Pillars for prevention and control of healthcare-associated infections: an Italian expert opinion statement

Utility of syndromic surveillance for the surveillance of healthcare-associated infections in resource-limited settings: a narrative review

Globally, Healthcare-associated infections (HCAIs) pose a significant threat to patient safety and healthcare systems. In low- and middle-income countries (LMICs), the lack of adequate resources to manage HCAIs, as well as the weak healthcare system, further exacerbate the burden of these infections. Traditional surveillance methods that rely on laboratory tests are cost-intensive and impractical in these settings, leading to ineffective monitoring and delayed management of HCAIs. The rates of HCAIs in resource-limited settings have not been well established for most LMICs, despite their negative consequences. This is partly due to costs associated with surveillance systems. Syndromic surveillance, a part of active surveillance, focuses on clinical observations and symptoms rather than laboratory confirmation for HCAI detection. Its cost-effectiveness and efficiency make it a beneficial approach for monitoring HCAIs in LMICs. It provides for early warning capabilities, enabling timely identification and response to potential HCAI outbreaks. Syndromic surveillance is highly sensitive and this helps balance the challenge of low sensitivity of laboratory-based surveillance systems. If syndromic surveillance is used hand-in-hand with laboratory-based surveillance systems, it will greatly contribute to establishing the true burden of HAIs in resource-limited settings. Additionally, its flexibility allows for adaptation to different healthcare settings and integration into existing health information systems, facilitating data-driven decision-making and resource allocation. Such a system would augment the event-based surveillance system that is based on alerts and rumours for early detection of events of outbreak potential. If well streamlined and targeted, to monitor priority HCAIs such as surgical site infections, hospital-acquired pneumonia, diarrheal illnesses, the cost and burden of the effects from these infections could be reduced. This approach would offer early detection capabilities and could be expanded into nationwide HCAI surveillance networks with standardised data collection, healthcare worker training, real-time reporting mechanisms, stakeholder collaboration, and continuous monitoring and evaluation. Syndromic surveillance offers a promising strategy for combating HCAIs in LMICs. It provides early warning capabilities, conserves resources, and enhances patient safety. Effective implementation depends on strategic interventions, stakeholder collaboration, and ongoing monitoring and evaluation to ensure sustained effectiveness in HCAI detection and response.

Medico-legal management of healthcare-associated infections: a cost-effectiveness analysis in an Italian tertiary hospital

Introduction

Healthcare-associated infections are the main reported adverse event in healthcare, with significant economic costs that include those caused by medical malpractice claims. In Italy, there is a fault-based compensation system, but in this specific field, the burden of proof on the hospitals is particularly heavy. Hence, we aimed to verify the economic impact of the inclusion of experts in hospital infection surveillance into internal committees for claims assessment and to evaluate what would have been the economic impact of a mandatory no-fault system rather than the current system.

Materials and methods

We compared two 4-year periods (T1: 2015-2018 and T2: 2019-2022), investigating the medical malpractice claims related to healthcare-associated infections in a large tertiary public hospital in Florence, Italy. Decisions of the internal committee, evolutions of the claims after the decision, and conclusions of the claims were registered. No-fault system simulations were used to evaluate the cost-effectiveness of the model.

Results

We observed a decrease in the number of claims after the implementation of infection prevention and control (IPC) experts into the committee (a 24% decrease in rejections and a 19% increase in admissions). We found a 6806.98 euros difference (not statistically significant) in compensations in T1 and T2. Moreover, our simulations found that a no-fault compensation system - if alternative to the traditional fault-based approach - could lead to gains or losses for the plaintiffs depending on the approach chosen. (We observed a 52% mean decrease in compensations with a 150000 euros maximal indemnity and a 134% mean increase with an indemnity tailored considering also life expectancy).

Discussion

Introducing experts in IPC into hospital committees for medico-legal claims management has proven to be cost-effective, offering a no-fault compensation system as an alternative to the traditional fault-based approach, supported by a properly evaluated maximal indemnity. Due to the limitations of our models, multicentric studies are recommended to verify our results.

Standard precautions compliance and its associated factors among nurses in Kazakhstan: A cross-sectional study

BACKGROUND

During the COVID-19 pandemic, with many nurses being infected, understanding compliance with standard precautions (SP) among nurses in Kazakhstan is crucial for improving infection prevention and control and preparedness for future emergencies. The study aimed to assess Kazakh nurses' SP compliance amid the COVID-19 pandemic and examine the factors associated with their compliance.

METHODS

Quantitative, cross-sectional design. This research surveyed 241 clinical nurses in Astana, Kazakhstan using a standardized tool from December 2021 to April 2022.

RESULTS

This study found 76.0% SP compliance among the nurses. The highest compliance was observed in the dimension "Decontamination of spills and used articles" (86.0% compliance rate), followed by "Use of protective devices" (83.5% compliance rate), "Prevention of cross-infection from person to person" (72.7% compliance rate), "Disposal of sharps" (65.4% compliance rate), and "Disposal of waste" (56.0% compliance rate). Nurses' age and educational qualification influences the nurses' SP compliance.

DISCUSSION

While the nurses' compliance rate in this study was moderate, specific areas warrant more attention, such as their compliance with proper waste and sharps disposal.

CONCLUSIONS

This study highlighted the experiences of nurses in Kazakhstan on their compliance with SP during the pandemic.

Nurses' knowledge, attitudes, and practices on CLABSI prevention in the Intensive Care Unit: An observational study

BACKGROUND

Management of central venous catheters (CVC) is a frequent procedure in intensive care units (ICUs) and the risk of bloodstream infections (CLABSI) is found to be high. The literature provides healthcare professionals with guidelines to prevent the risk of CLABSI infections. The aim of this study was to observe the knowledge, attitudes, and practices of ICU nurses on the prevention of CLABSI.

METHODS

A multicenter cross-sectional study was conducted between March 2023 and September 2023; the research was carried out among six ICUs in Bari both on the web and in paper mode. The survey consisted of multiple-choice questions structured in two sections: demographic sample data and the 2017 Esposito MR questionnaire, drawn up based on the 2011 guidelines of the Centers for Disease Control and Prevention, consisting of four dimensions: knowledge, attitudes, practices, information.

RESULTS

121 nurses (57.1%) participated in the study. 72% were unfamiliar with the guidelines, especially nurses aged 41-50 years (RR = 1.88; CI = 0.78-4.51; p = 0.13) and more than 10 years' work experience (RR = 1.56; CI = 0.76-3.23; p = 0.20). Regarding attitudes, nurses were aware of the usefulness of the guidelines (Me = 10; IQR = 8-10) and the importance of hand washing for prevention (Me = 10; IQR = 10-10) despite 39.7% (n = 48) believing that gloves replace hand washing, and there were no statistically significant differences in comparing scores with age, work experience, and educational qualification. 96.7% always substituted dressing for CVC; 120 nurses (99.2%) were always replacing infusion sets and 71.2% always sanitized the access ports before infusions. Finally, 102 participants (84.3%) felt the need to get more information about the prevention of CLABSI.

CONCLUSIONS

We observed a reduced knowledge of the guidelines for the prevention of CLABSI despite the attitudes and practices of the nurses being satisfactory. In addition to implementing training, strategies for disseminating guidelines should be adopted.

Nursing Students' Perceptions of a Novel Education Approach to Prevention and Control of Healthcare-Associated Infections: Insights from PrevInf Pilot Study

BACKGROUND

Healthcare-associated infections (HAIs) pose a significant global threat, particularly in developing regions such as Southeast Asia. International bodies emphasize the role of formal undergraduate training in the prevention and control of HAIs. To address this, we aimed to explore the perceptions of Southeast Asian nursing students regarding a novel educational approach developed by a European-Southeast Asian project consortium.

METHODS

A pilot study was conducted in four nursing higher education institutions from Cambodia and Vietnam. First, local nursing educators conducted a 2 h classroom-based training session. Then, students were invited to participate for the first time in one of twelve evidence-based simulation scenarios developed by the research team, covering a range of nursing care situations related to the prevention and control of HAIs. After attending both components, students were asked to complete a paper-based questionnaire and rate their agreement with a set of statements on the appropriateness and meaningfulness of both components.

RESULTS

A total of 430 nursing students enrolled in the pilot study; 77.4% were female, with an average age of 19.8 years. The PrevInf educational intervention received positive feedback from participating students across settings, with strong agreement on the importance of proactiveness in competency development (M = 5.9, SD = 1.4). Notable differences between Cambodian and Vietnamese students were observed in terms of their receptiveness to the pre-selected teaching materials (p = 0.001) and strategies (p = 0.01) used by the nursing educators during their experience with the simulation scenarios.

CONCLUSIONS

The PrevInf educational intervention shows promise in engaging Southeast Asian nursing students and fostering a deeper understanding of the prevention and control of HAIs. Further studies are warranted to refine the learning content and standardize the pedagogical strategies used by nursing educators across settings. This study was not registered.

Characterization and Photocatalytic and Antibacterial Properties of Ag- and TiOx-Based (x = 2, 3) Composite Nanomaterials under UV Irradiation

Metal and metal oxide nanostructured materials have been chemically and physically characterized and tested concerning methylene blue (MB) photoremoval and UV antibacterial activity against Escherichia coli and Staphylococcus aureus. In detail, silver nanoparticles and commercial BaTiO3 nanoparticles were modified to obtain nanocomposites through sonicated sol-gel TiO2 synthesis and the photodeposition of Ag nanoparticles, respectively. The characterization results of pristine nanomaterials and synthetized photocatalysts revealed significant differences in specific surface area (SSA), the presence of impurities in commercial Ag nanoparticles, an anatase phase with brookite traces for TiO2-based nanomaterials, and a mixed cubic-tetragonal phase for BaTiO3. Silver nanoparticles exhibited superior antibacterial activity at different dosages; however, they were inactive in the photoremoval of the dye. The silver-TiOx nanocomposite demonstrated an activity in the UV photodegradation of MB and UV inhibition of bacterial growth. Specifically, TiO2/AgNP (30-50 nm) reduced growth by 487.5 and 1.1 × 103 times for Escherichia coli and Staphylococcus aureus, respectively, at a dose of 500 μg/mL under UV irradiation.

Identification of essential contents and a standard framework for the development of an Infection Prevention and Control manual for healthcare facilities: A scoping review

BACKGROUND

Several international organizations have outlined the components of infection prevention and control (IPC) programs. To successfully implement an IPC program, hospital staff may adopt a manual that provides support for implementing the IPC measures, even requiring significant efforts. This study aims to identify essential aspects and develop a standardized structure for an IPC manual. The IPC manual framework can be customized and utilized by any health care facility, thereby facilitating adherence to international and national legislation.

METHODS

The study was conducted using the Joanna Briggs Institute methodology for scoping reviews. Reporting followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews standard. The search for evidence was performed on PubMed and Web of Science. Methodological quality was evaluated blindly by 2 reviewers using the Critical Appraisal Skills Program checklist.

RESULTS

Nineteen papers were included in the review. Data extraction considered the most recent guidelines and the categorization into the 8 Core Components established by the World Health Organization. Through the literature review, the essential elements and challenges of an IPC hospital manual were identified, and a framework was proposed.

CONCLUSIONS

By incorporating these essential elements into their IPC manual, health care facilities can establish a robust IPC framework. A potential future development stemming from this work could involve the creation of a standardized national IPC manual tailored for hospital settings.

Identifying a competency improvement strategy for infection prevention and control professionals: A rapid systematic review and cluster analysis

Remarkable progress has been made in infection prevention and control (IPC) in many countries, but some gaps emerged in the context of the coronavirus disease 2019 (COVID-19) pandemic. Core capabilities such as standard clinical precautions and tracing the source of infection were the focus of IPC in medical institutions during the pandemic. Therefore, the core competences of IPC professionals during the pandemic, and how these contributed to successful prevention and control of the epidemic, should be studied. To investigate, using a systematic review and cluster analysis, fundamental improvements in the competences of infection control and prevention professionals that may be emphasized in light of the COVID-19 pandemic. We searched the PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang Data, and CBM databases for original articles exploring core competencies of IPC professionals during the COVID-19 pandemic (from January 1, 2020 to February 7, 2023). Weiciyun software was used for data extraction and the Donohue formula was followed to distinguish high-frequency technical terms. Cluster analysis was performed using the within-group linkage method and squared Euclidean distance as the metric to determine the priority competencies for development. We identified 46 studies with 29 high-frequency technical terms. The most common term was "infection prevention and control training" (184 times, 17.3%), followed by "hand hygiene" (172 times, 16.2%). "Infection prevention and control in clinical practice" was the most-reported core competency (367 times, 34.5%), followed by "microbiology and surveillance" (292 times, 27.5%). Cluster analysis showed two key areas of competence: Category 1 (program management and leadership, patient safety and occupational health, education and microbiology and surveillance) and Category 2 (IPC in clinical practice). During the COVID-19 pandemic, IPC program management and leadership, microbiology and surveillance, education, patient safety, and occupational health were the most important focus of development and should be given due consideration by IPC professionals.

Incidence of catheter-associated urinary tract infections by Gram-negative bacilli and their ESBL and carbapenemase production in specialized hospitals of Bahir Dar, northwest Ethiopia

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) due to multidrug-resistant Gram-negative bacilli (GNB) is a common concern globally. Investigating the incidence of CAUTI and associated antibiotic resistance has paramount importance from the health care associated infections perspective. This study therefore assessed the incidence of CAUTIs due to GNB and the production of extended-spectrum beta-lactamase (ESBL) and carbapenemase among inpatients in specialized hospitals of Northwest, Ethiopia.

METHODS

A total of 363 patients with indwelling urinary catheters who were admitted in the hospital for > 48 h were consecutively enrolled and followed from 3 to 18 days. Data were collected through interviewing and review of medical records. Patients who developed at least one of the following: fever (> 38 OC), suprapubic tenderness, or costovertebral angle pain, coupled with a GNB positive urine culture of ≥ 103 CFU/mL with no more than two bacterial species were defined as CAUTI. The ESBL and carbapenemase production were detected and identified by chromogenic medium. Logistic regression analysis was done to identify associated factors.

RESULTS

From 363 patients followed, the incidence rate of CAUTI was 27.8 per 1000 catheter days. Catheterization for ≥ 8 days (AOR = 10.6, 95%CI:1.8-62.1) and hospitalization for > 10 days (AOR = 8.1, 95%CI: 2.4-27.2) were the factors significantly associated with CAUTIs. E. coli (n = 18, 34.6%), Proteus species (n = 7, 13.5%), and P. aeruginosa (n = 6, 11.5%) were the most frequent GNB. Isolates revealed high rates of resistance to amoxicillin-clavulanic acid (100%), cefazolin (n = 51, 98%), ceftazidime (n = 47, 90%) and cefotaxime (n = 46, 88%). Most of the GNB isolates (86.5%) were multidrug-resistant. Overall, 19.2% and 5.8% of GNB isolates were ESBL and carbapenemase producers, respectively.

CONCLUSIONS

Incidence of CAUTI with Gram-negative bacilli is high. As most of the GNB isolates are MDR and showed a super high rate of resistance to amoxicillin-clavulanic and third-generation cephalosporins, empirical treatment with these substances is virtually ineffective in patients with suspected GNB infection in Ethiopia. The expression of ESBL and carbapenemase among GNB isolates is also a concern. Therefore, improved infection prevention and control measures, careful use of catheters and third generation of cephalosporins are needed to improve patient outcomes and reduce the burden of CAUTIs and the spreading of antimicrobial resistance.

Infection prevention and control practices in the Pediatrics and Child Health Department of Tikur Anbessa Specialized Hospital, Ethiopia

Background

Infection prevention and control (IPC) is a set of practices that are designed to minimize the risk of healthcare-associated infections (HAIs) spreading among patients, healthcare workers, and visitors. Implementation of IPC is essential for reducing infection incidences, preventing antibiotic use, and minimizing antimicrobial resistance (AMR). The aim of the study was to assess IPC practices and associated factors in Pediatrics and Child Health at Tikur Anbessa Specialized Hospital.

Methods

In this study, we used a cross-sectional study design with a simple random sampling method. We determined the sample size using a single population proportion formula with the assumption of a 55% good IPC practice, a 5% accepted margin of error, and a 15% non-response rate and adjusted with the correction formula. The final sample size was 284 healthcare workers. The binary logistic regression model was used for analysis. The World Health Organization (WHO) Infection Prevention and Control Assessment Framework (IPCAF) tool was used to assess IPC core components.

Result

A total of 272 healthcare workers participated in the study, with a response rate of 96%. Of the total participants, 65.8% were female and 75.7% were nurses. The overall composite score showed that the prevalence of good IPC practices among healthcare workers was 50.4% (95% CI: 44.3-56.5). The final model revealed that nursing professionals and healthcare workers who received IPC training had AORs of 2.84 (95% CI: 1.34-6.05) and 2.48 (95% CI: 1.36-4.52), respectively. The final average total IPCAF score for the IPC level was 247.5 out of 800 points.

Conclusion

The prevalence of good IPC practice was suboptimal. The study participants, who were nursing professionals and healthcare workers who received IPC training, showed a statistically significant association with the IPC practice level. The facility-level IPCAF result showed a "Basic" level of practice based on the WHO categorization. These evidences can inform healthcare workers and decision-makers to identify areas for improvement in IPC practice at all levels. Training of healthcare workers and effective implementation of the eight IPC core components should be strengthened to improve suboptimal practices.

Using Kern model to design, implement, and evaluate an infection control program for improving knowledge and performance among undergraduate nursing students: a mixed methods study

BACKGROUND

Nurses and Nursing students are the front line of care in managing the care of infectious patients then they have more contact with patients than other students. Therefore, the aim of this study was designing, implementing and evaluating the infection control program among undergraduate nursing students using a mixed study.

METHOD

The mixed method approach with sequential exploratory (qualitative-quantitative) method was used. Kern model was applied in six steps included: 1-Needs assessment 2- Initial design 3- Goals and specific objectives 4- Educational strategy 5- Program implementation 6- Program evaluation. Thirty nursing students and 3 nursing faculty members were selected through purposive sampling for focus group in need assessment. Single-group semi-experimental study with a pre-test and post-test design was used in partnership with all eighth semester nursing students in program evaluation.

RESULT

Data analysis of focus group obtained two categories including: Need to improve knowledge in infection control and need to improve performance in infection control. With need assessment and literature review, educational content developed according to nursing students learning needs. Then, 3 faculty members prepared a course plan including goals, specific objectives, educational strategy for student assignments. One-way analysis of variance to compare the average score of knowledge, performance and its categories before, 2 weeks after the intervention and 2 months after the intervention shows a statistically significant difference (p > 0.001). Pearson's correlation coefficient shows that there is a negative linear relationship between work experience and knowledge score 2 weeks after and 2 months after the intervention (p < 0.05).

CONCLUSION

According to our results, it is recommended the need to revise the curriculum for the integration of the infection control program in the undergraduate nursing education. Of course, it is necessary to conduct more studies in the field by dividing this program into internship and field internship.

In vitro inhibition and eradication of multidrug-resistant Acinetobacter baumannii biofilms by riparin III and colistin combination

Acinetobacter baumannii, a prominent emerging pathogen, is responsible for persistent and recurrent healthcare-associated infections (HAIs). Its bacterial resistance and virulence factors, such as biofilm formation, contribute to its survival in hospital environments. Combination therapy has proven to be an effective approach for controlling these infections; however, antimicrobial resistance and compound toxicity can hinder antimicrobial efficacy. Numerous in vitro studies have demonstrated the synergistic effect of antimicrobials and natural products against multidrug-resistant (MDR) A. baumannii biofilm. Riparin III, a natural alkamide derived from Aniba riparia (Nees) Mez., possesses various biological activities, including significant antimicrobial potential. Nonetheless, no reports are available on the use of this compound in conjunction with conventional antimicrobials. Hence, this study aimed to investigate the inhibition and eradication of A. baumannii MDR biofilm by combining riparin III and colistin, along with potential ultrastructural changes observed in vitro. Clinical isolates of A. baumannii, known for their robust biofilm production, were inhibited, or eradicated in the presence of the riparin III/colistin combination. Furthermore, the combination resulted in several ultrastructural alterations within the biofilm, such as elongated cells and coccus morphology, partial or complete disruption of the biofilm's extracellular matrix, and cells exhibiting cytoplasmic material extravasation. At the synergistic concentrations, the riparin III/colistin combination exhibited a low hemolytic percentage, ranging from 5.74% to 6.19%, exerting inhibitory and eradicating effects on the A. baumannii biofilm, accompanied by notable ultrastructural changes. These findings suggest its potential as a promising alternative for therapeutic purposes.

Microbiological Analysis of Surgeons' Hands in a Public Hospital in São Luis, Maranhão State, Brazil: A Cross-Sectional Study

Antisepsis of the hands of medical personnel is one of the most important steps in the process of patient care, since direct contact can cause the cross-transfer of potentially pathogenic microorganisms at surgical sites. This study aimed to analyze the prevalence of microorganisms on the hands of 131 surgeons in a university hospital before the surgical procedure. Swabs were collected from each clinician's hands before and after handwashing. The samples were placed in a transport medium and immediately delivered to a private clinical analysis laboratory from São Luis-Maranhão. The microorganisms were identified by ionization source mass spectrometry and matrix-assisted laser desorption (MALDI-TOF), and antibiotic susceptibility tests (AST) were performed using the Vitek2 and Phoenix-BD automated system. The results showed a high frequency (100%) of microorganisms before handwashing, but after surgical antisepsis, the rate dropped significantly (p < 0.05) to 27.5%. The gram-positive species most detected were Staphylococcus spp. and Micrococcus luteus, representing 83.9%, followed by gram-negative species, Stenotrophomonas maltophilia, Acinetobacter baumanii, Pseudomonas aeruginosa, Pseudomonas gessardi, Pantoea septica, Serratia marcescens, and Burkholderia lata. The effectiveness of hand antisepsis was 72.5%, demonstrating that surgeons' hands are an important source of microorganisms that can cause infections in hospitalized patients in different care settings.

Infection Prevention and Control between Legal Requirements and "German Society for Hygiene and Microbiology" Expert Assessments: A Cross-Sectional Study in September-November 2022

BACKGROUND

In contrast to the beginning of the SARS-CoV-2 pandemic, more and more hospital issues are regulated by policy.

AIM

To identify differences between experts' recommendations and legal requirements regarding infection prevention and control (IPC) strategies.

METHODS

A cross-sectional study was conducted between 2022/09/29 - 2022/11/03 addressing 1319 members of the German Society for Hygiene and Microbiology (DGHM), the response rate was 12%. Reported here are the expert's recommendations on different IPC strategies.

FINDINGS

The majority (66%) of experts would recommend universal mask usage, with 34% recommending it seasonally, even after the SARS-CoV-2 pandemic. The medical microbiologists (MM) were more likely to recommend continuing to wear the masks indefinitely than IPC experts. Concerning the mask type, medical masks were recommended more frequently by IPC experts (47.3%), while FFP2 masks were more preferred by MM (31.8%). The majority (54.7%) would advise universal screening of employees, mainly in settings with extremely vulnerable patients and if the regional incidences were high, at a frequency of twice a week. With at least 50%, the dominant advice for employees being exposed to SARS-CoV-2 was working with daily testing and wearing a mask, regardless of the length of exposure.

CONCLUSIONS

The expert recommendations deviate from the legal situation and appear to be more differentiated and proportional. The influence of specific experience and expertise on the mask recommendation should be investigated in more detail. For relevant policy decisions, a quick, focused, and broad-based consultation of expertise could be of added value.

A Case of Ralstonia pickettii Bloodstream Infection and the Growing Problem of Healthcare Associated Infections in Frail Older Adults

Frailty is a clinically measurable state of vulnerability to developing increased dependency and/or mortality when exposed to a stressor. Chronic diseases, aggressive treatments, antibiotic overuse, microbiota changes, immune senescence, and increased use of medical devices and implants (i.e., central lines and catheters) expose modern patients to healthcare-associated infections (HAIs), multidrug-resistant bacteria, and new and unusual opportunistic pathogens. Older adults are among the main victims of HAIs and are associated with high costs, disability, morbidity, and mortality. Ralstonia pickettii is an emerging opportunistic pathogen that causes rare nosocomial infections in frail individuals. Herein, we present a case of bloodstream infection caused by R. pickettii in an 88-year-old woman with a relatively mild course. In addition to describing this unusual finding, this report discusses the problem of HAIs in older adults. Older age, comorbidities, and hospital admissions were among the main risk factors for HAIs. Adherence to guidelines, training, auditing, and surveillance is crucial for reducing the burden of HAIs in acute settings. Furthermore, avoiding incongruous hospitalizations would have positive implications both for preventing HAIs and improving patient quality of life.