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Consorti F, Melcarne R, Pisanelli D, Scorziello C, Giacomelli L. What Is a Disease for Doctors? A Realist Thematic Qualitative Analysis of the Interpretation of Clinical Vignettes. Healthcare (Basel) 2024; 12:1228. [PMID: 38921342 PMCID: PMC11204354 DOI: 10.3390/healthcare12121228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 06/16/2024] [Accepted: 06/17/2024] [Indexed: 06/27/2024] Open
Abstract
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.
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Affiliation(s)
- Fabrizio Consorti
- Department of General Surgery, University Sapienza of Rome, 00185 Rome, Italy; (R.M.); (C.S.); (L.G.)
| | - Rossella Melcarne
- Department of General Surgery, University Sapienza of Rome, 00185 Rome, Italy; (R.M.); (C.S.); (L.G.)
| | - Domenico Pisanelli
- Institute of Sciences and Technologies of Cognition, National Research Council, 00196 Roma, Italy;
| | - Chiara Scorziello
- Department of General Surgery, University Sapienza of Rome, 00185 Rome, Italy; (R.M.); (C.S.); (L.G.)
| | - Laura Giacomelli
- Department of General Surgery, University Sapienza of Rome, 00185 Rome, Italy; (R.M.); (C.S.); (L.G.)
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Abstract
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.
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Affiliation(s)
- Michael J. Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L. Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Yelena G. Bodien
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
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Zampieri FG, Cavalcanti AB, Taniguchi LU, Lisboa TC, Serpa-Neto A, Azevedo LCP, Nassar AP, Miranda TA, Gomes SPC, de Alencar Filho MS, da Silva RTA, Lacerda FH, Veiga VC, de Oliveira Manoel AL, Biondi RS, Maia IS, Lovato WJ, de Oliveira CD, Pizzol FD, Filho MC, Amendola CP, Westphal GA, Figueiredo RC, Caser EB, de Figueiredo LM, de Freitas FGR, Fernandes SS, Gobatto ALN, Paranhos JLR, de Melo RMV, Sousa MT, de Almeida GMB, Ferronatto BR, Ferreira DM, Ramos FJS, Thompson MM, Grion CMC, Santos RHN, Damiani LP, Machado FR. Attributable mortality due to nosocomial sepsis in Brazilian hospitals: a case-control study. Ann Intensive Care 2023; 13:32. [PMID: 37099045 PMCID: PMC10133434 DOI: 10.1186/s13613-023-01123-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/24/2023] [Indexed: 04/27/2023] Open
Abstract
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.
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Affiliation(s)
- Fernando G Zampieri
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil.
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building, 8440-112 St NW, Edmonton, AB, T6G2B7, Canada.
| | - Alexandre B Cavalcanti
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
| | - Leandro U Taniguchi
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Intensive Care Unit, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Thiago C Lisboa
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
- Unidade de Terapia Intensiva, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Ary Serpa-Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Luciano C P Azevedo
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Intensive Care Unit, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | | | - Tamiris A Miranda
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
| | - Samara P C Gomes
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
| | | | | | | | | | | | - Rodrigo S Biondi
- Instituto de Cardiologia do Distrito Federal, Brasilia, DF, Brazil
| | - Israel S Maia
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
- Hospital Nereu Ramos, Florianópolis, SC, Brazil
- Hospital Baía Sul, Florianópolis, SC, Brazil
| | - Wilson J Lovato
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | | | | | | | | | | | | | | | | | - Flávio Geraldo R de Freitas
- Hospital e Maternidade Sepaco, Sao Paulo, SP, Brazil
- Department of Anesthesiology, Pain and Critical Care-Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
| | | | | | | | | | | | | | | | - Denise M Ferreira
- Hospital das Clínicas da Universidade Federal de Goiás, Goiânia, GO, Brazil
| | | | - Marlus M Thompson
- Hospital Evangélico de Cachoeiro de Itapemirim, Cachoeiro de Itapemirim, ES, Brazil
| | - Cintia M C Grion
- Hospital Universitário Regional do Norte do Paraná, Londrina, PR, Brazil
| | | | - Lucas P Damiani
- HCor Research Institute, Rua Desembargador Eliseu Guilherme, 200, 8th Floor, São Paulo, Brazil
| | - Flavia R Machado
- Department of Anesthesiology, Pain and Critical Care-Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
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van der Linden R, Bolt T, Veen M. 'If it can't be coded, it doesn't exist'. A historical-philosophical analysis of the new ICD-11 classification of chronic pain. STUDIES IN HISTORY AND PHILOSOPHY OF SCIENCE 2022; 94:121-132. [PMID: 35749830 DOI: 10.1016/j.shpsa.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/10/2022] [Accepted: 06/06/2022] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Rik van der Linden
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - Timo Bolt
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - Mario Veen
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
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