Value-based healthcare payment models: a wolf in sheep's clothing for patients and clinicians

Value-based healthcare payment models are an alternative insurance payment system that compensates healthcare providers based on their patients' outcomes rather than the individual services healthcare workers provide. This shift from the current fee-for-service model that predominates our medical system has received renewed popularity and attention within organized medicine such as the American Medical Association. Advocates believe that this new payment model will address many of the unsolved issues in healthcare such as medical waste and unsustainable healthcare costs. In practice, however, this model is plagued with a myriad of unresolved issues of its own. In this commentary, we outline these issues and suggest that the intentions of those advocating for value-based payment models are either misguided or disingenuous. We then offer solutions that preserve our current fee-for-service model while making necessary changes that will benefit both physicians and patients nationwide.

An investigation of the effect of the universal model of family-centered care on patient and family outcomes in patients under home invasive mechanical ventilation

BACKGROUND

The number of patients under home mechanical ventilation is increasing worldwide. The unique nature of these patients and their complex health needs exposes home caregivers to various needs and challenges regarding different dimensions of care.

OBJECTIVE

The present study was conducted to investigate the effect of the universal model of family-centered care on the clinical outcomes of the patient and the family.

METHODS

This clinical trial was conducted between 2020 and 2021. A total of 60 patients under invasive mechanical ventilation was selected and divided into control (routine training that is usually given by hospital staff to families to care for patients) and intervention (comprehensive pre-discharge training program to post-discharge follow-up using the universal model of family-centered care) groups using random block design and universal model of family-centered care. Home caregivers' functional skills and burden, as well as patients' readmission and mortality rates, were compared in the two groups.

RESULTS

Implementing the intervention 1 and 3 months later effectively increased home caregivers' functional skills. Moreover, a statistically significant difference was observed between the two groups in terms of the psychological burden of caregiving (P < .001); the implementation of the intervention could highly reduce the psychological burden of caregiving in the intervention group (EF = 0.94). The hospital readmission and mortality rate in the intervention group was significantly lower than in the control group (P = .02 and P = .03, respectively).

CONCLUSIONS

Given the significant impact of the universal model of family-centered care on the clinical outcomes of the patient and the family, pre-discharge training and its post-discharge follow-up and continuity of education with an active presence of nurses, as one of the main pillars of the treatment, seems essential.

Increase in Newborns Ventilated Within the First Minute of Life and Reduced Mortality After Clinical Data-Guided Simulation Training

INTRODUCTION

Birth asphyxia-related deaths is a major global concern. Rapid initiation of ventilation within the "Golden Minute" is important for intact survival but reported to be challenging, especially in low-/middle-income countries. Helping Babies Breathe (HBB) is a simulation-based training program for newborn resuscitation. The aim of this HBB quality improvement (QI) intervention was to decrease time from birth to ventilation and document potential changes in perinatal outcomes.

METHOD

Prospective observational QI study in a rural Tanzanian hospital, October 1, 2017, to August 31, 2021, first-year baseline, second-year QI/simulation intervention, and 2-year postintervention. Trained research assistants observed wide-ranging information from all births (N = 12,938). The intervention included monthly targeted HBB simulation training addressing documented gaps in clinical care, clinical debriefings, and feedback meetings.

RESULTS

During the QI/simulation intervention, 68.5% nonbreathing newborns were ventilated within 60 seconds after birth compared with 15.8% during baseline and 42.2% and 28.9% during the 2 postintervention years ( P < 0.001). Time to first ventilation decreased from median 101 (quartiles 72-150) to 55 (45-67) seconds ( P < 0.001), before increasing to 67 (49-97) and 85 (57-133) seconds after intervention. More nonbreathing newborns were ventilated in the intervention period (12.9%) compared with baseline (8.5%) and the postintervention years (10.6% and 9.4%) ( P < 0.001). Assumed fresh stillborns decreased significantly from baseline to intervention (3.2%-0.7%) ( P = 0.013).

CONCLUSIONS

This QI study demonstrates an increase in nonbreathing newborns being ventilated within the Golden Minute and a significant reduction in fresh stillborns after introduction of an HBB QI/simulation intervention. Improvements are partially reversed after intervention, highlighting the need for continuous simulation-based training and research into QI efforts essential for sustainable changes.

Challenges with communication of critical laboratory results in a resource-limited setting in South Africa

Background

Critical laboratory results are test results suggesting a patient is in immediate danger unless treatment is administered promptly. There is a paucity of studies in sub-Saharan Africa on clinicians' utility of these results and affected patients' outcomes. In our resource-limited setting in South Africa, we rely on telephonic communication to convey critical results.

Objective

The aim of this study was to determine the average time for clinicians to acknowledge these results on the laboratory information system and to determine the outcome of affected patients.

Methods

A retrospective descriptive audit at Tygerberg Academic Hospital was conducted between 01 October 2021 and 31 March 2022. Critical results and the time of acknowledgement by clinicians on the laboratory information system were obtained from inpatients and outpatients. One hundred and twenty inpatient critical results were randomly selected for a folder review to determine patient outcome.

Results

Overall, 2514 critical results were reported, and 63 results were excluded. The remaining 2451 results were obtained from 1346 patients. The majority (94.5%) of results were obtained from inpatients, where 1681 (68.6%) were acknowledged within 24 h. The folder audit of 120 patients determined that 40 (33.3%) patients demised. In 82 (68.3%) patients, communication of a critical result did not alter clinical management.

Conclusion

Critical laboratory results are crucial to patient care. This study found that approximately one-third of critical laboratory results were not used within 24 h. Engaging clinicians in current practice and implementing a means of improved communication of critical results is required.

What this study adds

The study adds to the evidence of challenges experienced with communicating critical results to clinicians which could impact patient care. This is especially true in resource-limited settings; clinicians need to be made aware of the importance of these results, and communication modes need to be improved.

Introducing a framework to support the identification and tackling of health inequalities within specialised services

BACKGROUND

The potential for addressing healthcare inequalities in prescribed specialised services has historically been overlooked. There is evidence that prescribed specialised services can exacerbate inequalities even though they are often accessed at the end of complex pathways and by relatively small numbers of people. Leadership is required to facilitate a systematic approach to identifying and addressing inequalities in this area.

METHODS

A rapid literature review of articles from 2015 onwards and engagement with stakeholders was used to inform the development of a framework that both supports the identification of health inequalities within specialised services and provides recommendations for how to address them.

RESULTS

The framework aligns with existing national approaches in England to addressing health inequalities in other healthcare settings. It is prepopulated with features of services that may create inequalities and recommended ways of addressing them and can be readily adapted to suit population specific needs.

CONCLUSION

The potential for addressing health inequalities should be considered at all points along a healthcare pathway. Local service leaders need to be empowered and encouraged to identify and deliver on opportunities for change to continually improve patient access, experience and outcomes.

The Role of Therapists' Attachment and Introject in Their Treatment Process and Outcome: A Systematic Review

Previous reviews have examined empirical evidence of the relationship between therapists' internalized relational models, including therapists' attachment styles and Sullivan's notion of introject, and the therapeutic relationship. This review expands upon previous reviews by examining the effect of therapists' internalized relational models on the treatment process (e.g., therapeutic alliance and countertransference) and treatment outcomes (e.g., symptoms and functioning) more broadly. Our systematic search identified 42 empirical studies measuring therapist's internalized relational models, defined as therapist attachment style (i.e., the way the therapist relates to others) and/or introject (i.e., the way the therapist relates to themselves), in relation to therapy process and outcome, including 35 studies on attachment, nine studies on introject and two that examined both constructs. A rigorous quality assessment was conducted; two studies were rated as 'moderate', and 40 were rated as 'weak' in quality. Based on the study findings, it appears that more securely attached therapists may have stronger working alliances and more positive therapeutic processes with their patients. Contrary to expectations, therapist attachment security does not appear to impact treatment outcomes. Therapists who relate to themselves in a more affirming way may have stronger working alliances and better treatment outcomes, but very few studies have addressed this question thus far. More rigorous research, especially on the effect of therapists' introject, is needed. Therapists may consider the potential impact of their internalized relational models on the working alliance and other treatment processes that influence therapeutic outcomes.

The Role of Wearable Devices in Chronic Disease Monitoring and Patient Care: A Comprehensive Review

Wearable health devices are becoming vital in chronic disease management because they offer real-time monitoring and personalized care. This review explores their effectiveness and challenges across medical fields, including cardiology, respiratory health, neurology, endocrinology, orthopedics, oncology, and mental health. A thorough literature search identified studies focusing on wearable devices' impact on patient outcomes. In cardiology, wearables have proven effective for monitoring hypertension, detecting arrhythmias, and aiding cardiac rehabilitation. In respiratory health, these devices enhance asthma management and continuous monitoring of critical parameters. Neurological applications include seizure detection and Parkinson's disease management, with wearables showing promising results in improving patient outcomes. In endocrinology, wearable technology advances thyroid dysfunction monitoring, fertility tracking, and diabetes management. Orthopedic applications include improved postsurgical recovery and rehabilitation, while wearables help in early complication detection in oncology. Mental health benefits include anxiety detection, post-traumatic stress disorder management, and stress reduction through wearable biofeedback. In conclusion, wearable health devices offer transformative potential for managing chronic illnesses by enhancing real-time monitoring and patient engagement. Despite significant improvements in adherence and outcomes, challenges with data accuracy and privacy persist. However, with ongoing innovation and collaboration, we can all be part of the solution to maximize the benefits of wearable technologies in healthcare.

Textbook Outcome in Colorectal Surgery for Cancer: An Italian Version

Background/Objectives: The textbook outcome (TO) is a composite tool introduced to uniform surgical units and regulate surgical quality and outcomes. A patient is considered TO only if all predetermined items are met. In colorectal surgery, TO represents a new tool that can achieve important results given the prevalence of colorectal cancers. However, at present, there is a lack of uniformity in the TO's definition. This study utilized the Delphi process to define an Italian version of the TO in colorectal cancer. Methods: The survey consisted of two rounds of online questionnaires submitted to an expert panel in colorectal oncological surgery, renowned academic surgeons, who had attended multiple scientific conferences and who were authors of papers on this specific topic. Five main topics with 26 questions were investigated through an online modified Delphi method. Items with almost 75% agreement achieved consensus. Results: Twenty-eight Italian experts were selected and participated in the two rounds. The Italian version of the textbook outcome in colorectal surgery was defined as the presence of 90-day postoperative survival, negative margins and at least 12 lymph nodes, a minimally invasive approach, ostomy fashioning if preoperatively planned, postoperative complication < Clavien-Dindo 3b, at least 10 ERAS items, no readmission, proper CHT and RT regimens, complete colonoscopy after or before surgery and Tumor Board Evaluation. Conclusions: The textbook outcome in colorectal cancer patients is a quality instrument providing a complete overview of the care of such patients, from diagnosis to treatment. We hereby propose an Italian version of the TO with outcomes chosen by an expert panel.

Rethinking the tiered trauma team response: A case-series study in a regional trauma centre

OBJECTIVE

To reduce perceived unnecessary resource use, we modified our tiered trauma response. If a patient was not physiologically compromised, surgical registrar attendance was not mandated. We investigated the effect of this change on missed injury, unplanned representation to ED, diagnostic imaging rates and staff satisfaction.

METHODS

A retrospective case series study assessing the 3-month period before and after the intervention was conducted. Logistic regression analyses were used to examine the association between ordering of computerised tomography (CT) and ED length of stay (LOS), injury severity (ISS), age, surgical review and admission. A staff survey was conducted to investigate staff perceptions of the practice change. Free text data were analysed using inductive content analysis.

RESULTS

There were 105 patients in the control and 166 in the intervention group and their mean (SD) ISS was the same (ISS [SD] = 4 [±4] [P = 0.608]). A higher proportion of the control group were admitted (56.3% vs 42.2% [P = 0.032]) and they had a shorter ED LOS (274 min [202-456] vs 326 min [225-560], P = 0.044). The rate of missed injury was unchanged. A surgical review resulted in a 26-fold increase in receipt of a whole-body CT scan (odds ratio = 26.89, 95% confidence interval = 3.31-218.17). Just over half of survey respondents felt the change was safe (54.4%), and more surgical (90%) than ED staff (69%) reported the change as positive.

CONCLUSION

The removal of the surgical registrar from the initial trauma standby response did not result in any adverse events, reduced admissions, pathology and imaging, but resulted in an increased ED LOS and time to surgical review.

Clinical and laboratory characteristics and outcome predictors of cerebral venous sinus thrombosis in a referral neurology hospital in Bangladesh

OBJECTIVE

We aimed to describe clinical and laboratory characteristics and determine the predictors of outcome in patients with cerebral venous sinus thrombosis.

METHODS

This prospective study was conducted over 2 years among hospitalized patients with cerebral venous sinus thrombosis. Patient outcome was assessed using the Modified Rankin Scale (mRS) score at 3 months. Outcome predictors were identified using logistic regression analysis.

RESULTS

Eighty-one patients were included in this study. The median mRS outcome at 3 months was 1 (interquartile range 1-3). Poor outcomes were observed in 27.2% of patients, and the mortality rate was 9.8%. Factors associated with poor outcomes were age >60 years (relative risk [RR] 5.1), hemiparesis (RR 5.4), altered level of consciousness (RR 7.1), and transverse sinus involvement (RR 1.1). In general, mRS scores were not associated with D-dimer levels (RR 2.4). However, older patients with elevated D-dimer levels showed a significant association with poor outcomes (1.6) according to mRS scores.

CONCLUSION

Older age, hemiparesis, and altered consciousness levels were independent predictors of poor outcomes in patients with cerebral venous sinus thrombosis. High D-dimer level showed no association with functional disability, except in older patients.

Assessment of Turnaround Time (TAT) for Oral Squamous Cell Carcinoma Biopsies: A Single-Institution Experience

BACKGROUND

Oral squamous cell carcinoma (OSCC) is one of the most common cancers worldwide. A delay in the diagnosis of OSCC can have a drastic impact on management and patient outcomes. One of the most crucial elements in oral management is the timely histopathological final diagnosis. Turnaround time (TAT) is regarded as the most important component of the quality performance evaluation. Many labs have struggled to improve their TATs despite advancements in computerization, transport systems, and analytical technologies.  Aim: This study aimed to assess the TAT of OSCC cases, assess the mean TAT period, evaluate any TAT delays, and explore the reasons behind the TAT delays.  Materials and methods: OSCC reports in Saveetha Dental College and Hospitals, Chennai, for one year from January 1, 2022, to December 31, 2022, were retrieved from the Dental Information Archival Software (DIAS), and the mean TAT was noted. Further, the number of cases with delay in TAT was also observed, and the reason for their delay was listed. Descriptive statistics and graphical representation were performed utilizing IBM SPSS Statistics for Windows, V. 23.0 (IBM Corp., Armonk, NY, USA). One-way ANOVA was performed with a significance set at a p-value less than 0.05.

RESULTS

230 OSCC cases were retrieved and included in the TAT evaluation for this study. Among 230 cases, 161 (70%) were incisional and 69 (30%) were excisional biopsies. Only seven (4%) incisional cases and seven (10%) excisional biopsies showed a delay in TAT. The most common reason for the delay in TAT was the requirement for deeper sections and decalcification of bone specimens. Out of 161 incisional cases, only 48 (29%) have undergone excision and further treatment. Twenty-one out of 69 (30%) excisional cases were found to be referral cases from other private institutions. The overall average TAT for 12 months was 3.24 ± 0.41 days for incisional biopsies and 11.88 ± 2.07 days for excisional biopsies. One-way ANOVA revealed a statistically significant p-value of less than 0.00001.

CONCLUSION

Our study sheds light on specific challenges in TAT delay and opportunities for the improvement of TAT. This can result in faster TAT of OSCC reports, further improve patient care, and enable prompt treatment. This study quantified the TAT for OSCC cases and identified critical areas for process improvement. The findings can inform strategies to streamline diagnostic workflows, reduce delays, and ultimately improve the timely delivery of care to patients with OSCC.

Physical Activity, Bleedings and Quality of Life in Subjects with Haemophilia A without Inhibitors-A Multicenter, Observational Italian Study with a Wearable Device

Background: This study aimed to gather data on physical activity (PA), bleeding, health-related quality of life, and health status, using a wearable device and an electronic patient-reported outcome (ePRO) app, in individuals with moderate or severe hemophilia A (HA) without inhibitors receiving treatment according to the clinical practice. Methods: This is a 12-month multicenter cohort study conducted in Italy. The primary outcomes included the description of PA by type and intensity, adherence to World Health Organization guidelines, bleeding, and health-related quality of life by EQ-5D questionnaire. PA data were collected continuously through a fitness tracker worn by the patient; all the other variables were collected through ePRO questionnaires. Results: Only 54 of the 103 enrolled subjects (52.4%) used their fitness tracker for the defined valid period; adolescents were the least compliant age group. PA was performed at low rates and intensity. Approximately 52% of the subjects had sedentary behavior. The mean EQ-5D values did not change over time. At least one bleeding was reported in 43.7% of the subjects, mostly with sedentary behavior. The PA in the 2 days preceding the bleeding was comparable to the one observed in the overall observational period. Conclusions: The systematic recording of data through a fitness tracker and ePRO app shows that subjects with HA without inhibitors have lower-than-expected PA and that they still experience issues related to bleeding.

Tripartite Motif-Containing 2, a Glutamine Metabolism-Associated Protein, Predicts Poor Patient Outcome in Triple-Negative Breast Cancer Treated with Chemotherapy

BACKGROUND

Breast cancer (BC) remains heterogeneous in terms of prognosis and response to treatment. Metabolic reprogramming is a critical part of oncogenesis and a potential therapeutic target. Glutaminase (GLS), which generates glutamate from glutamine, plays a role in triple-negative breast cancer (TNBC). However, targeting GLS directly may be difficult, as it is essential for normal cell function. This study aimed to determine potential targets in BC associated with glutamine metabolism and evaluate their prognostic value in BC.

METHODS

The iNET model was used to identify genes in BC that are associated with GLS using RNA-sequencing data. The prognostic significance of tripartite motif-containing 2 (TRIM2) mRNA was assessed in BC transcriptomic data (n = 16,575), and TRIM2 protein expression was evaluated using immunohistochemistry (n = 749) in patients with early-stage invasive breast cancer with long-term follow-up. The associations between TRIM2 expression and clinicopathological features and patient outcomes were evaluated.

RESULTS

Pathway analysis identified TRIM2 expression as an important gene co-expressed with high GLS expression in BC. High TRIM2 mRNA and TRIM2 protein expression were associated with TNBC (p < 0.01). TRIM2 was a predictor of poor distant metastasis-free survival (DMFS) in TNBC (p < 0.01), and this was independent of established prognostic factors (p < 0.05), particularly in those who received chemotherapy (p < 0.05). In addition, TRIM2 was a predictor of shorter DMFS in TNBC treated with chemotherapy (p < 0.01).

CONCLUSIONS

This study provides evidence of an association between TRIM2 and poor patient outcomes in TNBC, especially those treated with chemotherapy. The molecular mechanisms and functional behaviour of TRIM2 and the functional link with GLS in BC warrant further exploration using in vitro models.

What Is the Impact of Multimodal Treatment in Patients with Leiomyosarcoma of Bone? A Multicenter Study of 35 Patients with an Ultra-Rare Tumor Entity

Primary leiomyosarcoma of bone (LMSoB) is extremely rare, comprising only <0.7% of primary malignant bone tumors, and is therefore considered an ultra-rare tumor entity. There is currently no consensus as to whether therapeutic strategies should be based on the biological characteristics of soft tissue leiomyosarcoma or on primary tumor localization in the bone. The use of perioperative chemotherapy and its effectiveness in this rare tumor entity remains unclear. We aimed to evaluate the impact of different treatment approaches in a multicenter setting with a total of 35 patients included. The 5-year overall survival (OS) was 74%. Patients with localized disease undergoing surgery had a significantly higher 5-year OS compared to patients who did not undergo surgical treatment (82% vs. 0%, p = 0.0015). Axial tumor localization was associated with worse event-free survival (EFS) probability (p < 0.001) and OS (p = 0.0082). A high proportion of our patients developed secondary metastases. Furthermore, the perioperative chemotherapy protocols applied to our patients were not associated with an improved EFS or OS. Therefore, the benefit of perioperative chemotherapy in LMSoB needs to be further investigated, and the choice of agents still needs to be clarified.

Development of a Management App for Postviral Fibromyalgia-Like Symptoms: Patient Preference-Guided Approach

BACKGROUND

Persistent fibromyalgia-like symptoms have been increasingly reported following viral infections, including SARS-CoV-2. About 30% of patients with post-COVID-19 syndrome fulfill the fibromyalgia criteria. This complex condition presents significant challenges in terms of self-management. Digital health interventions offer a viable means to assist patients in managing their health conditions. However, the challenge of ensuring their widespread adoption and adherence persists. This study responds to this need by developing a patient-centered digital health management app, incorporating patient preferences to enhance usability and effectiveness, ultimately aiming to improve patient outcomes and quality of life.

OBJECTIVE

This research aims to develop a digital health self-management app specifically for patients experiencing postviral fibromyalgia-like symptoms. By prioritizing patient preferences and engagement through the app's design and functionality, the study intends to facilitate better self-management practices and improve adherence.

METHODS

Using an exploratory study design, the research used patient preference surveys and usability testing as primary tools to inform the development process of the digital health solution. We gathered and analyzed patients' expectations regarding design features, content, and usability to steer the iterative app development.

RESULTS

The study uncovered crucial insights from patient surveys and usability testing, which influenced the app's design and functionality. Key findings included a preference for a symptom list over an automated chatbot, a desire to report on a moderate range of symptoms and activities, and the importance of an intuitive onboarding process. While usability testing identified some challenges in the onboarding process, it also confirmed the importance of aligning the app with patient needs to enhance engagement and satisfaction.

CONCLUSIONS

Incorporating patient feedback has been a significant factor in the development of the digital health app. Challenges encountered with user onboarding during usability testing have highlighted the importance of this process for user adoption. The study acknowledges the role of patient input in developing digital health technologies and suggests further research to improve onboarding procedures, aiming to enhance patient engagement and their ability to manage digital health resources effectively.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/32193.

Examining Nurse and Patient Factors Before and After Implementing an Oncology Acuity Tool: A Mixed Methods Study

Background and Purpose: To evaluate the nurse documentation compliance, pressure injury compliance, and fall prevention compliance before and after implementing an oncology acuity tool (OAT) at a specialized cancer center in Jordan. Methods: A mixed methods design was used. A qualitative approach was employed using a semistructured interview with 15 nurses selected by purposive sampling. In contrast, the quantitative approach included pre- and postdata obtained to identify the role of adopting the OAT in improving nursing documentation and applying fall and pressure injury-prevention precaution measures. Results: The thematic analysis developed seven themes, including oncology acuity score (OAS) and assignment processes, OAS and patient outcomes, OAS and nurse outcomes, limitations of the OAT, driving forces, restraining forces, and recommendations or suggestions. The results showed significant improvements in nursing documentation (p =.0385), application of pressure injury (p ≤ .00001), and falling precaution measures (p ≤ .00001). Conclusion: Nurse assignment, nursing compliance, and patients' and nurses' outcomes improved after utilizing the OAT.

Cancer-associated fibroblast spatial heterogeneity and EMILIN1 expression in the tumor microenvironment modulate TGF-β activity and CD8+ T-cell infiltration in breast cancer

Rationale: The tumor microenvironment (TME) and its multifaceted interactions with cancer cells are major targets for cancer treatment. Single-cell technologies have brought major insights into the TME, but the resulting complexity often precludes conclusions on function. Methods: We combined single-cell RNA sequencing and spatial transcriptomic data to explore the relationship between different cancer-associated fibroblast (CAF) populations and immune cell exclusion in breast tumors. The significance of the findings was then evaluated in a cohort of tumors (N=75) from breast cancer patients using immunohistochemistry analysis. Results: Our data show for the first time the degree of spatial organization of different CAF populations in breast cancer. We found that IL-iCAFs, Detox-iCAFs, and IFNγ-iCAFs tended to cluster together, while Wound-myCAFs, TGFβ-myCAFs, and ECM-myCAFs formed another group that overlapped with elevated TGF-β signaling. Differential gene expression analysis of areas with CD8+ T-cell infiltration/exclusion within the TGF-β signaling-rich zones identified elastin microfibrillar interface protein 1 (EMILIN1) as a top modulated gene. EMILIN1, a TGF-β inhibitor, was upregulated in IFNγ-iCAFs directly modulating TGFβ immunosuppressive function. Histological analysis of 75 breast cancer samples confirmed that high EMILIN1 expression in the tumor margins was related to high CD8+ T-cell infiltration, consistent with our spatial gene expression analysis. High EMILIN1 expression was also associated with better prognosis of patients with breast cancer, underscoring its functional significance for the recruitment of cytotoxic T cells into the tumor area. Conclusion: Our data show that correlating TGF-β signaling to a CAF subpopulation is not enough because proteins with TGF-β-modulating activity originating from other CAF subpopulations can alter its activity. Therefore, therapeutic targeting should remain focused on biological processes rather than on specific CAF subtypes.

Excretion of SARS-CoV-2 RNA in feces has no prognostic benefit in the outcome of COVID-19: A clinical and immunological study

This study explores the correlation between immunological and clinical characteristics in coronavirus disease 2019 (COVID-19) patients with detectable severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in feces, analyzing data from 251 patients admitted to Mostar University Clinical Hospital (UCH) from December 2021 to January 2022. Methods involved reverse transcription quantitative polymerase chain reaction (RT-qPCR) from nasopharyngeal (NP) swabs and feces, alongside serological tests for anti-SARS-CoV-2 spike IgGs. Demographic and clinical data were collected through questionnaires and medical records. The data analyses were performed using SPSS statistical software. Death occurred in 53 patients (21.1%, P < 0.001), mostly in the elderly (47/53, 88.7%, P = 0.001) and immunocompromised (19/53, 35.8%, P = 0.05), particularly those developing acute respiratory insufficiency (ARI) (46/53, 86.8%, P = 0.004), and severe/critical disease (46/53, 86.8%, P = 0.002). Among the patients with positive anti-SARS-CoV-2 IgG antibodies (86/251, 34.3%, P < 0.001), 41 (47.7%) were vaccinated and 45 (52.3%) unvaccinated (P = 0.666), showing no significant differences in clinical outcomes or mortality. Unvaccinated patients with a negative antibody titer had a higher incidence of ARI (96/123, 78%, P = 0.029) and intensive care unit (ICU) admission (22/123, 17.9%, P = 0.026), than those with a positive antibody titer. Forty-seven (62.7%) patients, out of the 75 hospitalized who provided a feces sample, were positive for SARS-CoV-2 RNA (P = 0.028), without statistical differences between fecal SARS-CoV-2 positive and negative groups regarding vaccination status (15/47, 31.9%, P = 0.493), antibody status (18/47, 38.3%, P = 0.628), or death outcome (5/47, 10.6%, P = 0.706). In conclusion, unvaccinated hospitalized patients with a severe COVID-19 presentation and a negative anti-spike SARS-CoV-2 IgG titer had adverse outcomes more frequently. This suggests cautious consideration for the diagnostic use of fecal samples compared to NP swabs.

Association of preclinical blood glucose with hospitalization rate and in-hospital mortality: A single-center retrospective cohort study

Objective

Critical illness is often accompanied by elevated blood glucose, which generally correlates with increased morbidity and mortality. Prehospital blood glucose (PBG) level might be a useful and easy-to-perform tool for risk assessment in emergency medicine. This retrospective single-center cohort study was designed to analyze the association of prehospital glucose measurements with hospitalization rate and in-hospital mortality.

Methods

Records of 970 patients admitted to a university hospital by an emergency physician were analyzed. Patients with a PBG ≥140 mg/dL (G1, n = 394, equal to 7.8 mmol/L) were compared with patients with a PBG <140 mg/dL (G2, n = 576). Multivariable logistic regression models were used to correct for age, prediagnosed diabetes, and sex.

Results

Five hundred thirty-four patients (55%) were hospitalized. In comparison to normoglycemic patients, hyperglycemic patients were more likely to be hospitalized with an adjusted odds ratio (OR) of 1.48 (95% confidence interval [CI] 1.11-1.97), more likely to be admitted to the intensive care unit (ICU) with an adjusted OR of 1.74 (95% CI 1.31-2.31) and more likely to die in the hospital with an adjusted OR of 1.84 (95% CI 0.96-3.53). Hospitalized hyperglycemic patients had a median length of stay of 6.0 days (interquartile range [IQR] 8.0) compared to 3.0 days (IQR 6.0) in the normoglycemic group (P < 0.001). In the subgroup analysis of cases without known diabetes, patients with PBG ≥140 mg/dL were more likely to be hospitalized with an adjusted OR of 1.49 (95% CI 1.10-2.03) and more likely to be admitted to ICU/intermediate care with an adjusted OR of 1.80 (95% CI 1.32-2.45), compared to normoglycemic patients.

Conclusion

Elevated PBG ≥140 mg/dL was associated with a higher hospitalization risk, a longer length of stay, and a higher mortality risk and may therefore be included in risk assessment scores.

Case report: Successful treatment of a patient undergoing haemodialysis with multifocal hepatocellular carcinoma using atezolizumab and bevacizumab

In the last five years, the advent of combination immune checkpoint inhibitor atezolizumab and anti-angiogenic agent bevacizumab has transformed treatment of unresectable hepatocellular carcinoma. As patient outcomes improve, healthcare professionals will more frequently encounter patients with concomitant hepatocellular cancer and end stage kidney disease on haemodialysis. We present the first case in the literature of a 58-year-old male with multifocal hepatocellular carcinoma undertaking regular haemodialysis who was successfully treated with atezolizumab and bevacizumab with a partial response and stable disease for two years, who suffered grade 1 fatigue, grade 2 hypertension and eventually grade 3 wound infection leading to cessation of bevacizumab. After disease progression on atezolizumab monotherapy, all chemotherapy was stopped. We embed this case in a review of the current literature of atezolizumab and bevacizumab use in patients undertaking haemodialysis and conclude that both targeted therapies may be safely used in these patients. We recommend joint close management of these patients between oncology and nephrology teams, with initial cardiovascular risk stratification before commencing atezolizumab and bevacizumab therapy. During therapy, there should be regular monitoring of blood pressure, or proteinuria if the patient is oliguric under guidance of the dialysis team if preservation of residual renal function is required.

[Evaluation of Patient Outcomes after Pharmacological Intervention in Home Health Care Utilizing Pharmaceutical Care Records]

The purpose of this study was to identify patient outcomes after pharmacist interventions in the home health care context using pharmaceutical care records accumulated during daily operations. We focused on 591 cases at Nakajima Pharmacy from April 2020 to December 2021, where dispensing fees were charged to prevent duplication of medication and unnecessary interactions of home patients (excluding those related to adjustment of ongoing medications). The study investigated the content and background of prescription changes, the follow-up rate, and patient outcomes. The most common circumstances that led to pharmacist intervention for homebound patients were symptom occurrence (uncontrolled symptom, new symptom, drug adverse event). Of the patients for whom pharmacist intervention was provided for symptoms, 72.8% received follow-up according to the pharmaceutical care records. Furthermore, 59.2% of patients with follow-up showed an improvement of their symptoms. In addition, many patients had their medications discontinued or the dosage reduced by the pharmacist despite stable symptoms. More than 90% of these patients showed no change in symptoms. Besides interventions associated with the occurrence of symptoms, many interventions related to medication adherence were found to result from the patient's physical condition, such as poor swallowing function. The results suggest that tracking pharmacy drug histories may help pharmacists to better understand the need for follow-up implementation and the changes in patient outcomes after interventions.

How Information Affects Patients with Parkinson's Disease: A Scoping Review of the Literature

Background

Patients with Parkinson's disease (PD) need to receive adequate information to manage their disease. However, little is known about how information provision affects patients.

Objective

To conduct a scoping review of the literature on the relationship between content, timing, manner of delivery, and source of PD-specific information on the one hand, and patient outcomes on the other.

Methods

All literature reporting about original data and published until April 2024 in peer-reviewed journals was searched in MEDLINE (Ovid), Embase (Ovid) and PsychInfo (Ovid). Subsequently, data were extracted and synthesized.

Results

40 publications describing the effects of information provision or patients' evaluation thereof were retrieved. Four categories of patient outcomes were described, namely 1) evaluation and experience of information provision; 2) physical functioning; 3) psychosocial well-being; and 4) quality of life. In intervention studies, patients generally valued the provided information. Findings from cross-sectional and qualitative studies showed the importance of tailoring information to individuals' needs and capabilities. Due to variation in study designs and outcomes, no unambiguous conclusions could be drawn regarding the relationship between information and outcomes.

Conclusions

This scoping review identified how PD patients acquire information and revealed a lack of systematic research into the effect of information on patient outcomes. Future studies should assess 1) what information is currently provided by clinicians; 2) what additional information might be beneficial to provide; and 3) how information can be effectively aligned to benefit patients. This will eventually yield insight into how information might optimally empower PD patients.

Comparison of hand dexterity and hand laterality task in duchenne muscular dystrophy patients with typically developing peers

BACKGROUND

Hand dexterity is important with Duchenne muscular dystrophy (DMD).

OBJECTIVE

The aim of this study was to compare hand dexterity and hand laterality task assessments in patients with DMD with typically-developing peers.

METHODS

The study included 25 DMD with a mean age of 10.2±2.38 and 21 typically-developing peers with a mean age of 10.33±2.26. Functional levels of DMD patients were determined by Brooke Upper Extremity Functional Classification Scale and Brooke Lower Extremity Functional Scale. The ABILHAND-Kids and 9-hole peg test were used to assess the hand dexterity of all participants, and assess the hand laterality task.

RESULTS

Patients with DMD had lower ABILHAND-Kids scores than their typically-developing peers (p < 0.001). Patients with DMD had higher 9-hole peg test duration on the dominant and non-dominant extremity compared to typically-developing peers (p < 0.001). Patients with DMD were found to be different from their typically-developing peers (p < 0.001) in lateralization response time and accuracy.

CONCLUSION

Patients with DMD were found to have lower manual dexterity and hand laterality task skills compared to their typically-developing peers. It is recommended that hand dexterity and upper extremity recognition capacities should be considered in assessment and intervention programs for physiotherapists and clinicians working in this field.

Inflammation-related prognostic markers in resected hepatocellular carcinoma

Hepatocellular carcinoma is usually detected late and therapeutic options are unsatisfactory. Despite marked progress in patient care, HCC remains among the deadliest cancers world-wide. While surgical resection remains a key option for early-stage HCC, the 5-year survival rates after surgical resection are limited. One reason for limited outcomes is the lack of reliable prognostic biomarkers to predict HCC recurrence. HCC prognosis has been shown to correlate with different systemic and pathological markers which are associated with patient survival and HCC recurrence. Liver inflammatory processes offer a large variety of systemic and pathological markers which may be exploited to improve the reliability of prognosis and decision making of liver surgeons and hepatologists. The following review aims to dissect the potential tools, targets and prognostic meaning of inflammatory markers in patients with resectable HCC. We analyze changes in circulant cellular populations and assess inflammatory biomarkers as a surrogate of impaired outcomes and provide an overview on predictive gene expression signatures including inflammatory transcriptional patterns, which are representative of poor survival in these patients.