Beyond bereavement: Identifying risk and protective factors for prolonged grief disorder.

Prolonged Grief Disorder (PGD) manifests as a long-lasting and incapacitating response to bereavement. The goal of this qualitative study is to understand the intricate interplay of risk and protective factors that underlie PGD by exploring into the perspectives of expert clinicians in Pakistan. Our investigation encompassed in-depth interviews with eight clinical experts comprising clinical psychologists (N = 4, possessing Higher Education Commission-recognized degrees) and psychiatrists (N = 4, certified by Pakistan Medical Commission). Collectively, these professionals possessed a wealth of knowledge exceeding five years in the specialized management of PGD. Thematic analysis of the transcribed interviews, conducted using NVIVO, revealed a comprehensive taxonomy of risk factors contributing to PGD. These encompassed maladaptive thought patterns, psychological distress, attachment styles, and environmental factors. We identified a host of protective factors that may mitigate the development of PGD. These encompassed cultural, social, and familial support systems, individual coping mechanisms, and various treatment modalities.

Experiences, awareness, perceptions and attitudes of women and girls towards menstrual hygiene management and safe menstrual products in Pakistan.

Background: The taboo of menstruation, lack of discussion on puberty, misinformation and poor awareness on menstrual hygiene management and limited access to safe menstrual products can negatively impact the physical and mental health of women and girls residing in low middle income countries. Aim: The aim of the study was to explore the experiences, awareness, perceptions and attitudes of women and girls towards menstrual hygiene management in Pakistan. Moreover, the study also assessed consumer satisfaction towards locally manufactured organic menstrual products. Methods: A descriptive cross-sectional study design was used with a sample of 400 women and girls selected through convenience sampling from high schools, universities, outpatient department and gynaecological clinics located in 2 cities, i.e., Islamabad and Rawalpindi, Pakistan. A pre-structured questionnaire was used to explore experiences, awareness, perceptions and attitudes of women and girls towards menstrual hygiene management. Moreover, each respondent was provided with sample of locally designed and manufactured organic menstrual hygiene & wellness kit by a group of women researchers named "FemPure" including organic sanitary pads, feminine wellness mist and feminine wellness wash. The respondents were asked to use the products and a telephonic follow-up was conducted to assess consumer satisfaction for the products after a period of 1 month. Data was analyzed statistically using SPSS 21. Results: The results of the study reported that 86.2% (n = 345) of the respondents had normal periods. Out of 400 respondents, 58.5% (n = 234) knew about any health conditions related to abnormal menstrual cycle while 88.3% (n = 353) were aware of female menstrual hygiene. Majority of the respondents 78.7% (n = 315) felt ashamed while buying sanitary pads. Out of 400 respondents, 5.4% (n = 22) were interested in getting awareness regarding menstrual hygiene. The results of the study showed that all the respondents (100%, n = 400) were satisfied with FemPure organic menstrual products. Conclusion: The study concluded that majority of women and girls faced menstrual hygiene issues during and after the cycle and were eager to receive information on MHM and use organic rash free menstrual wellness products which could be ordered via mobile app. The respondents were satisfied after the use of FemPure organic menstrual products.

Reduction of heart failure guideline-directed medication during hospitalization: prevalence, risk factors, and outcomes.

AIMS: Optimal management of heart failure with reduced ejection fraction (HFrEF) includes titration of guideline-directed medical therapy (GDMT) to the highest tolerated dose within the licensed range. During hospitalization, GDMT doses are often significantly altered, although it is unknown whether the cause of hospitalization influences this. METHODS AND RESULTS: We recruited 711 people with stable HFrEF from specialist heart failure clinics and prospectively assessed events occurring during first unplanned hospitalization. Dose changes of ACE inhibitors or angiotensin receptor blockers (ACEi/ARB), beta-blockers, mineralocorticoid receptor antagonists, and loop diuretics were recorded during 414 hospitalizations, categorized as due to decompensated heart failure, other cardiovascular causes, infection, or other non-cardiovascular causes. Most hospitalizations resulted in no change to GDMT. ACEi/ARB dose was reduced in 21% of hospitalizations and was more common during non-cardiovascular hospitalization (25.4% vs. 13.9%; P = 0.005). ACEi/ARB dose reduction was associated with older age and lower left ventricular ejection fraction at study recruitment, and poorer renal function, lower systolic blood pressure, higher serum potassium, and less frequent care from a cardiologist during admission. People experiencing ACEi/ARB reduction had worse age-adjusted survival after discharge, without differences in heart failure re-hospitalization. De-escalation of beta-blockers occurred in 8% of hospitalizations, most often due to other non-cardiovascular causes; this was not associated with post-discharge survival or re-hospitalization with heart failure. CONCLUSIONS: De-escalation of HFrEF GDMT is more common during non-cardiovascular hospitalization and for ACEi/ARB is associated with reduced survival. Post-discharge care plans should include robust plans to consider re-escalation of GDMT in these cases.

Diabetes mellitus and the causes of hospitalisation in people with heart failure.

INTRODUCTION: Diabetes mellitus (DM) is associated with increased risk of hospitalisation in people with heart failure and reduced ejection fraction (HFrEF). However, little is known about the causes of these events. METHODS: Prospective cohort study of 711 people with stable HFrEF. Hospitalisations were categorised by cause as: decompensated heart failure; other cardiovascular; infection or other non-cardiovascular. Rates of hospitalisation and burden of hospitalisation (percentage of follow-up time in hospital) were compared in people with and without DM. RESULTS: After a mean follow-up of 4.0 years, 1568 hospitalisations occurred in the entire cohort. DM (present in 32% [n=224]) was associated with a higher rate (mean 1.07 vs 0.78 per 100 patient-years; p<0.001) and burden (3.4 vs 2.2% of follow-up time; p<0.001) of hospitalisation. Cause-specific analyses revealed increased rate and burden of hospitalisation due to decompensated heart failure, other cardiovascular causes and infection in people with DM, whereas other non-cardiovascular causes were comparable. Infection made the largest contribution to the burden of hospitalisation in people with and without DM. CONCLUSIONS: In people with HFrEF, DM is associated with a greater burden of hospitalisation due to decompensated heart failure, other cardiovascular events and infection, with infection making the largest contribution.

Liver Transplant From Increased-Risk Donors in the Era of Direct-Acting Antivirals for Hepatitis C.

OBJECTIVES: The opioid epidemic and the associated deaths have increased the availability of increased-risk donor organs. Here, we assessed factors associated with increased-risk donor liver transplant and determined their impact on survival and response to direct-acting antivirals. MATERIALS AND METHODS: We analyzed anti-hepatitis C virus-positive deceased-donor liver transplant recipients from August 2013 through December 2017. We compared recipient and donor clinical and virologic features, response to direct-acting antivirals, and graft and patient survival rates in increased-risk versus tradi-tional or non-increased risk donor organ transplants. RESULTS: Of 153 transplant recipients, 89 (58%) were anti-hepatitis C virus positive, with 42/89 receiving increased-risk donor livers (mean age 62 years, 1 female, 80% white, and 60% with hepatoma). On univariable analysis, receipt of increased-risk donor liver was associated with simultaneous liver-kidney transplant, lower Model for End-Stage Liver Disease score, hepatitis C virus RNA positivity, pretransplant direct-acting antiviral nonresponse, and younger donor age. On multivariable analysis, only donor age and Model for End-Stage Liver Disease score were associated with increased-risk donor transplant. Among increased-risk donors, 12 (29%) were hepatitis C virus RNA positive, including one who was anti-hepatitis C virus antibody negative. Among recipients, 62 were hepatitis C virus RNA positive (35 with increased-risk livers), with 50 recipients (81%) having genotype 1. Posttransplant, recipient genotype changed in 6 and was mixed in 4 recipients. Of 55 recipients treated with direct-acting antivirals, 54 (98%) achieved viral clearance. Overall 1-year graft and patient survival was 93%. CONCLUSIONS: Increased-risk donor organs provided high levels of utility in liver transplant recipients who were anti-HCV positive, showing optimal graft and patient survival. Increased-risk donors were younger and preferably transplanted in hepatitis C virus RNA-positive recipients with lower Model for End-Stage Liver Disease score. Posttransplant direct-acting antiviral therapy was highly efficacious irrespective of pretransplant recipient and donor virologic status.

Maximizing the acquisition of core communication skills at the start of medical training.

BACKGROUND: Clinical communication teaching for medical undergraduates may involve real patient contact alongside simulated patient (SP) contact. However, there is still comparatively little known about the experience of learning with real patients and how that may impact on the SP encounter. AIM: To explore the impact of real patient contact on the experience of communication skills training and SP contact for first-year medical undergraduate students. METHODS: As part of the 6-year MBBS undergraduate medical degree at Imperial College London, students are obliged to undertake communication skills training, which involves teaching with simulated and real patients. In 2017 (toward the end of formal teaching), a small sample of Year 1 medical students, who had taken part in extra-curricular teaching with real patients were recruited for the study to compare their performance with a control group in a SP encounter. The performance of both groups was analyzed alongside follow-up focus group data from a sample of the study group. RESULTS: Quantitative analysis revealed there was no significant difference in communication skills during a scored SP interview between students with real patient contact and those without. Focus group data, however, revealed valuable insights into the experience of learning with real patients. Students reported a marked increase in their confidence and ability to naturalize their communication skills as a result of real patient contact. Students also reported that skills gained through real patient contact may not always transfer easily to the SP setting. CONCLUSION: Real patient contact is an invaluable component of communication training for undergraduate medical students. For successful implementation, there needs to be a clear curricular purpose at pedagogical, practical and organizational levels. Students' experience of real patient contact can provide an informed foundation upon which to implement other modes of teaching.

Sorafenib-induced Acute on Chronic Liver Failure in a Patient with Hepatocellular Carcinoma After Microwave Ablation.

Hepatocellular carcinoma (HCC) is becoming a rapidly prevalent hepatic tumor throughout the world. Initially, liver transplantation and resection were the only available options. But there is a recent advent of new treatment modalities like ablative embolization techniques and chemotherapy. Guidelines are available regarding the use of these techniques according to the stage of the tumor. Sorafenib is a chemotherapeutic agent approved for the management of advanced HCC. It works by inhibiting different tyrosine kinases, which halt the progression of the tumor. The common side effects associated with it are diarrhea, hand-foot skin reaction, and alopecia. Acute on chronic liver failure (ACLF), defined as the development of acute liver failure, in the setting of chronic liver disease, is a rare adverse event associated with sorafenib. Here, we present a case of a 65-year-old male presented to Nishtar Hospital Multan, Pakistan, who developed advanced-stage HCC due to underlying liver cirrhosis. There was no metastasis or vascular involvement. After discussing the options, he selected microwave ablation (MWA). There was a recurrence of the tumor after the procedure so he was started on sorafenib. A week after the initiation of a low dose drug (200 mg twice daily), he developed signs and symptoms of ACLF, which included hyperbilirubinemia, prolonged prothrombin time (PT), and flapping tremors. He was admitted to the intensive care unit (ICU) and was successfully managed. He was discharged with a follow-up scheduled after two weeks. This is a unique and rare adverse event of sorafenib.

The general practice perspective on barriers to integration between primary and social care: a London, United Kingdom-based qualitative interview study.

OBJECTIVE: There is an ongoing challenge of effective integration between primary and social care in the United Kingdom; current systems have led to fragmentation of services preventing holistic patient-centred care for vulnerable populations. To improve clinical outcomes and achieve financial efficiencies, the barriers to integration need to be identified and addressed. This study aims to explore the unique perspectives of frontline staff (general practitioners and practice managers) towards these barriers to integration. DESIGN: Qualitative study using semistructured interviews and thematic analysis to obtain results. SETTING: General practices within London. PARTICIPANTS: 18 general practitioners (GPs) and 7 practice managers (PMs) based in London with experience of working with social care. RESULTS: The study identified three overarching themes where frontline staff believed problems exist: accessing social services, interprofessional relationships and infrastructure. Issues with contacting staff from other sectors creates delays in referrals for patient care and perpetuates existing logistical challenges. Likewise, professionals noted a hostile working culture between sectors that has resulted in silo working mentalities. In addition to staff being overworked as well as often inefficient multidisciplinary team meetings, poor relationships across sectors cause a diffusion of responsibility, impacting the speed with which patient requests are responded to. Furthermore, participants identified that a lack of interoperability between information systems, lack of pooled budgets and misaligned incentives between managerial staff compound the infrastructural divide between both sectors. CONCLUSION: In this study, primary care staff identify intangible barriers to integration such as poor interprofessional relationships, in addition to more well-described structural issues such as insufficient funding and difficulty accessing social care. Participants believe that educating the next generation of medical professionals may lead to the development of collaborative, instead of siloed, working cultures and that change is needed at both an interpersonal and institutional level to successfully integrate care.

Medical school teaching on interprofessional relationships between primary and social care to enhance communication and integration of care - a pilot study.

Background: A pilot study to identify if the delivery of teaching session to medical students would have the potential to enhance communication and a culture of integration between primary and social care, ultimately improving interprofessional relationships between primary and social care. Health and social care integration is a topic of great debate in the developed world and the focus of the upcoming Green Paper by the Secretary of State for Health and Social Care in the NHS. There is much uncertainty to how this should be done and is hindered by the various current barriers. The literature identifies that collaborative cultures encourage effective interprofessional relationships and that communication is vital to integration of primary and social care and should be established early in medical training. Materials and Method: The General Medical Council's Outcomes for Graduates and Imperial College School of Medicine curriculum were reviewed out to identify outcomes relating to inter-professional relationships between primary and social care. The relevant year group was surveyed to identify if the learning objective was delivered. In order to determine if delivery of a teaching session on nurturing interprofessional relationships between primary and social care would be effective, it was delivered to early clinical years to measure benefits as a pilot study. This was devised of case-based scenarios derived from learning objectives developed with experienced health care professionals. A survey was administered before and after the teaching session to determine if the students felt they had improved with respect to the learning objectives. Results: The initial survey identified the majority of students found the learning objectives were not delivered. The teaching session found a statistically significant improvement in confidence to nurture interprofessional relationships between primary and social care. Conclusion: Effective interprofessional relationships between primary and social care, improving communication and collaborative cultures, can be effectively taught in medical school, to improve integration of primary and social care.