Is it time to re-evaluate the inevitability of ulcers at the end of life?

2021 ◽  
Vol 27 (9) ◽  
pp. 440-448
Author(s):  
Gillian Raine
Keyword(s):  
End Of Life ◽  
Clinical Judgment ◽  
Routine Care ◽  
Incidence Rates ◽  
Diagnostic Tools ◽  
Preventive Interventions ◽  
Pragmatic Study

Background: The prevention of pressure injuries/ulcers (PI/PUs) in patients at the end of life is achievable, albeit challenging. Objective diagnostic tools, such as sub-epidermal moisture (SEM) scanning, support healthcare practitioners' clinical judgment in preventing PI/PUs. Aim: A pragmatic study was conducted to assess the feasibility of preventing PI/PUs using SEM technology as an adjunct to routine care in a 22-bed inpatient hospice. Methods: Daily SEM scanning was introduced to support the device-trained practitioners' clinical judgment in detecting developing, non-visible PI/PUs. Preventive interventions were initiated by clinical judgment informed by Waterlow scores, visible, tactile skin and tissue assessments and scanner readings. Results: Prior to the study, the incidence of PI/PUs was 9%. The 6 month study period reported a 4.8% PI/PU incidence, 7/146 consenting patients developed a PI/PU, resulting in a 47% reduction in incidence rates. Conclusion: Preventing the development of PI/PUs is possible with clinical judgment aided by SEM data.

Law, ethics and clinical judgment in end-of-life decisions—How do Norwegian doctors think?

Resuscitation ◽  
2012 ◽  
Vol 83 (11) ◽  
pp. 1369-1373 ◽  
Author(s):  
Marianne K. Bahus ◽  
Petter Andreas Steen ◽  
Reidun Førde
Keyword(s):  
End Of Life ◽  
Clinical Judgment ◽  
End Of Life Decisions ◽  
Life Decisions

Overall infection risk in rheumatoid arthritis during treatment with abatacept, rituximab and tocilizumab; an observational cohort study

Rheumatology ◽  
2019 ◽  
Vol 59 (8) ◽  
pp. 1949-1956 ◽  
Author(s):  
Kathrine L Grøn ◽  
Bente Glintborg ◽  
Mette Nørgaard ◽  
Frank Mehnert ◽  
Mikkel Østergaard ◽  
...  
Keyword(s):  
Cohort Study ◽  
Relative Risk ◽  
Routine Care ◽  
Incidence Rates ◽  
Observational Cohort Study ◽  
Tnf Inhibitor ◽  
Observational Cohort ◽  
Never Smokers ◽  
And Gender ◽  
Rate Ratios

Abstract Objectives Most infections in patients with RA are treated in primary care with antibiotics. A small fraction require hospitalization. Only a few studies exist regarding the overall risk of infection (i.e. prescription of antibiotics or hospitalization due to infection) in patients initiating non-TNF-inhibitor therapy. In Danish RA patients initiating abatacept, rituximab and tocilizumab treatment in routine care, the aims were to compare adjusted incidence rates (IR) of infections and to estimate relative risk of infections across the drugs during 0–12 and 0–24 months. Methods This was an observational cohort study including all RA patients in the DANBIO registry starting a non-TNF-inhibitor from 2010 to 2017. Infections were defined as a prescription of antibiotics or hospitalization due to infection. Prescriptions, comorbidities and infections were captured through linkage to national registries. IRs of infections (age, gender adjusted) and rate ratios (as estimates of RR (relative risk)), adjusted for additional covariates) (Poisson regression) were calculated. Results We identified 3696 treatment episodes (abatacept 1115, rituximab 1017, tocilizumab 1564). At baseline, rituximab users were older and had more previous cancer. During 0–12 months, 1747 infections occurred. Age and gender-adjusted IRs per 100 person-years were as follows: abatacept: 76 (95% CI: 69, 84); rituximab: 87 (95% CI: 79, 96); tocilizumab: 77 (95% CI: 71, 84). Adjusted RRs were 0.94 (95% CI: 0.81, 1.08) for abatacept and 0.94 (95% CI: 0.81, 1.03) for tocilizumab compared with rituximab and 1.00 (95% CI: 0.88, 1.14) for abatacept compared with tocilizumab. RRs around 1 were observed after 24 months. Switchers and ever smokers had higher risk compared with biologic-naïve and never smokers, respectively. Conclusion Overall infections were common in non-TNF-inhibitor-treated RA patients, with a tendency towards rituximab having the highest risk, but CIs were wide in all analyses. Confounding by indication may at least partly explain any differences.

scholarly journals Clinical Skill: The Ebbing Art of Medicine

2021 ◽  
Vol 28 (1) ◽  
pp. 105-108
Author(s):  
Ananda Datta
Keyword(s):  
Clinical Judgment ◽  
Clinical Medicine ◽  
Clinical Skills ◽  
Clinical Skill ◽  
Clinical History ◽  
Diagnostic Tools ◽  
Patient Relationship ◽  
Physician Patient Relationship ◽  
Tools And Techniques ◽  
Physician Patient

Clinical history taking and physical examination are the essence of clinical medicine. However, the glare of modern diagnostic tools and techniques has overshadowed these basic but indispensable steps of diagnosis. Deterioration of clinical skills is a burning issue in this era due to over-reliance on high-end technology. Poor clinical judgment not only leads to mismanagement but also results in over-utilisation of health care resources. Moreover, with lesser time at the bedside, the physician-patient relationship is also getting compromised.

scholarly journals Ambiguous definitions for baseline serum creatinine affect acute kidney diagnosis at the emergency department

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Michael Niemantsverdriet ◽  
Meriem Khairoun ◽  
Ayman El Idrissi ◽  
Romy Koopsen ◽  
Imo Hoefer ◽  
...  
Keyword(s):  
Emergency Department ◽  
Serum Creatinine ◽  
Time Window ◽  
Time Windows ◽  
Kidney Injury ◽  
Routine Care ◽  
Diagnostic Tools ◽  
Baseline Serum ◽  
Kdigo Guidelines ◽  
Ed Visits

Abstract Background Acute kidney injury (AKI) incidence is increasing, however AKI is often missed at the emergency department (ED). AKI diagnosis depends on changes in kidney function by comparing a serum creatinine (SCr) measurement to a baseline value. However, it remains unclear to what extent different baseline values may affect AKI diagnosis at ED. Methods Routine care data from ED visits between 2012 and 2019 were extracted from the Utrecht Patient Oriented Database. We evaluated baseline definitions with criteria from the RIFLE, AKIN and KDIGO guidelines. We evaluated four baseline SCr definitions (lowest, most recent, mean, median), as well as five different time windows (up to 365 days prior to ED visit) to select a baseline and compared this to the first measured SCr at ED. As an outcome, we assessed AKI prevalence at ED. Results We included 47,373 ED visits with both SCr-ED and SCr-BL available. Of these, 46,100 visits had a SCr-BL from the − 365/− 7 days time window. Apart from the lowest value, AKI prevalence remained similar for the other definitions when varying the time window. The lowest value with the − 365/− 7 time window resulted in the highest prevalence (21.4%). Importantly, applying the guidelines with all criteria resulted in major differences in prevalence ranging from 5.9 to 24.0%. Conclusions AKI prevalence varies with the use of different baseline definitions in ED patients. Clinicians, as well as researchers and developers of automatic diagnostic tools should take these considerations into account when aiming to diagnose AKI in clinical and research settings.

scholarly journals COVID-19 and the dental profession: Establishing a safe dental practice for the coronavirus era

2020 ◽  
Vol 3 ◽  
pp. 41-48
Author(s):  
Behzad Mostoufi ◽  
Zack Ashkenazie ◽  
Jamaad Abdi ◽  
Elizabeth Chen ◽  
Louis G. DePaola
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Clinical Judgment ◽  
Routine Care ◽  
Dental Practice ◽  
Care Providers ◽  
Careful Planning ◽  
Negative Pressure Ventilation ◽  
Dental Profession ◽  
The Impact

The aim of this article was to provide evidence-based information for the oral health-care providers to better understand the COVID-19 disease and be prepared to treat their patients. The impact of the severe acute respiratory syndrome coronavirus 2 pandemic has been unprecedented, especially in health care. Overwhelming amount of information flooded the literature to the point that dentists and specialists alike might feel more confused than knowledgeable, which can make decision-making a challenge. Dental community is no stranger to infection control and to treat patients with highly infectious diseases. With careful planning, modifications, and sound clinical judgment, it is certainly feasible to provide routine care to the patients during the pandemic and serve the community. Negative pressure ventilation operatories and/or air purifiers are good addition to contain the droplet transmitted diseases including COVID-19. It is of particular importance for health-care providers to take appropriate measures to minimize the risk of infection to their patients, themselves, and other members of the dental team.

Incidence and Risk Factors for Agranulocytosis in Latin American Countries - The LATIN Study.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 3842-3842
Author(s):  
Nelson Hamerschlak ◽  
Eliane Maluf ◽  
Jose Eluf ◽  
Alexandre B. Cavalcante ◽  
Ricardo Pasquini ◽  
...  
Keyword(s):  
Risk Factors ◽  
Latin American ◽  
Population Attributable Risk ◽  
Public Health Problem ◽  
Incidence Rates ◽  
Diagnostic Tools ◽  
Protection Measures ◽  
Latin American Countries ◽  
Etiologic Fraction ◽  
Control Study

Abstract The association of agranulocytosis with the use of many different drugs has been documented. LATIN is a case-control study designed to identify risk factors for agranulocytosis and aplastic anemia, including drugs, and to estimate the incidence rates of both diseases in some Latin American countries. This report will cover just agranulocytosis. In 4 years, 52 cases of agranulocytosis were diagnosed. The overall incidence rate was 0.38 cases per 1 million inhabitant-years (0.35 for Brazil, 2.09 for Argentina, and no case verified in Monterrey, Mexico). Agranulocytosis patients more often took medications already associated with agranulocytosis than controls (76.7% of cases and 52.5% of controls; OR 3.7, 95% CI 1.3–12.5; p = 0.01), the most important being methimazole (OR 44.2, 95% CI 6.8 to infinite). The population attributable risk percent (etiologic fraction) was 56%. The use of nutrients supplements was more frequent among agranulocytosis patients than controls (p = 0.03). The agranulocytosis incidence in Latin America was lower than that of European countries and Israel. The rarity of the disease indicates that it is not a public health problem, and there is no reason for major protection measures other than improving diagnostic tools and making earlier agranulocytosis diagnosis.

scholarly journals Delirium in Acute Stroke: A Survey of Screening and Diagnostic Practice in Scotland

ISRN Stroke ◽  
2013 ◽  
Vol 2013 ◽  
pp. 1-7 ◽  
Author(s):  
Gail Carin-Levy ◽  
Kath Nicol ◽  
Frederike van Wijck ◽  
Gillian E. Mead
Keyword(s):  
Acute Stroke ◽  
Clinical Judgment ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Screening Tools ◽  
Diagnostic Tools ◽  
Free Text ◽  
Stroke Patients ◽  
Nominal Data ◽  
Doctors And Nurses

Aims. To survey the use of delirium screening and diagnostic tools in patients with acute stroke across Scotland and to establish whether doctors and nurses felt the tools used were suitable for stroke patients. Methods. An invitation to participate in a web-based survey was e-mailed to 217 doctors and nurses working in acute stroke across Scotland. Descriptive statistics were used to report nominal data, and content analysis was used to interpret free text responses. Results. Sixty-five responses were logged (30% return rate). 48% of the respondents reported that they routinely screened newly admitted patients for delirium. Following initial screening, 38% reported that they screened for delirium as the need arises. 43% reported using clinical judgment to diagnose delirium, and 32% stated that they combined clinical judgment with a standardised tool. 28% of the clinicians reported that they used the Confusion Assessment Method; however, only 13.5% felt that it was suitable for stroke patients. Conclusions. Screening for delirium is inconsistent in Scottish stroke services, and there is uncertainty regarding the suitability of screening tools with stroke patients. As the importance of early identification of delirium on stroke outcomes is articulated in recent publications, validating a screening tool to detect delirium in acute stroke is recommended.

P14.45 The incidence of major subtypes of primary brain tumours in adults in England 1995–2017

2021 ◽  
Vol 23 (Supplement_2) ◽  
pp. ii46-ii47
Author(s):  
H Wanis
Keyword(s):  
Brain Tumour ◽  
Brain Tumours ◽  
Incidence Rates ◽  
Diagnostic Tools ◽  
Cancer Registration ◽  
Molecular Testing ◽  
Malignant Tumours ◽  
Primary Brain Tumours ◽  
Primary Brain Tumour ◽  
European Standard Population

Abstract BACKGROUND Primary brain tumours are a complex heterogenous group of benign and malignant tumours. Reports on their occurrence in the English population by sex, age, and morphological subtype and on their incidence are currently not available. Using data from the National Cancer Registration and Analysis Service (NCRAS), the incidence of adult primary brain tumour by major subtypes in England will be described. METHODS Data on all adult English patients diagnosed with primary brain tumour between 1995 and 2017, excluding spinal, endocrinal and other CNS tumours, were extracted from NCRAS. Incidence rates were standardised to the 2013 European Standard Population. Results are presented by sex, age, and morphological subtype. RESULTS Between 1995 and 2017, a total of 133,669 cases of adult primary brain tumour were registered in England. Glioblastoma was the most frequent tumour subtype (31.8%), followed by meningioma (27.3%). The age-standardised incidence for glioblastoma increased from 3.27 per 100,000 population per year in 1995 to 7.34 in men in 2013 and from 2.00 to 4.45 in women. Meningioma incidence also increased from 1.89 to 3.41 per 100,000 in men and from 3.40 to 7.46 in women. The incidence of other astrocytic and unclassified brain tumours declined between 1995 and 2007 and remained stable thereafter. CONCLUSION Part of the increase in the incidence of major subtypes of brain tumours in England could be explained by advances in clinical practice including the adoption of new diagnostic tools, classifications and molecular testing, and improved cancer registration practices.

scholarly journals Appropriateness of intensive care treatments near the end of life during the COVID-19 pandemic

Breathe ◽  
2020 ◽  
Vol 16 (2) ◽  
pp. 200062
Author(s):  
Magnolia Cardona ◽  
Matthew Anstey ◽  
Ebony T. Lewis ◽  
Shantiban Shanmugam ◽  
Ken Hillman ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
End Of Life ◽  
Clinical Judgment ◽  
List Type ◽  
Social Constructs ◽  
Intensive Care Admission ◽  
Family Perspective ◽  
The Face ◽  
Patient Values

The patient and family perspective on the appropriateness of intensive care unit (ICU) treatments involves preferences, values and social constructs beyond medical criteria. The clinician's perception of inappropriateness is more reliant on clinical judgment. Earlier consultation with families before ICU admission and patient education on the outcomes of life-sustaining therapies may help reconcile these provider–patient disagreements. However, global emergencies like COVID-19 change the usual paradigm of end-of-life care, as it is a new disease with only scarce predictive information about it. Pandemics can also bring about the burdensome predicament of doctors having to make unwanted choices of rationing access to the ICU when demand for otherwise life-saving resources exceeds supply. Evidence-based prognostic checklists may guide treatment triage but the principles of shared decision-making are unchanged. Yet, they need to be altered with respect to COVID-19, defining likely outcomes and likelihood of benefit for the patient, and clarifying their willingness to take on the risks inherent to being in an ICU for 2 weeks for those eligible. For patients who are admitted during the prodrome of COVID-19 disease, or those who deteriorate in the second week, clinicians have some lead time in hospital to have appropriate discussions about ceilings of treatments offered based on severity.Key pointsThe patient and family perspective on inappropriateness of intensive care at the end of life often differs from the clinician's opinion due to the nonmedical frame of mind.To improve satisfaction with communication on treatment goals, consultation on patient values and inclusion of social constructs in addition to clinical prediction is a good start to reconcile differences between physician and health service users’ viewpoints.During pandemics, where health systems may collapse, different admission criteria driven by the need to ration services may be warranted.Educational aimsTo explore the extent to which older patients and their families are involved in decisions about appropriateness of intensive care admission or treatmentsTo understand how patients or their families define inappropriate intensive care admission or treatmentsTo reflect on the implications of decision to admit or not to admit to the intensive care unit in the face of acute resource shortages during a pandemic

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