Points to consider: EULAR-UEMS standards for the training of European rheumatologists

BACKGROUND

Postgraduate rheumatology training programmes are already established at a national level in most European countries. However, previous work has highlighted a substantial level of heterogeneity in the organisation and, in part, content of programmes.

OBJECTIVE

To define competences and standards of knowledge, skills and professional behaviours required for the training of rheumatologists.

METHODS

A European Alliance of Associations for Rheumatology (EULAR) task force (TF) of 23 experts, including two members of the European Union of Medical Specialists (UEMS) section of rheumatology, was convened. The mapping phase consisted of the retrieval of key documents on specialty training in rheumatology and other related specialties across a broad set of international sources. The content of these documents was extracted and represented the foundation for the document draft that underwent several rounds of online discussion within the TF, and afterwards was also distributed to a broad group of stakeholders for collecting feedback. The list of generated competences was voted on during the TF meetings, while the level of agreement (LoA) with each statement was established by anonymous online voting.

RESULTS

A total of 132 international training curricula were retrieved and extracted. In addition to the TF members, 253 stakeholders commented and voted on the competences through an online anonymous survey. The TF developed (1) an overarching framework indicating the areas that should be addressed during training, (2) 7 domains defining broad areas that rheumatology trainees should master by the end of the training programme, (3) 8 core themes defining the nuances of each domain and (4) 28 competences that trainees should acquire to cover each of the areas outlined in the overarching framework. A high LoA was achieved for all competences.

CONCLUSION

These points to consider for EULAR-UEMS standards for the training of European rheumatologists are now defined. Their dissemination and use can hopefully contribute to harmonising training across European countries.

Integrated care teams in primary care improve clinical outcomes and care processes in patients with non-communicable diseases

Introduction

Primary care physicians face the increasing burden of managing multimorbidities in an ageing population. Implementing an integrated care team (ICT) with defined roles and accountability to share consultation tasks is an emerging care model to address this issue. This study compared outcomes with ICT versus usual care for patients with multimorbidities in primary care.

Methods

Data was retrospectively extracted from the electronic medical records (EMRs) of consecutive adult Asian patients empanelled to ICT and those in UC at a typical primary care clinic (polyclinic) in eastern Singapore in 2018. The study population had hypertension, and/or hyperlipidaemia and/or type 2 diabetes mellitus (T2DM). Clinical outcomes included the proportion of patients (ICT vs. UC) who attained their treatment goals after 12 months. Process outcomes included the proportion of patients who completed annual diabetic eye and foot screenings, where applicable.

Results

Data from 3,302 EMRs (ICT = 1,723, UC = 1,579) from January 2016 to September 2017 was analysed. The ICT cohort was more likely to achieve treatment goals for systolic blood pressure (SBP) (adjusted odds ratio [AOR] = 1.52, 95% confidence interval [CI] = 1.38-1.68), low-density lipoprotein cholesterol (AOR = 1.72, 95% CI = 1.49-1.99), and glycated haemoglobin (AOR = 1.28, 95% CI = 1.09-1.51). The ICT group had higher uptake of diabetic retinal screening (89.1% vs. 83.0%, P < 0.001) and foot screening (85.2% vs. 77.9%, P < 0.001).

Conclusion

The ICT model yielded better clinical and process outcomes than UC, with more patients attaining treatment goals.

The Roles of the Nurses in Family Physician Team: A Qualitative Systematic Review

Background

There are various approaches in primary health care regarding the key role of nurses. This systematic review investigates the roles of nurses, as part of the family medicine team.

Materials and Methods

All published articles related to the role of nurses in the family medicine team from January 2000 to March 2022 were the subjects of this study. The eligibility criteria included original articles published in English or Persian in the last two decades. International credible scholarly databases (PubMed, Scopus, Magiran, IranMedex, and SID) were searched using keywords and syntax. Some of the keywords included "Family Health Nurse," "Nurses in Primary Care," "Family Medicine," "Family Physician Care Program," "General Physician Program," "Role," and "Nurse." Data were extracted based on Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER) technique and reported based on the structure of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

Results

Of 147 identified publications by the search strategy, eight eligible empirical studies were included. The results showed that besides providing nursing care, nurses play vital roles in communication and teamwork, assessment, securing health services relevant to communities' needs, education, empowerment, clinical practice, health promotion, prevention, reflective research practice, and counseling.

Conclusions

This study identified different roles nurses could play in providing primary health care. These findings are helpful for the replanning or reform of primary health care in countries, which aimed to expand the Family Physician Program (FPP) in their countries, including Iran.

Clarifying misbeliefs about hydroxychloroquine (HCQ): developing the HCQ benefits versus harm decision aid (HCQ-SAFE) per low health literacy standards

BACKGROUND

Up to 83% of patients with SLE stop taking hydroxychloroquine (HCQ) within the first year due to knowledge gaps regarding the survival benefits of HCQ versus inflated fears of rare toxicity. Thus, there is a need for a shared decision-making tool that highlights HCQ's significant benefits versus rare harms to improve patients' understanding and align treatments with their values. The objective of this study was to describe development and piloting of a decision aid (HCQ-SAFE) to facilitate HCQ adherence, and safe, effective use by engaging patients in therapeutic decision-making.

METHODS

HCQ-SAFE was developed via a collaborative process involving patients, clinicians, implementation scientists and health literacy experts. The initial prototype was informed by Agency for Healthcare Research and Quality (AHRQ) low literacy principles and key themes about HCQ use from six prior patient and clinician focus groups, with iterative expert and stakeholder feedback to deliver a final prototype. We implemented HCQ-SAFE in four clinics to examine usability and feasibility on Likert scales (0-7) and net promoter score (0%-100%).

RESULTS

The final HCQ-SAFE shared decision-making laminated tool organises data using pictograms showing how HCQ use reduces risk of organ damage, early death and blood clots versus low risk of eye toxicity.HCQ-SAFE was reviewed in all eligible patient visits (n=40) across four clinics on an average of ~8 min, including 25% non-English-speaking patients. All patients scored 100% on the knowledge post-test; no decisional conflicts were noted after using HCQ-SAFE. HCQ-SAFE garnered high clinician and patient satisfaction with 100% likelihood to recommend to peers.

CONCLUSIONS

HCQ-SAFE is a stakeholder-informed feasible shared decision-making tool that enhances communication and can potentially improve knowledge, clarify misbeliefs and engage patients in treatment decisions, including those with limited English proficiency.

Measures to Contain the Transmission of Hepatitis C in a Chronic Kidney Care Hospital Unit in the Triângulo Mineiro in Brazil: A Case Study

Objectives: Hepatitis C virus elimination is complex. The objective was to analyze measures to eliminate virus transmission in a hemodialysis unit. Methods: Case study composed of multiple units of analysis. The scenario is the hemodialysis unit of a Brazilian public hospital. Population composed of health service records. Descriptive analyzes were performed and the beginning of the event was considered as the moment of increased incidence of HCV. The intentional and purposeful collection of information for understanding the event and implementing interventions. Results: The subunits of analysis were related to: clinical-epidemiological profile, active search, transmission routes, management protocol and results achieved. In August 2019, out of 45 patients, six were reactive for anti-HCV. All received treatment. Patients had exposure to contaminated medical equipment, objects or hands of professionals. Preventive measures were adopted and routine techniques were corrected. Situational Analysis Committee guided the management of the event. No new cases were detected. Conclusions: Strategies for the microelimination of the C virus in a dialysis environment are demonstrated and it shows the multidisciplinary efforts in conducting the event.

A 29-year-old woman presenting for urgent cesarean hysterectomy: a multidisciplinary care challenge

This case describes a patient who needed an urgent cesarean hysterectomy for new-onset fetal heart rate abnormalities and preexisting placenta accreta spectrum. Rapid assembly of a multidisciplinary team consisting of obstetrics, anesthesiology, neonatology, and nursing contributed to a favorable clinical outcome.

Soft Tissue Grafting Procedures before Restorations in the Esthetic Zone: A Minimally Invasive Interdisciplinary Case Report

An esthetically pleasing smile is a valuable aspect of physical appearance and plays a significant role in social interaction. Achieving the perfect balance between extraoral and intraoral tissues is essential for a harmonious and attractive smile. However, certain intraoral deficiencies, such as non-carious cervical lesions and gingival recession, can severely compromise the overall aesthetics, particularly in the anterior zone. Addressing such conditions requires careful planning and meticulous execution of both surgical and restorative procedures. This interdisciplinary clinical report presents a complex case of a patient with esthetic complaints related to asymmetric anterior gingival architecture and severely discolored and eroded maxillary anterior teeth. The patient was treated using a combination of minimally invasive ceramic veneers and plastic mucogingival surgery, resulting in a successful outcome. The report emphasizes the potential of this approach in achieving optimal esthetic results in challenging cases, highlighting the importance of an interdisciplinary team approach in achieving a harmonious balance between dental and soft tissue aesthetics.

Polycystic Ovary Syndrome and Obesity: A Cross-Sectional Survey of Patients and Obstetricians/Gynecologists

Background: Polycystic ovary syndrome (PCOS) is an endocrine disorder commonly affecting women of reproductive age. Compared with women without PCOS, women with PCOS are more likely to have overweight or obesity. Materials and Methods: To better understand the role of obstetricians/gynecologists (OB/GYNs) in diagnosis and treatment of patients with PCOS and obesity, we conducted an anonymous, United States population-based, cross-sectional online survey with 251 patients with PCOS and obesity and 305 health care professionals (HCPs), of which 125 were OB/GYNs. Results: In the most common patient journey, most patients were diagnosed (66%) and treated (59%) by OB/GYNs. Most patients (51%) considered OB/GYNs to be the coordinator of their PCOS care. For ongoing management of patients with PCOS and obesity, OB/GYNs reported prescribing general improvements in lifestyle (91%), oral contraceptives (91%), metformin (85%), letrozole (74%), spironolactone (71%), specific diets (60%), medroxyprogesterone (45%), and anti-obesity medications (27%). OB/GYNs were significantly more likely than other HCPs surveyed to strongly agree with the statement that they do not know enough about anti-obesity medications to feel comfortable prescribing them to their patients with PCOS and obesity (p < 0.05). Most OB/GYNs believed that consultation with a dietitian/nutritionist (75%) or access to a physician who specializes in obesity (67%) were the most beneficial types of support for their patients with PCOS and obesity. Conclusions: OB/GYNs recognize the importance of obesity management for the treatment of PCOS; however, utilization of effective obesity tools to treat these patients is low. OB/GYNs may benefit from additional education on obesity management strategies.

Prevalence of flu-like syndrome in healthcare workers in Brazil: a national study, 2020

OBJECTIVE

To evaluate the prevalence of reported symptoms of flu-like syndrome (FS) among HCW and compare HCW and non-HCW on the chance of reporting these symptoms, this study analyzed data of a population-based survey conducted in Brazil.

METHODS

A cross-sectional analysis was performed with self-reported data from the Brazilian National Household Sample Survey (PNAD Covid-19) from May 2020. The authors analyzed a probability sample of 125,179 workers, aged 18 to 65, with monthly income lower than US$ 3 500. The variable HCW or non-HCW was the covariate of interest and having reported FS symptoms or not was the outcome variable. Authors tested interactions of HCW with other covariates. A logit model - when controlling for sociodemographic, employment, and geographic characteristics - investigated the chance of HCW reporting FS compared to non-HCW.

RESULTS

HCW have a significant effect (odds ratio of 1.369) on reporting FS symptoms when compared to non-HCW. HCW account for 4.17% of the sample, with a higher frequency of FS (3.38%) than observed for non-HCW (2.43%). Female, non-white and older individuals had higher chance to report FS.

CONCLUSIONS

The HCW had a higher chance of reporting symptoms than non-HCW aged over 18 years in the labor force. These results emphasize guidelines for preventive measures to reduce workplace exposures in the healthcare facilities. The prevalence is disproportionately affecting HCW women and HCW non-whites. In the regions North and Northeast the steeper progression is consistent with the hypothesis of socioeconomic factors, and it explains the greater prevalence in HCW and non-HCW living in those territories.

Palliative Care in a Specialized Palliative Cancer Care Unit in Portugal: A Complex Reality

Introduction The goal of palliative care (PC) is to improve the quality of life of patients and their families through the involvement of a multidisciplinary team. PC improves symptom control and end-of-life care. Despite the fact that the benefits of PC have long been acknowledged, Portugal's demands are currently unmet. The majority of patients have been identified as having a high level of complexity and are referred for symptom management and end-of-life care. Study aim The study aimed to analyze the sociodemographic, disease and hospitalization characteristics of the patients admitted to a specialized PC unit. Materials and methods We conducted a retrospective, single-center study of palliative care patients admitted to a Portuguese oncology institute's acute palliative care unit during a three-month period. Patients' information such as social demographics, clinical data, patient and family member's psychological, social, nutritional and spiritual counseling and knowledge on diagnosis and therapy objectives were collected from physician's records and analyzed using SPSS Statistics for Windows, Version 23.0 (IBM SPSS Statistics for Windows). Results A total of 41 patients were included, with a mean age of 66.4 years. Spouses were the primary caregivers. There was no indication for targeted therapy in any of the patients. Prior to hospitalization, 58.5% did not receive follow-up by PC. The most frequently reported symptoms were pain (75.6%), tiredness (68.3%), anorexia (61%) and emotional distress (58.5%). Patients were referred to counseling for psychological (43.3%), spiritual (19.5%), nutritional (58.5%) and social services (34.1%). During hospitalization, 75% of patients died; out of which, 70.9% were not previously followed up on by the PC team. Conclusion PC patients are complex, with multiple clinical-psychological-social-spiritual issues, and their management in non-PC wards can be challenging. Since the use of a multidisciplinary approach can improve patients' and families' quality of life, it is critical to train, expand and integrate the PC teams into the existing teams, allowing patients a better quality of life until they pass.

Anesthetic Care of the Pregnant Patient With Cardiovascular Disease: A Scientific Statement From the American Heart Association

The pregnancy-related mortality rate in the United States is excessively high. The American Heart Association is dedicated to fighting heart disease and recognizes that cardiovascular disease, preexisting or acquired during pregnancy, is the leading cause of maternal mortality in the United States. Comprehensive scientific statements from cardiology and obstetrics experts guide the treatment of cardio-obstetric patients before, during, and after pregnancy. This scientific statement aims to highlight the role of specialized cardio-obstetric anesthesiology care, presenting a systematic approach to the care of these patients from the anesthesiology perspective. The anesthesiologist is a critical part of the pregnancy heart team as the perioperative physician who is trained to prevent or promptly recognize and treat patients with peripartum cardiovascular decompensation. Maternal morbidity is attenuated with expert anesthesiology peripartum care, which includes the management of neuraxial anesthesia, inotrope and vasopressor support, transthoracic echocardiography, optimization of delivery location, and consideration of advanced critical care and mechanical support when needed. Standardizing the anesthesiology approach to patients with high peripartum cardiovascular risk and ensuring that cardio-obstetrics patients have access to the appropriate care team, facilities, and advanced cardiovascular therapies will contribute to improving peripartum morbidity and mortality.

Laying the foundations for gene therapy in Italy for patients with haemophilia A: A Delphi consensus study

INTRODUCTION

Current treatment for haemophilia A involves factor VIII replacement or non-replacement (emicizumab) therapies, neither of which permanently normalise factor VIII levels. Gene therapy using adeno-associated viral (AAV) vectors is an emerging long-term treatment strategy for people with severe haemophilia A (PwSHA) that is likely to be available for clinical use in the near future.

AIM

This article proposes practical guidelines for the assessment, treatment, and follow-up of potential PwSHA candidates for AAV-based gene therapy.

METHOD

Using the Delphi method, a working group of Italian stakeholders with expertise in and knowledge of the care of adults with haemophilia A analysed literature for AAV-based gene therapy and drafted a list of statements that were circulated to a panel of Italian peers. During two rounds of voting, panel members voted on their agreement with each statement to reach a consensus.

RESULTS

The Delphi process yielded 40 statements regarding haemophilia A gene therapy, across five topics: (1) organisational model; (2) multidisciplinary team; (3) patient engagement; (4) laboratory surveillance; and (5) patient follow-up and gene therapy outcomes. The consensus was reached for all 40 statements, with the second round of voting needed for five statements.

CONCLUSION

Use of the hub-and-spoke organisational model and multidisciplinary teams are expected to optimise patient selection for gene therapy, as well as the management of dosing and patient follow-up, patient engagement, laboratory surveillance, and patient expectations regarding outcomes. This approach should allow the benefits of AAV-based gene therapy for haemophilia A to be maximised.

Gut microbiota in SLE: from animal models to clinical evidence and pharmacological perspectives

Systemic lupus erythematosus (SLE) is a multifactorial autoimmune disease driven by complex interactions between genetics and environmental factors. SLE is characterised by breaking self-immune tolerance and autoantibody production that triggers inflammation and damage of multiple organs. Given the highly heterogeneous nature of SLE, the treatments currently used are still not satisfactory with considerable side effects, and the development of new therapies is a major health issue for better patient management. In this context, mouse models significantly contribute to our knowledge of the pathogenesis of SLE and are an invaluable tool for testing novel therapeutic targets. Here, we discuss the role of the most used SLE mouse models and their contribution to therapeutic improvement. Considering the complexity of developing targeted therapies for SLE, adjuvant therapies are also increasingly proposed. Indeed, murine and human studies have recently revealed that gut microbiota is a potential target and holds great promises for successful new SLE therapies. However, the mechanisms of gut microbiota dysbiosis in SLE remain unclear to date. In this review, we propose an inventory of existing studies investigating the relationship between gut microbiota dysbiosis and SLE to establish microbiome signature that may serve as a potential biomarker of the disease and its severity as well as a new potential therapy target. This approach may open new possibilities for early diagnosis, prevention and therapeutic perspectives of SLE based on gut microbiome.

Nutrition support teams: Institution, evolution, and innovation

The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.

Study What You Do: Developing a Psychotherapy Tracking Database in a Large-Scale Integrated Behavioral Health Service

PURPOSE

Many individuals with behavioral health challenges receive services in primary care, and integrated behavioral health (IBH) programs can help increase access to evidence-based interventions. IBH programs can benefit substantially from integrating standardized tracking databases that allow for the implementation of measurement-based care to evaluate patient-, clinician-, and practice-level outcomes. We describe the development and integration of Mayo Clinic's pediatric and adult primary care psychotherapy tracking database.

METHODS

IBH practice leaders directed the development of a large psychotherapy tracking database that continuously populates from Mayo Clinic's electronic health record system. The database captures numerous patient variables including demographics, behavioral health and substance use issues, psychotherapy principles used, and self-reported symptoms. We retrieved current data for patients empaneled in Mayo Clinic's pediatric and adult primary care psychotherapy programs from June 2014 to June 2022.

RESULTS

The tracking database contained data for 16,923 adult patients and 6,298 pediatric patients. The mean age of adult patients was 43.2 years (SD 18.3), 88.1% were non-Latine White, and 66.7% identified as female. The mean age of pediatric patients was 11.6 years (SD 4.2), 82.5% were non-Latine White, and 56.9% identified as female. We provide examples of practical applications of the database across clinical, educational, research, and administrative domains.

CONCLUSIONS

The development and integration of a psychotherapy tracking database supports clinician communication, examination of patient outcomes, practice quality improvement efforts, and clinically relevant research. Our description of Mayo Clinic's IBH database may serve as a model for other IBH practices.

Behavioral Health Within Primary Care Postgraduate Dental Curricula: A Mixed Methods Study

PURPOSE

This study evaluated the integration of behavioral health topics (anxiety disorder, depressive disorder, eating disorders, opioid use disorder, and intimate partner violence) into primary care postgraduate dental curricula.

METHODS

We used a sequential mixed methods approach. We sent a 46-item online questionnaire to directors of 265 Advanced Education in Graduate Dentistry programs and General Practice Residency programs asking about inclusion of behavioral health content in their curriculum. Multivariate logistic regression analysis was used to identify factors associated with inclusion of this content. We also interviewed 13 of the program directors, conducted content analysis, and identified themes pertaining to inclusion.

RESULTS

A total of 111 program directors completed the survey (42% response rate). Less than 50% of programs taught their residents to identify anxiety disorder, depressive disorder, eating disorders, and intimate partner violence (86% taught identification of opioid use disorder). From the interviews, we identified 8 main themes: influences on the inclusion of behavioral health in the curriculum; training strategies; reasons for incorporating the training strategies; training outcomes (ie, ways in which residents were evaluated); training outputs (ie, ways in which a program's success was quantified); barriers to inclusion; solutions to barriers; and reflections on how the current program can be made better. Programs housed in settings with no to minimal integration were 91% less likely (odds ratio = 0.09; 95% CI, 0.02-0.47) to include identifying depressive disorder in their curriculum compared with programs in settings with close to full integration. Other influences for including behavioral health content were organizational/government standards and patient populations. Barriers to including behavioral health training included organizational culture and lack of time.

CONCLUSIONS

Advanced Education in General Dentistry and General Practice Residency programs need to make greater efforts to include in their curricula training on behavioral health conditions, particularly anxiety disorder, depressive disorder, eating disorders, and intimate partner violence.

Evaluation of the Oral Health Knowledge Network's Impact on Pediatric Clinicians and Patient Care

PURPOSE

Oral disease has a major impact on the overall health of US children, with dental caries being the most prevalent chronic disease in this age group. Given nationwide shortages of dental professionals, interprofessional clinicians and staff with proper training can influence oral health access. The American Academy of Pediatrics created the Oral Health Knowledge Network (OHKN) in 2018 to bring together pediatric clinicians via monthly virtual sessions to learn from experts, share resources, and network.

METHODS

The Center for Integration of Primary Care and Oral Health partnered with the American Academy of Pediatrics to evaluate the OHKN in 2021. The mixed method evaluation included an online survey and qualitative interviews among program participants. They were asked to provide information on their professional role and prior commitment to medical-dental integration as well as feedback on the OHKN learning sessions.

RESULTS

Of the 72 program participants invited, 41 (57%) completed the survey questionnaire and 11 took part in the qualitative interviews. Analysis showed that OHKN participation supported both clinicians and nonclinicians in integrating oral health into primary care. The greatest clinical impact was incorporating oral health training for medical professionals (cited by 82% of respondents), while the greatest nonclinical impact was learning new information (cited by 85% of respondents). The qualitative interviews highlighted the participants' prior commitment to medical-dental integration as well as drivers for their current medical-dental integration work.

CONCLUSIONS

Overall, the OHKN had a positive impact on pediatric clinicians and nonclinicians and, as a learning collaborative, successfully educated and motivated health care professionals to improve their patients' access to oral health through rapid resource sharing as well as clinical practice change.

Contribution of Pharmaceutical Care to Person-centered Health Care and the Safety of Pharmacotherapy for Hospitalized Older Individuals in Brazil: An Investigative Single-arm Intervention Trial

BACKGROUND

Adverse drug events (ADE) and medication errors (ME) provide large numbers of victims. Older people are more susceptible to these events, due to the continuing search for several chronic degenerative disease treatments. The Third Global Patient Safety Challenge announced the objective of reducing unnecessary polypharmacy, encouraging deprescription, and aiming to ensure the prescription of medications in an appropriate manner, based on the best evidence and taking into account the individual factors of people.

OBJECTIVE

To evaluate whether Pharmaceutical Care (PC), when inserted in a geriatric ward and the context of person-centered health care, cooperates with the safety of pharmacotherapy in older individuals in Brazil.

METHODS

This is an investigative, single-arm, preliminary study.

INCLUSION CRITERIA

individuals aged ≥60 years and admitted to the geriatric ward between August 2019 to January 2020. The PC (with the practice of pharmacotherapeutic follow-up, medication reconciliation, and pharmacotherapy review) was made available to identify ADE and ME, as well as the associated factors and clinical outcomes, were analyzed.

RESULTS

60 participants were included. It was found that, on hospital admission, 93.3% of them were polymedicated and 86.7% had a history of using potentially inappropriate medications (PIM). ADE and ME were detected in 43 individuals (71.7%) and, in total, 115 incidents were identified, with drugs that act on the nervous system associated with them (31.9%). Acceptance of the PC's recommendations reached the rate of 85.2%. Polypharmacy (p=0.03) and the presence of multiple diseases (p=0.03) had an effect on the presentation of ADE and ME. The number of medications in use decreased in the comparison between admission and hospital discharge (p<0.0001).

CONCLUSION

This investigative study indicated that ADE and ME are linked to the polypharmacy in use at the beginning of hospitalization. On the other hand, we showed that the PC (inserted in the multidisciplinary team) contributed to the deprescribing of medications at hospital discharge. Therefore, the PC can provide improvements in this scenario.

The connections of physical and psychosocial symptoms among patients with terminal illnesses: A network analysis

BACKGROUND

Patients with terminal illnesses have different symptoms. The goal of palliative care is to alleviate the suffering induced by these symptoms. Available research on symptoms has focused on their prevalence or identification of clusters. Little is known about the central symptoms contributing to the maintenance of the whole system of symptoms or the mechanism of influence between symptoms, particularly between physical and psychosocial symptoms.

AIM

The study used network analysis to explore symptom clusters among patients with terminal illnesses and identify the central symptoms, the bridge symptoms, and pathways between physical and psychosocial symptoms.

DESIGN AND SETTING/PARTICIPANTS

This is a retrospective cohort study using baseline symptom assessment of 677 adults with terminal illnesses receiving care from the Integrated Community End-of-Life Care Support Teams.

RESULTS

Three symptom clusters were identified: physical, psychological, and practical clusters. "Weakness or lack of energy" was identified as the crucial symptom affecting the changes of other symptoms, followed by depression and anxiety. Three connections between the psychological and physical symptoms were identified: anxiety-pain, depression-constipation, and perceived family anxiety-poor appetite pathways. Pathways of practical concern-peace and practical concern-depression were indicated between practical and psychological symptoms.

CONCLUSIONS

This study is the first of its kind to investigate the connections and mechanism of influence between symptoms among patients with terminal illnesses. It offers clear pathways for intervention with the most influential symptoms of weakness, anxiety, and depression.

2021 EULAR points to consider to support people with rheumatic and musculoskeletal diseases to participate in healthy and sustainable paid work

AIM

As part of its strategic objectives for 2023, EULAR aims to improve the work participation of people with rheumatic and musculoskeletal diseases (RMDs). One strategic initiative focused on the development of overarching points to consider (PtC) to support people with RMDs in healthy and sustainable paid work participation.

METHODS

EULAR's standardised operating procedures were followed. A steering group identified six research areas on paid work participation. Three systematic literature reviews, several non-systematic reviews and two surveys were conducted. A multidisciplinary taskforce of 25 experts from 10 European countries and Canada formulated overarching principles and PtC after discussion of the results of literature reviews and surveys. Consensus was obtained through voting, with levels of agreement obtained anonymously.

RESULTS

Three overarching principles and 11 PtC were formulated. The PtC recognise various stakeholders are important to improving work participation. Five PtC emphasise shared responsibilities (eg, obligation to provide active support) (PtC 1, 2, 3, 5, 6). One encourages people with RMDs to discuss work limitations when necessary at each phase of their working life (PtC 4) and two focus on the role of interventions by healthcare providers or employers (PtC 7, 8). Employers are encouraged to create inclusive and flexible workplaces (PtC 10) and policymakers to make necessary changes in social and labour policies (PtC 9, 11). A research agenda highlights the necessity for stronger evidence aimed at personalising work-related support to the diverse needs of people with RMDs.

CONCLUSION

Implementation of these EULAR PtC will improve healthy and sustainable work participation of people with RMDs.

A Qualitative Study of the Limits and Possibilities of Integrating Palliative Care in Heart Failure

Heart failure is a progressive condition with a high burden of symptoms and clinical decompensations that causes psychological and social suffering, poor quality of life, and limited life expectancy. Therefore, it requires palliative care to control symptoms and signs, but integrating it with clinical care is complicated. We aimed to discuss the limits and possibilities of integrating palliative care in heart failure. This was a qualitative descriptive study. Semi-structured qualitative interviews were carried out between July 2020 and July 2021. We applied the thematic content analysis and the SWOT matrix. Ethical principles were respected. Ten professionals from an Institute specializing in cardiovascular diseases in Rio de Janeiro, Brazil, participated in the study, including physicians, nurses, psychologist, and occupational therapist. We identified 4 categories related to intervening factors: the patient's profile, the emotional aspects of professionals facing these patients, the challenges to integrating and sustaining palliative care in practice, and the ways for assistance planning in this context. The existence of a specialized team, the palliative care commission, and the institutional palliative care protocol, aligned with the realistic perception of the assistance, organizational, political, and social problems, may promote the advancement of palliative care in heart failure.

Psychometric Evaluation of the Collaborative Practice Scale in Certified Nurse-Midwife and Obstetrician Teams

Background and Purpose: Team-based care has been proposed as a means of improving maternity care in the United States. Methods: The study evaluated the individual and group-level psychometric properties of the Collaborative Practice Scale (CPS) among 108 midwives and physicians who provided team-based care in military hospitals. Results: Psychometric properties of the CPS included Cronbach's alpha of .98. Internal consistency was measured with item-to-total correlations from .83 to .94 and inter-item correlations from .71 to .88. Principal components analysis resulted in a single-factor loading, accounting for 80% of total variance. Properties of the scale at the group level; strong within team agreement (r wg( j ) = .94) and between team variance (ICC1 = .15, ICC2 = .65). Conclusion: The CPS demonstrated reliability and validity of the instrument at the individual and group levels. The collaborative process can be measured among midwife-physician teams.

Major depressive episode in hospital workers during the Covid-19 pandemic in Brazil

OBJECTIVES

To estimate prevalence and factors associated with major depressive episode (MDE), emphasizing occupational aspects, in workers of a public teaching hospital that is a reference for Covid-19 treatment.

METHODS

A cross-sectional study was carried out between October and December 2020, after the first peak of the pandemic, interviewing 1,155 workers. The prevalence of MDE was estimated using the Patient Health Questionnaire (PHQ-9) algorithm. Multivariate hierarchical analysis was conducted using Poisson regression to assess associated factors.

RESULTS

MDE prevalence was 15.3% (95%CI: 13.3-17.5) and was higher among young, white and female workers, those with a family history of depression, resident professionals, nursing professionals, workers who were exposed to three or more situations of moral dilemma, and those who had to put off a physiological need until later. Having a risk factor for Covid-19, being a smoker and being physically inactive were also positively associated with MDE.

CONCLUSIONS

The study points to the considerable prevalence of MDE among tertiary health care workers; reviewing work processes is essential to reduce occupational stress and minimize the effects of the pandemic on mental health, preventing those problems from becoming chronic.

Comparing complications and perioperative teams in microsurgical breast reconstruction: retrospective cohort study

Background

Subspecialization with dedicated perioperative teams has become common practice in some surgical disciplines. While surgeon experience, the number of surgeons involved, and enhanced recovery after surgery (ERAS) pathways are known factors affecting the outcome after microsurgical breast reconstruction, the impact of the perioperative team has not been studied.

Methods

We conducted a retrospective cohort study consisting of a chart review of all patients who underwent microsurgical breast reconstruction from January 2019-April 2020. Surgery was performed by three microsurgeons at two institutions with different perioperative teams-one being a small clinic [private clinic (PC), 33 beds] and the other being a larger hospital [corporate hospital (CH), 335 beds]. Patients were grouped into two cohorts according to the institution where surgery was performed. The primary outcomes studied were frequency of revision surgery, flap loss and patient length-of-stay (LOS).

Results

One hundred and fifty microsurgical breast reconstructions were performed in 125 patients. Demographic data [age, body mass index (BMI), current tobacco use, donor site] was found statistically comparable between both cohorts. In the PC cohort with fewer perioperative care providers, lower rates of revision surgery and flap loss were observed (P value =0.009 and 0.04, respectively). LOS was not significantly different between the two cohorts (P value =0.44).

Conclusions

The outcome of microsurgical breast reconstruction depends on multiple factors. In this study, fewer flap complications occurred at the small clinic. One reason among others might be the lower number of perioperative care providers involved and hence higher likelihood of sharing microsurgical cases, which facilitates routine and ensures less variability in care. The value of perioperative team subspecialization in microsurgical breast reconstruction needs to be assessed in prospective studies.