Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Management of critical bleeding

The management of major bleeding is a critical aspect of modern healthcare and it is imperative to emphasize the importance of applying Patient Blood Management (PBM) principles. Although transfusion support remains a vital component of bleeding control, treating severe bleeding goes beyond simply replacing lost blood. A more comprehensive, multidisciplinary approach is essential to optimize patient outcomes and minimize the risks associated with excessive transfusions.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Definition of Patient Blood Management

Managing the patient's blood and hematopoietic system is like managing any of the other organs and organ systems during patient care. Specialists control the heart, kidneys, endocrine system, etc. and the patient's blood requires similar clinical treatment. The hematopoietic system and its circulatory products are fundamental for the healthy functioning of the human body. In simple terms, Patient Blood Management (PBM) is an organized, patient-centered approach in which the entire healthcare team coordinates efforts to improve outcomes by managing and preserving the patient's own blood. By reducing dependence on blood transfusions, PBM seeks to improve clinical outcomes, reduce the risks and costs associated with transfusions, and improve the safety and quality of patient care. Essentially, the concept of PBM is about the holistic management and preservation of the patient's own blood in the medical and surgical context.

Transition from pediatric to adult care in patients with Turner syndrome in Italy: a consensus statement by the TRAMITI project

PURPOSE

Transition from pediatric to adult care is associated with significant challenges in patients with Turner syndrome (TS). The objective of the TRansition Age Management In Turner syndrome in Italy (TRAMITI) project was to improve the care provided to patients with TS by harnessing the knowledge and expertise of various Italian centers through a Delphi-like consensus process.

METHODS

A panel of 15 physicians and 1 psychologist discussed 4 key domains: transition and referral, sexual and bone health and oncological risks, social and psychological aspects and systemic and metabolic disorders.

RESULTS

A total of 41 consensus statements were drafted. The transition from pediatric to adult care is a critical period for patients with TS, necessitating tailored approaches and early disclosure of the diagnosis to promote self-reliance and healthcare autonomy. Fertility preservation and bone health strategies are recommended to mitigate long-term complications, and psychiatric evaluations are recommended to address the increased prevalence of anxiety and depression. The consensus also addresses the heightened risk of metabolic, cardiovascular and autoimmune disorders in patients with TS; regular screenings and interventions are advised to manage these conditions effectively. In addition, cardiac abnormalities, including aortic dissections, require regular monitoring and early surgical intervention if certain criteria are met.

CONCLUSIONS

The TRAMITI consensus statement provides valuable insights and evidence-based recommendations to guide healthcare practitioners in delivering comprehensive and patient-centered care for patients with TS. By addressing the complex medical and psychosocial aspects of the condition, this consensus aims to enhance TS management and improve the overall well-being and long-term outcomes of these individuals.

Description of self-care behaviours in patients with non-valvular atrial fibrillation on oral anticoagulant therapy: A scoping review

AIM

The primary aim of this scoping review was to explore and categorise the medication-related self-care behaviours exhibited by patients with non-valvular atrial fibrillation (NVAF) who are on oral anticoagulant (OAC) therapy.

METHODS AND RESULTS

A scoping review was performed, and the systematic search of the literature yielded an initial 887 records. After deduplication and screening, 61 studies were included in the analysis, ranging from 2003 to 2023. The studies represented a wide geographical distribution and diverse methodologies. The results identified 16 self-care behaviours: a higher focus of the included literature on self-care monitoring (60.65% of studies), followed by self-care management and self-care maintenance (each 16.39%). These behaviours ranged from regular blood testing to consulting healthcare providers and lifestyle changes. The results also highlighted the relationship between treatment satisfaction, self-efficacy, and adherence. Several studies emphasised the critical role of healthcare providers in influencing medication adherence. Furthermore, patient knowledge, quality of life, and psychological factors were identified as key elements affecting self-care behaviours.

CONCLUSION

The review provides a comprehensive landscape of medication-related self-care behaviors among NVAF patients on OAC therapy. It underscores the predominance of self-care monitoring behaviours and the critical roles of healthcare providers, psychological factors, and patient knowledge in influencing these behaviours. The findings also highlight the necessity for an integrated, patient-centred approach to improving self-care and self-management in OAC treatment. Future research should focus on addressing the identified gaps, including the relative lack of studies on lifestyle modification, emotional well-being, and technology-assisted interventions.

REGISTRATION

This review is part of a broader project and is documented at ClinicalTrials.gov (NCT05820854).

A personalized approach to modify axillary crutches using 3D printing technology

3D printers can produce specific medical objects that are tailored to the individual patient's needs, and if they are combined with a personalized orthopedic rehabilitation, it can result in improved functional outcomes. We present a 26-year-old male war victim with multiple injuries in his lower and upper limbs. The use of standard crutches was impossible, so we developed a customized 3D-printed crutch with a relative low cost. The gait and balance scores-as a part of the Tinetti score-improved immediately, and the patient's QUEST 2.0 questionnaire was high after 4 weeks of the crutches use, indicating high patient's satisfaction.

Cross-analyzing addiction specialist and patient opinions and experiences about addictive disorder screening in primary care to identify interaction-related obstacles: a qualitative study

BACKGROUND

Promptly identifying individuals with addictive disorders reduces mortality and morbidity and improves quality of life. Although screening in primary care with the Screening, Brief Intervention and Referral Treatment strategy has been recommended since 2008, it remains underutilized. This may be due to barriers including lack of time, patient reluctance or perhaps the timing and approach for discussing addiction with their patients.

OBJECTIVE

This study aims to explore and cross-analyze patient and addiction specialist experiences and opinions about early addictive disorder screening in primary care to identify interaction-related screening obstacles.

DESIGN AND PARTICIPANTS

Qualitative study with purposive maximum variation sampling among nine addiction specialists and eight individuals with addiction disorders conducted between April 2017 and November 2019 in Val-de-Loire, France.

MAIN MEASURES

Using a grounded theory approach, verbatim data was collected from face-to-face interviews with addiction specialists and individuals with addiction disorders. These interviews explored their opinions and experiences with addiction screening in primary care. Initially, two independent investigators analyzed the coded verbatim according to the data triangulation principle. Secondly, convergences and divergences between addiction specialist and addict verbatim categories were identified, analyzed, and conceptualized.

KEY RESULTS

Four main interaction-related obstacles to early addictive disorder screening in primary care were identified and conceptualized: the new concepts of shared self-censorship and the patient's personal red line, issues not addressed during consultations, and opposition between how physicians and patients would like to approach addictive disorder screening.

CONCLUSIONS

To continue analysis of addictive disorder screening dynamics, further studies to examine the perspectives of all those involved in primary care are required. The information revealed from these studies will provide ideas to help patients and caregivers start discussing addiction and to help implement a collaborative team-based care approach.

TRIAL REGISTRATION

This study is registered with the Commission Nationale de l'Informatique et des Libertés (CNIL) under No. 2017-093.

Patient Perspectives on Recovery and Information Needs After Surgery: A Qualitative Study of Veterans

INTRODUCTION

Little is known about patients' postoperative emotional and social functioning and preferences for recovery settings. This qualitative study explores patients' perspectives on factors influencing postoperative recovery, including the proportion of time recovering at home (home time) and unmet information needs.

METHODS

Semistructured interviews were conducted between September and December 2020 with veteran patients aged 65 y or older who underwent surgery at a single hospital. A purposeful sampling strategy was used to identify patients with a broad representation of major operations and various amounts of home time. One-hour interviews were audio-recorded, transcribed verbatim, and anonymized for analysis. A rigorous team-based in-depth thematic analysis was performed. Validation techniques to enhance the quality and credibility of the study included triangulation, independent coding, and search for disconfirming evidence.

RESULTS

Twelve patients were interviewed (11 [91.7%] males; mean (standard deviation) age, 72.3 [4.8] y). Five factors that influenced the recovery process emerged: (1) professional support services, (2) informal caregiver support, (3) environment for recovery, (4) individual traits, and (5) physical and functional impairments. The analysis also elucidated four unmet information needs regarding recovery: (1) personalized and detailed information, (2) anticipated recovery time, (3) possible complications, and (4) comprehensive information about discharge location options.

CONCLUSIONS

The study demonstrated that patients recovering from surgery require wide-ranging levels of support to meet their unique needs and preferences. Patients value easy-to-understand and personalized information about recovery from providers. These findings may be helpful to develop strategies that better support patients in their postoperative recovery and post-acute care transition pathways.

Designing a Consumer-Friendly Radiology Report using a Patient-Centered Approach

Patient portals have helped accelerate patient engagement in treatment. Patient understanding of radiology reports has become a necessity, and we are working to design a patient-friendly radiology report that can be easily understood. We have based the design of this new radiology report on the results of a previous study that examined patient desires and needs by exploring their questions posted on online discussion forums. The current design was tested by presenting it in two groups, a control group, and an intervention group. In our evaluation, we relied on the following five concepts: understanding (quiz), cosmetics appearance, perceived ease of use, acceptance, and preference. The results showed that the new design outperformed the current design in all five concepts with an overall of (P < .00). Based on these results, we have determined that the radiology report should include both an image and notes section, and the design can be applied to all types of radiological examinations using various imaging devices. We believe this design will be an important building block in facilitating patient understanding of radiology reports.

Psychotherapy for Mixed Depression and Mixed Mania

Treatment guidelines for mixed states of depression or (hypo)mania focus almost exclusively on psychopharmacologic intervention without tapping into the benefits of psychotherapy. The authors highlight the complex clinical picture and illness course of mixed states, and discuss the benefit of taking a patient-centered approach to treatment incorporating techniques from a variety of evidence-based psychotherapies. A careful assessment of suicide risk as well as interventions designed specifically for anxiety are also recommended.

The Lived Experience of First-Episode Psychosis: A Systematic Review and Metasynthesis of Qualitative Studies

Both research and care have focused on first episodes of psychosis (FEPs) as a way to address the issue of early stages of schizophrenia and to reduce the duration of untreated psychosis. The objective of this study was to explore specifically the lived experience of FEP from the point of view of patients and their families by applying a metasynthetic approach, including a systematic review of the literature and analyses of qualitative studies on the subject. This metasynthesis follows thematic synthesis procedures. Four databases were systematically searched for qualitative studies reporting FEP from the patient or family's perspective. Article quality was assessed with the Critical Appraisal Skills Program. Thematic analysis was used to identify key themes and synthesize them. Thirty-eight articles were included, covering data from 554 participants (378 patients and 176 relatives). Three themes emerged from the analyses: (1) When and how does a FEP start? (2) What are its negative and positive aspects? (3) How do patients and families recount FEPs? Our results found important discrepancies between the experiences of patients and those of their families, especially regarding positive aspects. In light of the confusion reported by patients and notable in our results, we also discuss the gap between the name, FEP, and the lived experience of patients and family members in order to explore its practical implications.

Diagnosis and Management of Hypothyroidism: Addressing the Knowledge-Action Gaps

Hypothyroidism presents a large epidemiological burden in India. As a result of subtle and nonspecific clinical symptoms and signs, the condition often goes undiagnosed and is not adequately treated when it is detected. There is heterogeneity in the diagnostic and treatment approaches to hypothyroidism. As a result of the physiological changes in thyroid hormones with age and illness, it is important to tailor the diagnosis and management of this condition in specific populations including pregnant women, infants, children, geriatric patients, and those with comorbid conditions. Enhanced understanding and education of physicians and patients can help to improve the outcomes of treatment in hypothyroidism which should be focused on patient-centered care. Policies and reforms should be crafted and implemented at the national level to curb public health challenges of hypothyroidism. This publication summarizes the recommendations of a national advisory board meeting to identify and bridge the gaps in understanding of the diagnosis and treatment of hypothyroidism in India. As a complement to clinical judgment, these recommendations will foster the diagnosis and management of hypothyroidism in the community and clinics for the benefit of the patients.

FUNDING

Merck Ltd, India.

Cardiac arrest teams perspectives on communication and ethical conflicts related to awareness during CPR, a focus group study protocol

Background

Awareness during Cardio Pulmonary Resuscitation (CPR) also called CPR induced consciousness (CPRIC) is a rare, but increasingly reported condition with significant clinical implications. Health professionals lack guidelines about patients with CPRIC, and to this date, no studies have addressed the complexity of communication and ethical aspects when continuing CPR while the patient is conscious.

Methods

We aim to explore Cardiac arrest team members perspectives regarding communication and ethical conflicts related to awareness during CPR. We have designed a qualitative, descriptive study using focus groups to discuss and reflect on patients with awareness during CPR. Focus groups consist of cardiac arrest team members (senior and training medical doctors, nurses and hospital porters). We will be presenting already published case reports about patients with CPRIC to focus groups to facilitate discussion and debate regarding the team members perceptions. Data analysis is inductive and based on systematic text condensation.

Discussion

Previous studies have suggested that external stressors affect the performance of a Cardiac arrest team. As a result of our analysis, we will aim to describe communicative and ethical challenges and concerns regarding awareness during CPR. Recent studies in the area point to a desire for guidelines and we hope to contribute with knowledge, that can inform the further process when developing guidelines and training team members to handle these stressful and important cases.

Trial registration

The study involves no healthcare intervention on human participants.

Partnering with patients in translational oncology research: ethical approach

Background

The research program CARPEM (cancer research and personalized medicine) brings together the expertise of researchers and hospital-based oncologists to develop translational research in the context of personalized or “precision” medicine for cancer. There is recognition that patient involvement can help to take into account their needs and priorities in the development of this emerging practice but there is currently no consensus about how this can be achieved. In this study, we developed an empirical ethical research action aiming to improve patient representatives’ involvement in the development of the translational research program together with health professionals. The aim is to promote common understanding and sharing of knowledge between all parties and to establish a long-term partnership integrating patient’s expectations.

Methods

Two distinct committees were settled in CARPEM: an “Expert Committee”, gathering healthcare and research professionals, and a “Patient Committee”, gathering patients and patient representatives. A multidisciplinary team trained in medical ethics research ensured communication between the two committees as well as analysis of discussions, minutes and outputs from all stakeholders.

Results

The results highlight the efficiency of the transfer of knowledge between interested parties. Patient representatives and professionals were able to identify new ethical challenges and co-elaborate new procedures to gather information and consent forms for adapting to practices and recommendations developed during the process. Moreover, included patient representatives became full partners and participated in the transfer of knowledge to the public via conferences and publications.

Conclusions

Empirical ethical research based on a patient-centered approach could help in establishing a fair model for coordination and support actions during cancer research, striking a balance between the regulatory framework, researcher needs and patient expectations. Our approach addresses the concept of translational ethics as a way to handle the main remaining gap between combining care and research activities in the medical pathway and the existing framework.

A holistic approach to chronic pain management that involves all stakeholders: change is needed

Chronic pain affects a large proportion of the population, imposing significant individual distress and a considerable burden on society, yet treatment is not always instituted and/or adequate. Comprehensive multidisciplinary management based on the biopsychosocial model of pain has been shown to be clinically effective and cost-efficient, but is not widely available. A literature review of stakeholder groups revealed many reasons for this, including: i) many patients believe healthcare professionals lack relevant knowledge, and consultations are rushed, ii) general practitioners consider that pain management has a low priority and is under-resourced, iii) pain specialists cite non-adherence to evidence-based treatment, sub-optimal prescribing, and chronic pain not being regarded as a disease in its own right, iv) nurses', pharmacists' and physiotherapists' skills are not fully utilized, and v) psychological therapy is employed infrequently and often too late. Many of the issues relating to physicians could be addressed by improving medical training, both at undergraduate and postgraduate levels - for example, by making pain medicine a compulsory core subject of the undergraduate medical curriculum. This would improve physician/patient communication, increase the use of standardized pain assessment tools, and allow more patients to participate in treatment decisions. Patient care would also benefit from improved training for other multidisciplinary team members; for example, nurses could provide counseling and follow-up support, psychologists offer coping skills training, and physiotherapists have a greater role in rehabilitation. Equally important measures include the widespread adoption of a patient-centered approach, chronic pain being recognized as a disease in its own right, and the development of universal guidelines for managing chronic non-cancer pain. Perhaps the greatest barrier to improvement is lack of political will at both national and international level. Some powerful initiatives and collaborations are currently lobbying policy-making bodies to raise standards and reduce unnecessary pain - it is vital they continue.