A typology of clinical conditions

What Is a Disease for Doctors? A Realist Thematic Qualitative Analysis of the Interpretation of Clinical Vignettes

Given the long-standing debate about the nature of the concept of disease, the objective of this study was to understand how doctors categorize a condition as a disease or not, and what the kind of information they use is. A survey with a set of eighteen clinical vignettes was designed, and nineteen physicians and senior students purposefully selected were asked to interpret those situations as diseases or not and to produce an anonymous short written piece of text providing the motivation of their choice. Realist thematic analysis was used to analyse the answers, and four themes emerged: the temporal dimension of a disease, reification of disease, disease as an existential condition, and disease as a motivation to action. The respondents' interpretations were very heterogeneous, supporting the idea that physicians do not share a common prototypical concept of disease. The results suggested that the interpretation of a condition as a disease or not is the final outcome of a process, in which information from objective, subjective, and socially mediated elements is taken into consideration. According to a critical realist and systemic approach, we hypothesize that the context of doctor-patient relationship could influence the interpretation of the same condition as being a disease or not.

Covert consciousness

Covert consciousness is a state of residual awareness following severe brain injury or neurological disorder that evades routine bedside behavioral detection. Patients with covert consciousness have preserved awareness but are incapable of self-expression through ordinary means of behavior or communication. Growing recognition of the limitations of bedside neurobehavioral examination in reliably detecting consciousness, along with advances in neurotechnologies capable of detecting brain states or subtle signs indicative of consciousness not discernible by routine examination, carry promise to transform approaches to classifying, diagnosing, prognosticating and treating disorders of consciousness. Here we describe and critically evaluate the evolving clinical category of covert consciousness, including approaches to its diagnosis through neuroimaging, electrophysiology, and novel behavioral tools, its prognostic relevance, and open questions pertaining to optimal clinical management of patients with covert consciousness recovering from severe brain injury.

An account of medical treatment, with a preliminary account of medical conditions

In this article, I present a philosophical account of medical treatment. In support of this account, I offer a suggestive account of medical conditions. The account of medical treatment uses three desiderata to demarcate treatment from non-treatment. Namely, a treatment should: (1) be describable by features that enable it to be standardized and characterized as a discrete intervention, (2) target a specific medical condition, and (3) have the possibility of being effective. The account of medical conditions underlies the second desideratum and attempts to tie medical conditions closely to biological dysfunction, while also including some conditions for which biological dysfunction is absent or its presence uncertain. I offer a simple typology of treatments and show how the accounts are relevant to treatment effectiveness, disease, placebos, contested treatments, and treatment standardization.

Two years on, a perspective on MAFLD

To provide clarity for research studies and clinical care, a set of positive criteria for adults and children with metabolic (dysfunction) associated fatty liver disease (MAFLD) was recently published and has subsequently been widely endorsed. The development and subsequent validation of the criteria for MAFLD has created a positive momentum for change. During the course of the ongoing discussion on the redefinition, some concerns have surfaced that we thought needs clarification. In this review, we provide a perspective on MAFLD and bringing clarity to some of the key aspects that have been recently raised.

Attributable mortality due to nosocomial sepsis in Brazilian hospitals: a case-control study

BACKGROUND

Nosocomial sepsis is a major healthcare issue, but there are few data on estimates of its attributable mortality. We aimed to estimate attributable mortality fraction (AF) due to nosocomial sepsis.

METHODS

Matched 1:1 case-control study in 37 hospitals in Brazil. Hospitalized patients in participating hospitals were included. Cases were hospital non-survivors and controls were hospital survivors, which were matched by admission type and date of discharge. Exposure was defined as occurrence of nosocomial sepsis, defined as antibiotic prescription plus presence of organ dysfunction attributed to sepsis without an alternative reason for organ failure; alternative definitions were explored. Main outcome measurement was nosocomial sepsis-attributable fractions, estimated using inversed-weight probabilities methods using generalized mixed model considering time-dependency of sepsis occurrence.

RESULTS

3588 patients from 37 hospitals were included. Mean age was 63 years and 48.8% were female at birth. 470 sepsis episodes occurred in 388 patients (311 in cases and 77 in control group), with pneumonia being the most common source of infection (44.3%). Average AF for sepsis mortality was 0.076 (95% CI 0.068-0.084) for medical admissions; 0.043 (95% CI 0.032-0.055) for elective surgical admissions; and 0.036 (95% CI 0.017-0.055) for emergency surgeries. In a time-dependent analysis, AF for sepsis rose linearly for medical admissions, reaching close to 0.12 on day 28; AF plateaued earlier for other admission types (0.04 for elective surgery and 0.07 for urgent surgery). Alternative sepsis definitions yield different estimates.

CONCLUSION

The impact of nosocomial sepsis on outcome is more pronounced in medical admissions and tends to increase over time. The results, however, are sensitive to sepsis definitions.

'If it can't be coded, it doesn't exist'. A historical-philosophical analysis of the new ICD-11 classification of chronic pain

Chronic pain entails a large burden of disease and high social costs, but is seldom 'in the picture' and barely understood. Until recently, it was not systematically classified but instead viewed as a symptom or sign. In the new International Classification of Diseases, (ICD)-11, to be implemented in 2022, 'chronic' pain is now classified as a separate disease category and, to a certain extent, approached as a 'disease in its own right'. Reasons that have been given for this are not based so much on new scientific insights, but are rather of pragmatic nature. To explore the background of these recent changes in definition and classification of chronic pain, this paper provides a historical-philosophical analysis. By sketching a brief history of how pain experts have been working on the definition and taxonomy since the 1970s, we demonstrate the various social and practical functions that underlie the new ICD-11 classification of chronic pain. Building on this historical-empirical basis, we discuss philosophical issues regarding defining and classifying chronic pain, in particular performativity and pragmatism, and discuss their implications for the broader philosophical debate on health and disease.

Disease definitions in respiratory and sleep medicine: changes in diagnostic criteria and categories over time and clinical implications

The latest issue of Breathe focuses on disease definitions in respiratory and sleep medicine: read the introductory editorial by Chief Editor @ClaudiaCDobler https://bit.ly/3A7CeYj.

Theoretical and clinical disease and the biostatistical theory

Although concepts of disease have received much scrutiny, the benefits of distinguishing between theoretical and clinical disease-and what is meant by those terms-may not be as readily apparent. One way of characterizing the distinction between theoretical and clinical conceptions of disease is by relying on Boorse's biostatistical theory (BST) for a conception of theoretical disease. Clinical disease could then be defined as theoretical disease that is diagnosed. Explicating this distinction provides a useful extension of the BST. The benefits of this approach are clearly and non-normatively demarcating disease from non-disease, while allowing for values and purpose to determine what criteria are used in clinical practice to represent a disease's underlying dysfunction. Through discussion of a variety of medical conditions, including polycystic ovary syndrome and type 2 diabetes mellitus, I explore how the relationship between BST-based theoretical and clinical disease could make sense of various features of clinical practice and medical theory. It could do this by lending focus to a nuanced understanding of the pathophysiological defects present in disease and the means by which they are assessed. This could contribute to making sense of revised nosologies and diagnostic criteria.