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What We Can Learn About Patient Safety While Driving to Work
Get PDFThis Viewpoint discusses strategies used with driving that can be applied to health care to promote consistent and predictable physician and patient actions
Parallel Plights in Advancing Menstrual Equity: A Scoping Review of Period Poverty in India and the United States
Get PDFAs calls for improved menstrual health management have gained momentum in sociopolitical contexts, period poverty and menstrual equity have gradually been established and recognized in the discipline of public health. These conversations typically take place in the context of low- and middle-income countries (LMICs) where donor-sponsored projects are already underway. Nevertheless, research on period poverty in high-income countries (HICs) is seldom performed. In addition, current literature on the topic tends to generalize HICs and LMICs, thereby ignoring crucial cultural and socioeconomic distinctions that necessitate a more detailed comparison of individual countries facing period poverty. This case examines the current body of research on period poverty in the United States and India, and compares the causes, effects, and approaches toward ameliorating this phenomenon. Through performing a scoping review of the current literature on period poverty, this case illustrates that—as opposed to the breadth of research available on period poverty in LMICs—research on period poverty in HICs is underrepresented. In addition, the findings demonstrate a stunning parallel between the contributing factors of period poverty in India and the United States, suggesting that the current approach to isolate conversations on the topic based on regional economic incongruencies is inappropriate. Finally, this case identifies dismantling the stigmatization of periods, investing in water or hygiene infrastructure, promoting the economic mobilization of females, and reforming menstrual health curricula in schools as essential to ending period poverty
Linking tumor immune infiltration to enhanced longevity in recurrence-free breast cancer
Get PDFBackground The infiltration of tumor-infiltrating B cells and plasma cells in early-stage breast cancer has been associated with a reduced risk of distant metastasis. However, the influence of B-cell tumor infiltration on overall patient survival remains unclear. Materials and methods This study explored the relationship between an antitumor immune response, measured by a 14-gene B-cell/immunoglobulin (IGG) signature, and mortality risk in 9638 breast cancer patients across three datasets. Associations with tumor subtype, stage, and age were examined. IGG was characterized using spatial GeoMx profiling and single-cell RNA sequencing, and its relationship with tertiary lymphoid structures (TLSs) was evaluated. The predictive value of each of the 14 IGG genes for B-cell receptor (BCR) and T-cell receptor (TCR) clonality and longevity was also assessed, along with its association with longevity in other cancer types. Results High IGG signature expression was significantly associated with a 41%-47% reduction in death risk in breast cancer survivors (P < 0.001), regardless of age, tumor stage, or subtype. Similar associations were observed in other cancers, including melanoma. In breast cancer, the IGG signature was significantly linked to overall survival without relapse in patients aged 41-70 years at diagnosis. Additionally, IGG expression correlated with the presence of TLSs and higher B- and T-cell polyclonality. A specific subset of seven IGG genes strongly correlated with BCR and TCR clonality, with predictive power for identifying clonality and improved longevity, especially when combining two of these genes. Conclusions This study uncovers a significant link between immune gene expression in tumors and extended longevity in breast cancer survivors, even in the absence of recurrence. The IGG signature, particularly its key gene subset, emerges as a powerful marker of sustained antitumor immunity and overall patient fitness. These findings pave the way for personalized treatment strategies that enhance both survival and long-term health outcomes
Cryptic coral diversity is associated with symbioses, physiology, and response to thermal challenge
Get PDFCoral persistence in the Anthropocene depends on interactions among holobiont partners (coral animals and microbial symbionts) and their environment. Cryptic coral lineages-genetically distinct yet morphologically similar groups-are critically important as they often exhibit functional diversity relevant to thermal tolerance. In addition, environmental parameters such as thermal variability may promote tolerance, but how variability interacts with holobiont partners to shape responses to thermal challenge remains unclear. Here, we identified three cryptic lineages of Siderastrea siderea in Bocas del Toro, Panamá that differ in distributions across inshore and offshore reefs, microbial associations, phenotypic traits of holobiont partners (i.e., phenomes), and skeleton morphologies. A thermal variability experiment failed to increase thermal tolerance, but subsequent thermal challenge and recovery revealed that one lineage maintained elevated energetic reserves, photochemical efficiency, and growth. Last, coral cores highlighted that this lineage also exhibited greater growth historically. Functional variation among cryptic lineages highlights their importance in predicting coral reef responses to climate change
A World Without WHO—A Crossroads for US Global Health Leadership
Get PDFThis Viewpoint explores concerns surrounding possible US withdrawal from the World Health Organization and the effect this would have on US global health leadership and health security
Utilisation of a national database to characterise renal function in patients with COVID19 infection
Get PDFRationale The incidence of renal function alterations among patients with COVID19 is unknown. Objective To determine the incidence of acute kidney injury (AKI) or augmented renal clearance (ARC) in patients hospitalised with COVID19 and identify risk factors for patients who may exhibit each renal alteration. Methods Retrospective, observational cohort analysis of hospitalise, adult patients within the National COVID Cohort Collaborative (N3C) database with laboratory confirmed COVID19 and available data to calculate creatinine clearance using the Cockcroft–Gault equation from 1 January 2020 through 9 April 2022. Measurements Incidence of AKI or ARC and patient demographics. Main results 15 608 patients were included for renal function characterisation where 20.9% experienced AKI and 34.8% exhibited ARC. ARC lasted longer than AKI; however, AKI was associated with increased hospital length of stay and mortality. 11 274 patients were included in logistic regression analysis. Height and White race were the only variables associated with decreased risk of AKI while male sex and diabetes were associated with increased risk. Male sex, Black race and hypertension were associated with decreased risk of ARC. Age was associated with decreased risk of both AKI and ARC while weight and Hispanic ethnicity were associated with increased risk in both renal alterations. Conclusions A significant proportion of patients exhibit renal alterations during their hospitalisation for COVID19. These results provide initial evidence of identifying patients at risk of AKI or ARC, but more research is needed, especially with respect to use of biomarkers for renal alteration risk stratification
Racial and Educational Isolation are Associated with Worse Outcomes in Congenital Heart Disease
Get PDFSociodemographic factors influence outcomes in children with congenital heart disease (CHD). We predict an association between measures of social isolation and outcomes in infants with complex CHD. These measures, racial (RI) and educational (EI) isolation range from 0 to 1, with 0 being no isolation and 1 being fully isolated within a specific population. We identified patients less than 1 year old undergoing CHD surgery in North Carolina from 2008 to 2013. We used negative binomial and logistic regression models to assess the case-mix adjusted associations between RI and EI and length of stay, complications, mortality, and resource utilization. We quantified the association of race with these indices and outcomes. We included 1217 infants undergoing CHD surgery. Black infants had increased LOS (p < 0.001), other complications (p = 0.03), and death (p = 0.02). RI up to 0.3 was associated with decreased outpatient encounters (p < 0.001). RI was associated with increased inpatient encounters RI up to 0.3 (p < 0.001) but decreased for RI beyond 0.3 (p = 0.01). There was an association with increased risk of one or more emergency department visits (p = 0.001) at higher levels of EI. Race and RI showed a cumulative effect with children with Black race and greater than median RI having increased LOS (p < 0.001) and fewer outpatient encounters (p = 0.02). RI, EI, and Black race are associated with poorer outcomes. Children with Black race and greater than median levels of RI are at the highest risk of poor outcomes. These differences may be caused by differential access to resources or community support
Median Arcuate Ligament Syndrome: Where Are We Today?
Get PDFMedian arcuate ligament syndrome, or celiac artery compression syndrome (eponym: Dunbar syndrome), has historically been attributed to pathophysiologic vascular compression causing downstream ischemic symptoms of the organs supplied by the celiac trunk. However, the more we learn about the histology, clinical presentation, and treatment outcomes, health care providers are increasingly correlating the symptoms of MALS with the long-term, repetitive compression of the celiac ganglion rather than the celiac trunk. This article provides a comprehensive review of current MALS literature, emphasizing the multidisciplinary approach these patients require in all phases of their care. With most patients with MALS waiting an average of 10.5 months to 2.6 years, 9, 10 our need for better diagnostic protocols and clearer understanding of the pathophysiology of the disease is paramount. Further investigation into patient outcomes, associated conditions, and linked pathophysiology would help better characterize this disease with hopes of moving it from a diagnosis of exclusion to one of standard work-up with decreased time to treatment and symptom relief for patients
Stressors contributing to burnout among acute care and trauma surgery care teams: a systems-analysis approach
Get PDFBackground Burnout negatively impacts healthcare professionals’ well-being, leading to an increased risk of human errors and patient harm. There are limited assessments of burnout and associated stressors among acute care and trauma surgery teams.
Methods Acute care and trauma surgery team members at a US academic medical center were administered a survey that included a 2-item Maslach Burnout Inventory and 21 workplace stressors based on the National Academy of Medicine’s systems model of clinician burnout and professional well-being. Stressors were summarized and presented to participants in focus groups. Contextual inquiries (CIs) were conducted to gather additional information about key stressors. Qualitative data were used to generate an affinity model, which participants then validated and used to prioritize top stressors. Participants rated stressors by level of impact and level of effort, and improvement recommendations were made based on these results.
Results 74% (n=14/19) acute care and trauma surgery team members reported high burnout. Key stressors included inadequate staffing, organizational culture, excessive workload, and inefficient workflows. Attending faculty (surgeons) classified the following key priorities for improvement: (i) improve throughput and patient flow, (ii) provide better information technology support, and (iii) improve rewards and support. Non-faculty (advanced practice providers (APPs), nurses, staff) classified the following for improvement: (i) align APP job responsibilities, (ii) improve lack of recognition from leadership, and (iii) robust and consistent APP training.
Conclusions A contextual design approach to studying burnout using surveys, focus groups, CIs, modeling, and validation and prioritization is a feasible method for identifying key stressors and improvements that may enable more impactful and appropriately targeted interventions. Results indicate high levels of burnout among acute care and trauma surgery team members, requiring prioritized attention to operational and relationship issues necessary to care for patients. Efforts to improve surgery teams’ workflows, auxiliary support, compensation, and relationships with leadership may address burnout.
Level of evidence Level V
Targeted distribution of long-lasting insecticidal nets by community health workers to sustain household coverage: A pilot feasibility study in Western Uganda
Get PDFUniversal coverage is defined by the World Health Organization as 1 long-lasting insecticidal net (LLIN) for 2 people in a household. While Uganda has been a leader in the distribution of LLINs, there are concerns regarding the longevity of LLINs. The main aim of this study was to address the LLIN coverage gap that emerges in the period after mass distribution campaigns through the implementation of a novel LLIN distribution strategy utilizing the existing community healthcare worker (CHW) infrastructure. We conducted a pilot feasibility study in two villages randomized to be the control or intervention. CHWs in both villages carried out their regular duties and calculated household eligibility to receive LLINs, classified as having a child under five positive for malaria and being below universal coverage. Only CHWs in the intervention village distributed LLINs to eligible households to reach universal coverage. Summary statistics were calculated for intervention implementation and malaria outcomes. Structured interviews were conducted with CHWs to assess burden and community acceptability of the intervention. Of the children evaluated by the CHWs, 102 of 169 (60.3%) and 112 of 171 (65.5%) were tested for malaria, of which 62 (60.7%) and 71 (63.3%) tested positive in the intervention and control villages, respectively. Only three households were at universal coverage. There was an increase from 4.0% to 6.5% of households meeting universal coverage in the intervention village, compared to a decrease from 7.8% to 1.8% in the control village after the follow-up period. There was an increase in the number of children under the age of 5 who slept under an LLIN the previous night from 15.7% to 31.6% in the intervention village compared to a decrease in the control village from 29.1% to 10.5%. No CHWs reported an increased burden from the intervention and all reported favorable opinions. Our pilot study demonstrates the feasibility and acceptability of targeted LLIN distributions leveraging the existing structure to supplement national distribution campaigns in Uganda. Overall, this work highlights the critical need for novel approaches to sustain LLIN coverage between distribution campaigns, particularly towards the end of the 3-year cycle