Measuring moral distress in health professionals using the MMD-HP-SPA scale.

BACKGROUND: Moral distress (MD) is the psychological damage caused when people are forced to witness or carry out actions which go against their fundamental moral values. The main objective was to evaluate the prevalence and predictive factors associated with MD among health professionals during the pandemic and to determine its causes. METHODS: A regional, observational and cross-sectional study in a sample of 566 professionals from the Public Health Service of Andalusia (68.7% female; 66.9% physicians) who completed the MMD-HP-SPA scale to determine the level of MD (0-432 points). Five dimensions were used: i) Health care; ii) Therapeutic obstinacy-futility, iii) Interpersonal relations of the Healthcare Team, iv) External pressure; v) Covering up of medical malpractice. RESULTS: The mean level of MD was 127.3 (SD=66.7; 95% CI 121.8-132.8), being higher in female (135 vs. 110.3; p<0.01), in nursing professionals (137.8 vs. 122; p<0.01) and in the community setting (136.2 vs. 118.3; p<0.001), with these variables showing statistical significance in the multiple linear regression model (p<0.001; r2=0.052). With similar results, the multiple logistic regression model showed being female was a higher risk factor (OR=2.27; 95% CI 1.5-3.4; p<0.001). 70% of the sources of MD belonged to the dimension "Health Care" and the cause "Having to attend to more patients than I can safely attend to" obtained the highest average value (Mean=9.8; SD=4.9). CONCLUSIONS: Female, nursing professionals, and those from the community setting presented a higher risk of MD. The healthcare model needs to implement an ethical approach to public health issues to alleviate MD among its professionals.

[The importance of self-regulation: Analysis of the activity of the medical ethics and deontology commission in Cordoba]. / Importancia de la autorregulación: análisis de la actividad de la comisión de ética y deontología médica en Córdoba.

OBJECTIVE: to analyse the activity of the Medical Ethics and Deontology Commission (MEDC) of the College of Physicians of Cordoba regarding conflictive situations in the profession from 2013 through 2021. MATERIAL AND METHODS: cross-sectional observational study, in which 83 cases of complaints submitted to the College were collected. RESULTS: the incidence was 2.6 complaints‰ members/year, with a total of 92 doctors reported. 61.4% were submitted by the patient, 92.8% of which were addressed to a single doctor. 30.1% were in the speciality of family medicine, 50.6% in the public sector and 72% in outpatient care. In 37.7% the chapter of the Code of Medical Ethics concerned was chapter IV (quality of medical care). In 89.2% of cases the parties came to make a statement, with a higher risk of disciplinary proceedings being observed when the statement was both, oral and written (OR:4.61; p=0.026). The median resolution time was 63 days, significantly longer in cases proposed for disciplinary proceedings (146 days vs. 58.50 days; OR:1.01; p=0.008). The MEDC found 15.7% (n=13) to be in breach of ethics, with 15 doctors being disciplined (16.3%) and 4 sanctioned (26.7%) with a warning and temporary suspension from practice. CONCLUSIONS: The role of the MEDC is fundamental in the self-regulation of professional practice. Inappropriate behaviour during patient care or between colleagues has serious ethical implications, disciplinary repercussions for the physician, and it particularly undermines patients' trust in the medical profession.

Importancia de la autorregulación: análisis de la actividad de la comisión de ética y deontología médica en Córdoba / The importance of self-regulation: Analysis of the activity of the medical ethics and deontology commission in Cordoba

Objetivo: analizar la actividad de la Comisión de Ética y Deontología Médica (CEDM) del Colegio Ofi-cial de Médicos de Córdoba, respecto a situaciones conflictivas en la profesión en el período 2013-2021.Material y métodos: estudio observacional transversal, en el que finalmente se recogieron 83 casos de re-clamaciones presentadas ante el Colegio. Resultados: la incidencia fue de 2,6 reclamaciones‰ colegiados/año, con un total de 92 médicos denunciados. El 61,4% fueron presentadas por el paciente, dirigidas en un92,8% a un solo médico. El 30,1% fue en la especialidad de medicina de familia, siendo el 50,6% en el ám-bito público y el 72% en asistencia ambulatoria. En el 37,7% el capítulo del Código de Deontología Médicaafectado fue el IV (calidad de la atención médica). En el 89,2% las partes acudieron a declarar, observán-dose mayor riesgo de expediente disciplinario cuando la declaración era oral y escrita (OR:4,61; p=0,026).La mediana de los plazos de resolución fue de 63 días, significativamente mayores en los casos propuestospara expediente disciplinario (146 días vs. 58,50 días; OR:1,01; p=0,008). La CEDM dictaminó infraccióndeontológica en el 15,7% (n=13), siendo expedientados 15 médicos (16,3%) y 4 sancionados (26,7%) me-diante apercibimiento y suspensión temporal del ejercicio. Conclusiones: La función de la CEDM resultafundamental en la autorregulación del ejercicio profesional. Los comportamientos inapropiados durantela asistencia al paciente o entre compañeros, conllevan graves implicaciones éticas, repercusiones discipli-narias para el médico, y especialmente, socavan la confianza de los pacientes en la profesión médica.(AU)

Objective: to analyse the activity of the Medical Ethics and Deontology Commission (MEDC) of the Co-llege of Physicians of Cordoba regarding conflictive situations in the profession from 2013 through 2021.Material and methods: cross-sectional observational study, in which 83 cases of complaints submitted tothe College were collected. Results: the incidence was 2.6 complaints‰ members/year, with a total of 92doctors reported. 61.4% were submitted by the patient, 92.8% of which were addressed to a single doctor.30.1% were in the speciality of family medicine, 50.6% in the public sector and 72% in outpatient care.In 37.7% the chapter of the Code of Medical Ethics concerned was chapter IV (quality of medical care).In 89.2% of cases the parties came to make a statement, with a higher risk of disciplinary proceedingsbeing observed when the statement was both, oral and written (OR:4.61; p=0.026). The median resolutiontime was 63 days, significantly longer in cases proposed for disciplinary proceedings (146 days vs. 58.50days; OR:1.01; p=0.008). The MEDC found 15.7% (n=13) to be in breach of ethics, with 15 doctors beingdisciplined (16.3%) and 4 sanctioned (26.7%) with a warning and temporary suspension from practice.Conclusions: The role of the MEDC is fundamental in the self-regulation of professional practice. Inappro-priate behaviour during patient care or between colleagues has serious ethical implications, disciplinaryrepercussions for the physician, and it particularly undermines patients’ trust in the medical profession.(AU)

Forensic age estimation: comparison and validation of the Iscan method in 3D reconstructions using a surface scanner in a Spanish population.

When investigating a death, post-mortem identification provides with results of great legal and humanitarian significance. The effectiveness of the methods used to estimate age depends on the reference population, considering variables such as sex and ancestry. The aim of this study was to validate the Iscan method to estimate age in a Spanish forensic population, comparing the estimates obtained in dry bones and 3D reconstructions created with a surface scanner. We carried out a cross-sectional study on 109 autopsied corpses (67% male), scanning the sternal end of the right fourth rib in a 3D mesh, using an EinScan-Pro® surface scanner (precision: 0.05 mm). Two observers estimated the phases in dry bones and 3D images according to the Iscan method and to the sex of the subject. The mean age was 57.73 years (SD = 19.12 years;18-93 years). The intra-observer agreement was almost perfect in bones (κ = 0.877-0.960) and 3D images (κ = 0.954), while the inter-observer agreement was almost perfect in bones (κ = 0.813) and substantial in 3D images (κ = 0.727). The correlation with the Iscan phases was very strong in bones (Rho = 0.794-0.820; p < 0.001) and strong in 3D images (Rho = 0.690-0.691; p < 0.001). Both sex-adjusted linear regression models were significant (dry bones: R2 = 0.65; SEE = ± 11.264 years; 3D images: R2 = 0.50; SEE = ± 13.537 years) from phase 4 onwards. An overestimation of age was observed in the first phases, and an underestimation in the later ones. Virtual analysis using a surface scanner in the fourth rib is a valid means of estimating age. However, the error values and confidence intervals were considerable, so the joint use of different methods and anatomical sites is recommended.

Study of the Psychometric Properties of the Spanish Version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA).

BACKGROUND: The early detection of moral distress requires a validated and reliable instrument. The aim of this study was to carry out an advanced analysis of the psychometric properties of the moral distress scale for health professionals (MMD-HP-SPA) by performing a validation of the construct and its internal and external reliability. METHODS: We performed a multicentre cross-sectional study in health professionals belonging to the Andalusian public health system. Construct validity was performed by exploratory (n = 300) and confirmatory (n = 275) factor analysis (EFA/CFA) in different subgroups; we also analysed the internal consistency and temporal reliability of the scale. RESULTS: 384 doctors and 191 nurses took part in the survey. The overall mean for moral distress was 128.5 (SD = 70.9), 95% CI [122.7-134.3], and it was higher in nurses at 140.5 (SD = 74.9) than in doctors at 122.5 (SD = 68.1), F = 8.37 p < 0.01. The EFA produced a model of five components which accounted for 54.8% of the variance of the model. The CFA achieved a goodness of fit of Chi2 = 972.4; AIC = 1144.3; RMSEA = 0.086; CFI = 0.844; TLI = 0.828; NFI = 0.785. CONCLUSIONS: The MMD-HP-SPA scale has solid construct validity, excellent internal consistency, optimal temporal reliability, and underlying dimensions which effectively explore the causes of moral distress in health professionals, thus guaranteeing its use in hospital and community settings.

Relationship between Child Abuse and Delinquent Behavior in Male Adolescents Deprived of Liberty.

The objective is to identify the prevalence of child abuse and criminal behavior among young male prisoners in Ecuador. METHOD: A total of 425 young people between 12 and 18 years of age, deprived of liberty from different centers for adolescent offenders in Ecuador, were used. The level of abuse to which they had been subjected in childhood was evaluated, as well as the risk factors present in their history. The relationship between abuse, risk factors, and criminal behavior was analyzed. RESULTS: A high prevalence of the different types of abuse was found in the mean age of 15.03 years standard deviation (SD = 1.34). CONCLUSION: In addition, a relationship was discovered between the abuse suffered during childhood and the risk factors present in criminal behavior during adolescence, which was demonstrated in this article. The practical implications of these results are discussed, taking into consideration their relevance for prevention.

Epidemiology and autopsy findings of 500 drowning deaths.

INTRODUCTION: Drowning is a significant public health problem worldwide and the WHO reported that drowning is the world's third leading unintentional injury death. Nevertheless, there is still uncertainty regarding the estimate of local and global drowning deaths. In addition, the postmortem diagnosis of drowning is challenging and the physiological mechanisms of death by drowning are complex and not very well understood. PURPOSE: To analyze a large series of bodies retrieved from the water in Connecticut (U.S.) in order to compare epidemiologic and toxicological data with those of the literature, as well as to examine the weights of the lungs and brains in drowning deaths. MATERIAL AND METHOD: We conducted a descriptive, retrospective, population-based analysis of all bodies retrieved from the water and subjected to a forensic autopsy at the Office of the Chief Medical Examiner in Connecticut (2008-2020, n = 500). Variables collected were sex, age, date of death, location of drowning, season, type of water, cause of death, manner of death, circumstances of death, signs of decomposition, BMI, brain weight, lung weight, presence of pulmonary edema, stomach contents, and toxicological analysis. RESULTS: The death rates of drownings in Connecticut ranges from 0.75 to 1.28/100,000/year. They occurred predominantly in males (73.4%) and most were accidents (75.6%), though this gender difference diminishes in suicides (55.4% of males). Sex distribution is also different in bathtub drownings, where women drown more frequently (67.3%). Weights of the brains (p = 0.013) and lungs (p < 0.001) were higher in saltwater drownings. CONCLUSIONS: Drowning is more frequently an accident involving men, except for suicides where there is only a slight difference among sex. Heavy lungs and cerebral edema continue to be identified in numerous drowning deaths. These anatomic findings, however, must still be interpreted in the context of the entire case investigation. Weights of the brains and lungs are higher in salt water, although these organs' weights are mostly dependent on other variables such as BMI and decomposition.

Impact of the COVID-19 Pandemic on Palliative Care in Cancer Patients in Spain.

BACKGROUND: The COVID-19 pandemic outbreak has severely affected healthcare organizations worldwide, and the provision of palliative care (PC) to cancer patients has been no exception. The aim of this paper was to analyse the levels of health care provided by the Clinical Management Unit for PC in Córdoba (Spain) for cancer patients. METHOD: a retrospective cohort study was conducted. It analyzed the PC internal management database including all cancer patients treated in the period of 2018-2021. RESULTS: 1967 cases were studied. There was a drop in cancer cases (p = 0.008), deaths at the PC hospital (p < 0.001), and referrals from primary care (p < 0.001). However, there was a rise in highly complex clinical situations (p = 0.020) and in ECOG performance status scores of 3-4 (p < 0.001). The pandemic was not shown to be a risk factor for survival in the PC program (0.99 [0.82-1.20]; p = 0.931). However, being female (p = 0.005), being older and having a high Karnofsky Performance Status (KPS) score (p < 0.001) could be indicators of a longer stay. CONCLUSION: The COVID-19 pandemic has presented a challenge in the management of patients requiring PC and has highlighted the urgent needs of the healthcare system if it is to continue providing a level of care which meets the needs of patients and their families.

The role of undergraduate medical students training in respect for patient confidentiality.

BACKGROUND: Encouraging professional integrity is vital for providing a standard of excellence in quality medical care and education and in promoting a culture of respect and responsibility. The primary objective of this work consisted of studying the relationship of medical students to the right to patient privacy in Spain, specifically by analysing the conditions for accessing patient clinical histories (CHs). METHODS: A cross-sectional study was conducted based on a questionnaire sent by e-mail to final-year students at 41 Spanish universities. It had 14 multiple choice and closed questions framed in 3 large blocks. The first question addressed basic general knowledge issues on the right to privacy and the obligation for confidentiality. The two remaining blocks were made up of questions directed towards evaluating the frequency with which certain requirements and action steps related to students attending patients were performed and regarding the guarantees associated with accessing and handling patient CHs both on paper and in the Electronic Medical Record. RESULTS: A total of 245 valid replies were considered. A total of 67.8 % of participants were women, with an average age of 24.05 ± 3.49 years. Up to 90.6 % were aware that confidentiality affected the data in CHs, although 43.3 % possessed non-anonymized photocopies of patient clinical reports outside the healthcare context, and only 49.8 % of the students were always adequately identified. A total of 59.2 % accessed patient CHs on some occasions by using passwords belonging to healthcare professionals, 77.2 % of them did not have the patients' express consent, and 71.9 % accessed a CH that was not anonymised. CONCLUSIONS: The role of healthcare institutions and universities is considered to be fundamental in implementing educational measures regarding the risks and ethical and legal problems arising from the use of CHs among professionals and students. A thorough study of medical ethics is needed through the analysis of clinical cases and direct exposure to situations in which the patient's confidentiality is questioned.

Structural abnormalities in the human diaphragm in drowning and hanging deaths: preliminary results.

PURPOSE: Previous experiments in rats have indicated that there are histological changes in skeletal muscle in drowning deaths; these changes include muscle fibers that contain ragged red fibers (RRF). The purpose of this study was to examine whether these changes also occur in humans. METHODS: Histologic and histochemical examinations of three muscles (diaphragm, pectoralis, and psoas) were performed on 24 cadavers with three different causes of death: 8 drowning, 8 hanging, and 8 sudden cardiac disease. Muscle samples were stained with hematoxylin-eosin, MGT, nicotinamide adenine dinucleotide-tetrazolium reductase, succinate dehydrogenase, ATPase, and acid phosphatase via standard staining procedures. RESULTS: There were statistically significant differences in the detection of RRFs in these cohorts. Additionally, several other cytoarchitectural changes (whorled and core-like fibers) were observed in the diaphragm in the drowning cohort and to a lesser extent in the hangings. These structural abnormalities were not observed in the sudden cardiac disease deaths, thus suggesting a common mechanism for the production of these muscular changes that is not shared in the cardiac death group. The mechanism is most likely intense hypoxia and mechanical trauma of the respiratory muscles in the setting of active blood circulation with intense muscle contraction. CONCLUSIONS: Our results confirmed that there are histological changes in the diaphragm in drownings and, to a lesser extent, in hangings.

Control de calidad de los partes de lesiones emitidos en Atención Primaria y Urgencias de la provincia de Córdoba / Quality control of injury reports issued by Primary Health Care and Emergency Medical Services in the province of Córdoba

Introducción: Los partes de lesiones son documentos médico-legales que contienen la comunicación a la autoridad judicial de cualquier lesión consecuencia de una conducta delictiva, accidental o autoinflingida. La experiencia diaria indica una elevada prevalencia de cumplimentación incompleta o errónea, lo que dificulta la tarea del médico forense y, con ello, la posterior reparación del daño producido a la víctima. El objetivo de este trabajo es evaluar la calidad de la cumplimentación de los partes de lesiones emitidos por Atención Primaria y Urgencias en el ámbito provincial de Córdoba mediante la propuesta de una escala e identificar los errores más prevalentes cometidos durante dicha cumplimentación. Material y métodos: Estudio descriptivo, transversal y retrospectivo. Se seleccionaron 127 partes de lesiones del archivo del Instituto de Medicina Legal y Ciencias Forenses de Córdoba, emitidos por los servicios de Urgencias y Atención Primaria entre 1 de enero y 30 de junio de 2015, mediante un muestreo consecutivo, y se les aplicó una escala de calidad de realización propia. Resultados: El 18,1% de los partes de lesiones son de baja o ínfima calidad, encuadrándose la mayoría (78,7%) como de calidad intermedia. No obstante, la generalidad de los partes son muy defectuosos en los apartados estrictamente médico-legales, que son los relacionados con la descripción de las lesiones (localización, tipo, dimensión y estado evolutivo de las mismas), que han obtenido las puntuaciones más bajas. Conclusiones: Se demuestra la deficiente calidad de los partes de lesiones emitidos por los servicios de Atención Primaria y Urgencias en nuestra provincia y se hace necesaria una estrategia para mejorar la cumplimentación de estos documentos médico-legales

Introduction: Injury reports are medico-legal documents containing the required information about injuries (from accidental, criminal or self-inflicted origin) to be delivered to the judicial authority. Nevertheless, forensic routine work suggests a high rate of inadequate or erroneous injury reports. This hinders forensic evaluation and, consequently, damage repair. The main objective of this paper is to evaluate the quality of the completion of injury reports issued by Primary Care and Emergency services in Córdoba, Spain, by using a new scale, as well as to identify the most prevalent mistakes made during that completion. Material and methods: Descriptive cross-sectional and retrospective study conducted on 127 injury reports issued by Primary Care and Emergency services selected from the archive of the Institute of Legal Medicine and Forensic Science of Córdoba, using consecutive sampling, between 1 January 2015 and 30 June 2015. A quality scale of our own creation was then applied to them. Results: The analysis showed that 18.1% of injury reports are of low or very low quality, while the majority (78.7%) are considered as intermediate quality. Nevertheless, most of them are very poorly described −with the lowest scores− in relation to strictly medico-legal parts; the description of the injury, including type, dimension and evolutionary stage. Conclusions: The study shows the poor quality of the injury reports issued by Primary Care and Emergency services within the province of Córdoba. Further strategies are needed in order to improve the completion of these medico-legal documents

Assessment of Doctors' Knowledge and Attitudes Towards Confidentiality in Hospital Care.

The physician's duty of confidentiality is based on the observance of the patient's privacy and intimacy and on the importance of respecting both of these rights, thus creating a relationship of confidence and collaboration between doctor and patient. The main objective of this work consists of analyzing the aspects that are related to the confidentiality of patients' data with respect to the training, conduct and opinions of doctors from different Clinical Management Units of a third-level hospital via a questionnaire. The present study aimed to define the problem and determine whether the opinions of these professionals correspond to those observed in a previous work conducted at the same center. Of the 200 questionnaires that were collected, 62.5% were from consultants and the rest were from residents (37.5%) with an average of 14.4 ± 12.5 years in professional practice. The respondents noted habitual situations in which confidentiality was breached in the reference hospital (74%). The section on their attitudes and behaviors towards situations related to confidentiality showed a slightly lower average score than that of their medical knowledge; significant differences in these scores were observed between the consultants and residents as well as between the extreme age groups (≤ 30 vs. ≥ 51 years) and years of professional practice, thus more inadequate attitudes were consistently noted in younger doctors who had fewer years of experience. Finally, the respondents answered that the training of doctors in the aspects of healthcare law and ethics was the most important measure that the hospital could adopt regarding confidentiality practices.

Use of XRD and SEM/EDX to predict age and sex from fire-affected dental remains.

In fire scenarios, the application and accuracy of traditional odontological methods are often limited. Crystalline studies and elemental profiling have been evaluated for their applicability in determining biological profiles (age and sex) from human dentition, particularly fire- and heat-affected dental remains. Thirty-seven teeth were paired according to tooth type and donor age/sex for the analysis of crown and root surfaces pre- and post-incineration using X-ray diffraction (XRD) and scanning electron microscopy (SEM/EDX). In unburned crowns, carbon (C) content showed a positive correlation with age, whereas phosphorus (P) and calcium (Ca) contents showed a negative correlation with age. In unburned roots, C, P and Ca contents also showed significant changes that were opposite of those observed in the crowns. In relation to sex, females exhibited a higher C ratio than males, whereas males showed significantly higher levels of oxygen (O), P and Ca in unburned roots. Incineration resulted in an increase in the crystallite size that correlated with increasing temperature. No differences in hydroxyapatite (HA) crystallite size were found between age groups; however, unburned teeth from females exhibited a larger crystallite size than did those from males. The challenges of using XRD with a 3D sample were overcome to allow analysis of whole teeth in a nondestructive manner. Further studies may be useful in helping predict the temperature of a fire.

Confidentiality breaches in clinical practice: what happens in hospitals?

BACKGROUND: Respect for confidentiality is important to safeguard the well-being of patients and ensure the confidence of society in the doctor-patient relationship. The aim of our study is to examine real situations in which there has been a breach of confidentiality, by means of direct observation in clinical practice. METHODS: By means of direct observation, our study examines real situations in which there has been a breach of confidentiality in a tertiary hospital. To observe and collect data on these situations, we recruited students enrolled in the Medical Degree Program at the University of Cordoba. The observers recorded their entries on standardized templates during clinical internships in different departments: Internal Medicine; Gynecology and Obstetrics; Pediatrics; Emergency Medicine; General and Digestive Surgery; Maxillofacial Surgery; Plastic Surgery; Orthopedics and Traumatology; Digestive; Dermatology; Rheumatology; Mental Health; Nephrology; Pneumology; Neurology; and Ophthalmology. RESULTS: Following 7138 days and 33157 h of observation, we found an estimated Frequency Index of one breach per 62.5 h. As regards the typology of the observed breaches, the most frequent (54,6 %) were related to the consultation and/or disclosure of clinical and/or personal data to medical personnel not involved in the patient's clinical care, as well as people external to the hospital. As regards their severity, severe breaches were the most frequent, accounting for 46.7 % of all incidents. Most of the reported incidents were observed in public areas (37.9 %), such as corridors, elevators, the cafeteria, stairs, and locker rooms. CONCLUSIONS: In addition to aspects related to hospital organization or infrastructure, we have shown that all healthcare personnel are involved in confidentiality breaches, especially physicians. While most are committed unintentionally, a non-negligible number are severe, repeated breaches (9.5 %), thus suggesting a certain carelessness, perhaps through ignorance about certain behaviors that can jeopardize patient confidentiality.