation of identification-situation-background-assessment-recommendation (ISBAR) tool to improve quality and safety measure in a lithotripsy and endourological unit
A lack of professional communication and collaboration may be one of the main causes of medication errors. The objective was to evaluate the results of the implementation of ISBAR as a communication and safety tool in a Lithotripsy and Endourologic Unit of a tertiary public hospital
Estimating Adherence Based on Prescription or Dispensation Information: Impact on Thresholds and Outcomes. A Real-World Study With Atrial Fibrillation Patients Treated With Oral Anticoagulants in Spain
Objective: To estimate drug exposure, Proportion of Days Covered (PDC) and percentage of patients with PDC â„ 80% from a cohort of atrial fibrillation patients initiating oral anticoagulant (OAC) treatment. We employed three different approaches to estimate PDC, using either data from prescription and dispensing (PD cohort) or two common designs based on dispensing information only, requiring at least one (D1) or at least two (D2) refills for inclusion in the cohorts. Finally, we assessed the impact of adherence on health outcomes according to each method.Methods: Population-based retrospective cohort of all patients with Non Valvular Atrial Fibrillation (NVAF), who were newly prescribed acenocoumarol, apixaban, dabigatran or rivaroxaban from November 2011 to December 2015 in the region of Valencia (Spain). Patients were followed for 12 months to assess adherence using three different approaches (PD, D1 and D2 cohorts). To analyze the relationship between adherence (PDC â„ 80) defined according to each method of calculation and health outcomes (death for any cause, stroke or bleeding) Cox regression models were used. For the identification of clinical events patients were followed from the end of the adherence assessment period to the end of the available follow-up period.Results: PD cohort included all patients with an OAC prescription (n = 38,802), D1 cohort excluded fully non-adherent patients (n = 265) and D2 cohort also excluded patients without two refills separated by 180 days (n = 2,614). PDC â„ 80% ranged from 94% in the PD cohort to 75% in the D1 cohort. Drug exposure among adherent (PDC â„ 80%) and non-adherent (PDC < 80%) patients was different between cohorts. In adjusted analysis, high adherence was associated with a reduced risk of death [Hazard Ratio (HR): from 0.82 to 0.86] and (except in the PD cohort) the risk for ischemic stroke (HR: from 0.61 to 0.64) without increasing the risk of bleeding.Conclusion: Common approaches to assess adherence using measures based on daysâ supply exclude groups of non-adherent patients and, also, misattribute periods of doctorsâ discontinuation to patient non-adherence, misestimating adherence overall. Physician-initiated discontinuation is a major contributor to reduced OAC exposure. When using the PDC80 threshold, very different groups of patients may be classified as adherent or non-adherent depending on the method used for the calculation of daysâ supply measures. High adherence and high exposure to OAC treatment in NVAF patients is associated with better health outcomes
Design and validation of the INCUE questionnaire: Assessment of primary healthcare Nursesâ basic training needs in palliative care
Many instruments have been created to measure knowledge and attitudes in palliative care. However, not only is it important to acquire knowledge, but also that this knowledge should reach patients and their relatives through application in clinical practice. This study aimed to develop and psychometrically test the INCUE questionnaire (InvestigaciĂłn Cuidados Enfermeros/Investigation into Nursesâ Care Understanding of End-of-Life) to assess the basic training needs of primary or home healthcare nurses in palliative care. A questionnaire was developed based on the classical theory of tests and factor analysis models. Initially, 18 experts developed 67 items in two blocks and determined content validity by two rounds of expert panels. Exploratory factor analysis and reliability testing were conducted with a non-probabilistic sample of 370 nurses. Some items were observed to have very low homogeneity indices or presented convergence problems and were eliminated. Questionnaire reliability was 0.700 in the theoretical block (KR20 Index) and 0.941 in the practical block (Cronbachâs alpha). The model converges and shows an adequate fit, specifically CFI = 0.977, TLI = 0.977 and RMSEA = 0.05. The correlation between the two factors in the model is Ï = 0.63. The questionnaire objectively evaluates primary or home healthcare nursesâ knowledge of palliative care and its practical application, thereby facilitating more efficient training plans.This questionnaire is being developed as part of a project to pinpoint the training needs of primary care nurses in the field of palliative care at the Dr Peset Health Department in Valencia (Project EAPCP19-V01)This project has received funding under the first Call for R + D Grants in Nursing 2019 (UGP-19-258), from the FundaciĂł per al Foment de la InvestigaciĂł SanitĂ ria i BioĂšdica de la Comunitat Valenciana (Fisabio).EnfermerĂ
Unmasking the hidden tuberculosis mortality burden in a large postmortem study in Maputo Central Hospital, Mozambique
Sensitive tools are
needed to accurately establish the diagnosis of tuberculosis
(TB) at death, especially in low-income countries. The objective
of this study was to evaluate the burden of TB in a series of
patients who died in a tertiary referral hospital in sub-Saharan
Africa using an in-house real time PCR (TB-PCR) and the Xpert
MTB/RIF Ultra (Xpert Ultra) assay.Complete diagnostic autopsies
were performed in a series of 223 deaths (56.5% being
HIV-positive), including 54 children, 57 maternal deaths and 112
other adults occurring at the Maputo Central Hospital,
Mozambique. TB-PCR was performed in all lung, cerebrospinal
fluid and central nervous system samples in HIV-positive
patients. All samples positive for TB-PCR or showing
histological findings suggestive of TB were analysed with the
Xpert Ultra assay.TB was identified as the cause of death in 31
patients: 3/54 (6%) children, 5/57 (9%) maternal deaths and
23/112 (21%) other adults. The sensitivity of the main clinical
diagnosis to detect TB as the cause of death was 19.4% (95% CI:
7.5-37.5) and the specificity was 97.4% (94.0-99.1) compared to
autopsy findings. Concomitant TB (TB disease in a patient dying
of other causes) was found in 31 additional cases. Xpert Ultra
helped to identify 15 cases of concomitant TB. In 18 patients, "
- " DNA was identified by TB-PCR and Xpert Ultra in the absence
of histological TB lesions. Overall, 62 cases (27.8%) had TB
disease at death and 80 (35.9%) had TB findings.The use of
highly sensitive, easy to perform molecular tests in complete
diagnostic autopsies may contribute to identifying TB cases at
death that would have otherwise been missed. Routine use of
these tools in certain diagnostic algorithms for hospitalised
patients needs to be considered. Clinical diagnosis showed poor
sensitivity for the diagnosis of TB at death
High within-host diversity found from direct genotyping on post-mortem tuberculosis specimens in a high-burden setting
Objectives: To characterize the clonal complexity in Mycobacterium tuberculosis (MTB) infections considering factors that help maximize the detection of coexisting strains/variants. Methods: Genotypic analysis by Mycobacterial Interspersed Repetitive-Unit-Variable-Number Tandem-Repeats (MIRU-VNTR) was performed directly on 70 biopsy specimens from two or more different tissues involving 28 tuberculosis cases diagnosed post-mortem in Mozambique, a country with a high tuberculosis burden. Results: Genotypic data from isolates collected from two or more tissues were obtained for 23 of the 28 cases (82.1%), allowing the analysis of within-patient diversity. MIRU-VNTR analysis revealed clonal diversity in ten cases (35.7%). Five cases showed allelic differences in three or more loci, suggesting mixed infection with two different strains. In half of the cases showing within-host diversity, one of the specimens associated with clonal heterogeneity was brain tissue. Conclusions: Direct MTB genotyping from post-mortem tissue samples revealed a frequent within-host Mycobacterium tuberculosis diversity, including mixed and polyclonal infections. Most of this diversity would have been overlooked if only standard analysis of respiratory specimens had been performed
Validity of a minimally invasive autopsy for cause of death determination in maternal deaths in Mozambique: An observational study
BACKGROUND: Despite global health efforts to reduce maternal
mortality, rates continue to be unacceptably high in large parts
of the world. Feasible, acceptable, and accurate postmortem
sampling methods could provide the necessary evidence to improve
the understanding of the real causes of maternal mortality,
guiding the design of interventions to reduce this burden.
METHODS AND FINDINGS: The validity of a minimally invasive
autopsy (MIA) method in determining the cause of death was
assessed in an observational study in 57 maternal deaths by
comparing the results of the MIA with those of the gold standard
(complete diagnostic autopsy [CDA], which includes any available
clinical information). Concordance between the MIA and the gold
standard diagnostic categories was assessed by the kappa
statistic, and the sensitivity, specificity, positive and
negative predictive values and their 95% confidence intervals
(95% CI) to identify the categories of diagnoses were estimated.
The main limitation of the study is that both the MIA and the
CDA include some degree of subjective interpretation in the
attribution of cause of death. A cause of death was identified
in the CDA in 98% (56/57) of cases, with indirect obstetric
conditions accounting for 32 (56%) deaths and direct obstetric
complications for 24 (42%) deaths. Nonobstetric infectious
diseases (22/32, 69%) and obstetric hemorrhage (13/24, 54%) were
the most common causes of death among indirect and direct
obstetric conditions, respectively. Thirty-six (63%) women were
HIV positive, and HIV-related conditions accounted for 16 (28%)
of all deaths. Cerebral malaria caused 4 (7%) deaths. The MIA
identified a cause of death in 86% of women. The overall
concordance of the MIA with the CDA was moderate (kappa = 0.48,
95% CI: 0.31-0.66). Both methods agreed in 68% of the diagnostic
categories and the agreement was higher for indirect (91%) than
for direct obstetric causes (38%). All HIV infections and
cerebral malaria cases were identified in the MIA. The main
limitation of the technique is its relatively low performance
for identifying obstetric causes of death in the absence of
clinical information. CONCLUSIONS: The MIA procedure could be a
valuable tool to determine the causes of maternal death,
especially for indirect obstetric conditions, most of which are
infectious diseases. The information provided by the MIA could
help to prioritize interventions to reduce maternal mortality
and to monitor progress towards achieving global health targets
High prevalence and mortality due to Histoplasma capsulatum in the Brazilian Amazon: An autopsy study
Background: Histoplasmosis is acquired by inhalation of spores of the dimorphic fungus Histoplasma spp. Although this pathogen is distributed worldwide, it is more prevalent in the Americas. However, the real burden of histoplasmosis remains undefined in many endemic regions. Methodology: We conducted a series of 61 autopsies to individuals who died in a hospital in the Brazilian Amazon focused on infectious diseases. We performed a detailed histological and microbiological evaluation with genetic characterization of Histoplasma strains with the aim to evaluate the contribution of histoplasmosis to morbidity and mortality. Additionally, we assessed the clinicopathological correlation. Principal findings: Evidence of Histoplasma infection was detected in 21 patients (34%). Eight cases were disseminated infections, all of them occurred in HIV-positive patients. Six cases were localized histoplasmosis, limited to the lungs. In seven patients Histoplasma DNA was detected by PCR in patients with no histological lesions. Histoplasma infection was detected in 38% of HIV-positive patients and was a major contributor to death in 22% of them. Lungs, liver and spleen were affected in all cases of disseminated histoplasmosis. Phylogenetic analysis of the strains suggested a high diversity of Histoplasma species circulating in the Brazilian Amazon. Histoplasmosis was clinically missed in 75% of the disseminated infections. Conclusions: The high incidence of histoplasmosis, the low index of clinical suspicion, and the severity of the disseminated disease highlight the need of proactively implementing sensitive routine screening methods for this pathogen in endemic areas. Antifungal prophylaxis against Histoplasma should be encouraged in the severely immunocompromised HIV patients in these areas. In conclusion, substantial mortality is associated with disseminated histoplasmosis among HIV-positive patients in the Brazilian Amazon
Validity of a minimally invasive autopsy for cause of death determination in stillborn babies and neonates in Mozambique: an observational study
Background Over 5 million stillbirths and neonatal deaths occur annually. Limited and imprecise information on the cause of these deaths hampers progress in achieving global health targets. Complete diagnostic autopsies (CDAs) the gold standard for cause of death determination are difficult to perform in most high-burden settings. Therefore, validation of simpler and more feasible methods is needed. Methods and findings In this observational study, the validity of a minimally invasive autopsy (MIA) method in determining the cause of death was assessed in 18 stillbirths and 41 neonatal deaths by comparing the results of the MIA with those of the CDA. Concordance between the categories of diseases obtained by the 2 methods was assessed by the Kappa statistic, and the sensitivity, specificity, positive, and negative predictive values of the MIA diagnoses were calculated. A cause of death was identified in 16/18 (89%) and 15/18 (83%) stillborn babies in the CDA and the MIA, respectively. Fetal growth restriction accounted for 39%, infectious diseases for 22%, intrapartum hypoxia for 17%, and intrauterine hypoxia for 11% of stillborn babies. Overall, the MIA showed in this group a substantial concordance with the CDA (Kappa = 0.78, 95% CI [0.56-0.99]). A cause of death was identified in all (100%) and 35/41 (85%) neonatal deaths in the CDA and the MIA, respectively. In this group, the majority of deaths were due to infectious diseases (66%). The overall concordance of the MIA with the CDA in neonates was moderate (Kappa = 0.40, 95% CI [0.18-0.63]). A high percentage of accuracy was observed for the MIA in all the diagnostic categories in both stillbirths and neonates (>75%). The main limitation of this study is that some degree of subjective interpretation is inherent to cause-of-death attribution in both the MIA and the CDA; this is especially so in stillbirths and in relation to fetal growth restriction. Conclusions The MIA could be a useful tool for cause-of-death determination in stillbirths and neonatal deaths. These findings may help to accelerate progress towards meeting global health targets by obtaining more accurate information on the causes of death in these age groups, which is essential in guiding the design of new interventions and increasing the effectiveness of those already implemented
Minimally Invasive Autopsy Practice in COVID-19 Cases: Biosafety and Findings
Postmortem studies are crucial for providing insight into emergent diseases. However,
a complete autopsy is frequently not feasible in highly transmissible diseases due to biohazard
challenges. Minimally invasive autopsy (MIA) is a needle-based approach aimed at collecting
samples of key organs without opening the body, which may be a valid alternative in these cases. We
aimed to: (a) provide biosafety guidelines for conducting MIAs in COVID-19 cases, (b) compare the
performance of MIA versus complete autopsy, and (c) evaluate the safety of the procedure. Between
October and December 2020, MIAs were conducted in six deceased patients with PCR-confirmed
COVID-19, in a basic autopsy room, with reinforced personal protective equipment. Samples from
the lungs and key organs were successfully obtained in all cases. A complete autopsy was performed
on the same body immediately after the MIA. The diagnoses of the MIA matched those of the
complete autopsy. In four patients, COVID-19 was the main cause of death, being responsible for the
different stages of diffuse alveolar damage. No COVID-19 infection was detected in the personnel performing the MIAs or complete autopsies. In conclusion, MIA might be a feasible, adequate and
safe alternative for cause of death investigation in COVID-19 cases
Postmortem Interval and Diagnostic Performance of the Autopsy Methods
Postmortem studies, including the complete diagnostic autopsy (CDA) and the minimally invasive autopsy (MIA), an innovative approach to post-mortem sampling and cause of death investigation, are commonly performed within 24âhours after death because the quality of the tissues deteriorates over time. This short timeframe may hamper the feasibility of the procedure. In this study, we compared the diagnostic performance of the two postmortem procedures when carried out earlier and later than 24âhours after death, as well as the impact of increasing postmortem intervals (PMIs) on the results of the microbiological tests in a series of 282 coupled MIA/CDA procedures performed at the Maputo Central Hospital in Mozambique between 2013 and 2015. 214 procedures were conducted within 24âhours of death (early autopsies), and 68 after 24âhours of death (late autopsies). No significant differences were observed in the number of non-conclusive diagnoses (2/214 [1%] vs. 1/68 [1%] pâ=â0.5645 for the CDA; 27/214 [13%] vs. 5/68 [7%] pâ=â0.2332 for the MIA). However, increasing PMIs were associated with a raise in the number of bacteria identified (rate: 1.014 per hour [95%CI: 1.002-1.026]; pâ=â0.0228). This increase was mainly due to rising numbers of bacteria of the Enterobacteriaceae family and Pseudomonas genus strains. Thus, performing MIA or CDA more than 24âhours after death can still render reliable diagnostic results, not only for non-infectious conditions but also for many infectious diseases, although, the contribution of Enterobacteriaceae and Pseudomonas spp. as etiological agents of infections leading to death may be overestimated
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