Evaluation of Montreal Cognitive Assessment (MoCA) Administered via Videoconference.

OBJECTIVES: Telemedicine provides much potential for promoting health care. The Montreal Cognitive Assessment (MoCA) is a screening tool for identifying mild cognitive impairment. This study aims to evaluate the agreement between MoCA assessed face-to-face vs via videoconference using a mobile phone. DESIGN: A randomized crossover study. SETTING AND PARTICIPANTS: A randomly selected sample of patients admitted to the geriatric rehabilitation department in a large tertiary medical center in 2021-2022. METHODS: The MoCA was conducted twice for each patient, with a 10- to 20-day interval between assessments. To avoid a learning effect, alternate MoCA versions were used for each patient. Intraclass correlation coefficient (ICC), kappa, weighted kappa, and the Bland-Altman plot were used to evaluate the agreement between administration methods. To identify variables associated with low agreement, data on participant characteristics, order of administration methods, and test versions were collected, and univariate and multivariable analyses were performed. RESULTS: Forty-four patients were included in the study. The median age was 83 years [interquartile range (IQR 76-87)] and 75% were females. Median overall MoCA score was 24 points (IQR 21-26) when administered face-to-face, and 23.5 points (IQR 21-26) via videoconference. Excellent agreement (ICC = 0.89) was observed in the total MoCA score. Moderate-substantial agreement was observed in subsection scores (kappa 0.436-0.686), except for the language subsection where fair agreement was observed (kappa 0.331). Anxiety was assessed by Hospital Anxiety and Depression Scale and associated with lower agreement (ICC = 0.76 in patients with anxiety vs ICC = 0.92 in patients without anxiety). None of the other studied variables were associated with a difference between administration methods. CONCLUSIONS AND IMPLICATIONS: Conducting a MoCA via videoconference using a mobile phone is another method of providing medical care to people without significant visual or hearing impairment that restricts their use of a mobile phone, during routine times and in emergencies where social distancing is needed.

A new metabolic syndrome prediction model for self-evaluation as a primary screening tool in an apparently MetS-free population.

BACKGROUND: Metabolic syndrome (MetS) is a growing global public health concern associated with increased morbidity and mortality. The study aimed to establish a simple self-evaluated prediction model to identify MetS. METHODS: A cross-sectional study based on the American National Health and Nutrition Examination Survey database was performed. Participants aged ≥20 in the 2009-2018 surveys, with no current pregnancy or major morbidities, were included. The model was built with data from 2009 to 2016 and validated using 2017-2018 data. MetS was defined according to AHA/NHLBI guidelines. Multivariable logistic regression was applied to build a prediction model. The area under the receiver operating characteristic curve (AUC) was used to assess the discrimination ability and the maximal Youden's index was used to identify the optimal cut-off value. RESULTS: The study included 4245 individuals (median age 37, IQR 28-49, 51.8% females) in the training group and 911 individuals (median age 37, IQR 28-52, 52.5% females) in the validation group. Older age, male gender, non-Black race, no postsecondary education, and higher BMI were significantly associated with increased risk of MetS. The final model included age, gender, race, education, and BMI, and showed good discrimination ability (AUC = 0.810, 95% CI 0.793-0.827, sensitivity 80.4%, specificity 66.2%, positive likelihood ratio 2.379, negative likelihood ratio 0.296, PPV 59.6% and NPV 84.5%). CONCLUSION: A new model for self-evaluation may serve as a primary, easy-to-use screening tool to identify MetS in an apparently MetS-free population. A simple application may serve for primary and secondary prevention, thus enabling risk reduction in the development of cardiovascular morbidity and health expenditure.

Assessing the country-level involvement of nurses in COVID-19 vaccination campaigns: A qualitative study.

BACKGROUND: As each country individually manages the COVID-19 pandemic, mass vaccination campaigns have varied considerably. Implementation campaigns often depend on nurses; however, nurses are not consistently involved in higher-level planning, prioritization, and policy development decisions. This study aimed to examine the involvement and engagement of nurses in country-level COVID-19 mass vaccination policies and practices in 10 Office of Economic Cooperation and Development countries, identify barriers and factors to enhancing the engagement of nurses in the evidence-informed mass vaccination decision-making processes, and suggest areas for improvement. METHODS: A qualitative study using in-depth semi-structured interviews was conducted as a follow-up study to an International Council of Nurses survey. The study sample included a purposeful sample of 14 country-representative nurses from 10 Office of Economic Cooperation and Development countries. Interview questions focused on each country's overall COVID-19 vaccination campaign and policies, participants' perspectives regarding the involvement of nurses in the planning, design, and implementation of the mass vaccination program observed outcomes, and the impact of nursing on the outcomes. Interviews were recorded, transcribed, translated where necessary, coded, and thematically analyzed. RESULTS: Main areas of involvement identified by participants were membership in advising and decision-making committees, operationalization planning, implementation and coordination processes, education efforts, and nurses' interactions with the media. Seven themes emerged among perceived facilitators of nursing involvement: existing systems and infrastructure, nursing profession-related skills and competencies, communication and messaging, multidisciplinary and interagency work, recognition and visibility of nurses and nursing, trust in nurses, and nursing pride. Meanwhile, perceived barriers included lack of a voice, recognition and appreciation for nursing, workforce-related challenges, decentralization of responsibility and authority, supply and access issues, downstream effects of the pandemic, and non-COVID-related nursing barriers. Three main themes emerged among suggestions made by participants for improved involvement of nursing: culture change within nursing and healthcare, opportunities and momentum to build upon, and perceptions of responsible parties. CONCLUSIONS: Nurses play a central role in providing health services but are inconsistently included in the policy, planning, and decision-making processes. Findings highlighted the critical importance of nursing leadership roles and expanded roles for nurses. Nursing should be represented by high-level leaders as part of multidisciplinary decision-making groups, educational initiatives for involvement in health policy should be implemented in nursing schools and continuing education, and advocacy and inclusion efforts should utilize bottom-up and top-down approaches concurrently.

Predictors of reinfection with pre-Omicron and Omicron variants of concern among individuals who recovered from COVID-19 in the first year of the pandemic.

OBJECTIVES: The predictors of SARS-CoV-2 reinfection are unclear. We examined predictors of reinfection with pre-Omicron and Omicron variants among COVID-19-recovered individuals. METHODS: Randomly selected COVID-19-recovered patients (N = 1004) who donated convalescent plasma during 2020 were interviewed between August 2021 and March 2022 regarding COVID-19 vaccination and laboratory-proven reinfection. The sera from 224 (22.3%) participants were tested for antispike (anti-S) immunoglobulin G and neutralizing antibodies. RESULTS: The participants' median age was 31.1 years (78.6% males). The overall reinfection incidence rate was 12.8%; 2.7% versus 21.6% for the pre-Omicron (mostly Delta) versus Omicron variants. Negative associations were found between fever during the first illness and pre-Omicron reinfection: relative risk 0.29 (95% confidence interval 0.09-0.94), high anti-N level at first illness and Omicron reinfection: 0.53 (0.33-0.85), and overall reinfection: 0.56 (0.37-0.84), as well as between subsequent COVID-19 vaccination with the BNT162b2 vaccine and pre-Omicron 0.15 (0.07-0.32), Omicron 0.48 (0.25-0.45), and overall reinfections 0.38 (0.25-0.58). These variables significantly correlated with immunoglobulin G anti-S follow-up levels. High pre-existing anti-S binding and neutralizing antibody levels against the SARS-CoV-2 Wuhan and Alpha strains predicted protection against Omicron reinfections. CONCLUSION: Strong immune responses after the first COVID-19 infection and subsequent vaccination with the BNT162b2 vaccine provided cross-protection against reinfections with the Delta and Omicron variants.

Fast vs. Regular Track for Lung and Pancreatic Cancer Diagnosis-Time from Initial Finding to Final Diagnosis and Patient Survival.

BACKGROUND: Health systems around the world have begun implementing unique tracks to expedite diagnosis and improve survival of patients with suspected cancers. This study aimed to compare characteristics and survival between patients diagnosed by way of fast and regular diagnostic tracks. METHODS: A historical cohort study of patients (age ≥ 18) diagnosed with lung or pancreatic cancers between 09/2017 and 03/2020 on a fast diagnostic track and treated in a tertiary hospital versus a random sample of patients with the same cancer types who began treatment in the hospital over the same period of time after being diagnosed utilizing the regular track in the community. RESULTS: The study included 336 patients (108 fast-track diagnostics, 228 regular track diagnostics). Advanced stages III-IV at diagnosis were more likely in the fast-track group (94.4% vs. 81.1%, p = 0.001). The median time from initial cancer suspicion to diagnosis was 21 days (IQR 14-37) for the fast-track vs. 31 days (IQR 18-51) for the regular track (p < 0.001). During the follow-up period, 56 patients from the fast-track and 131 patients from the regular track died. No significant difference was found in the median survival time between the fast and regular tracks, whether from the onset of symptoms, diagnosis, or treatment initiation. CONCLUSION: Patients referred to the fast-track were more likely to be diagnosed at a further advanced stage of their cancer. The fast-track shortened the time until diagnosis and treatment but no difference was found in median survival between the tracks, perhaps due to late referral and high fatality rates.

Multicenter Surveillance of Antimicrobial Resistance among Gram-Negative Bacteria Isolated from Bloodstream Infections in Ghana.

BACKGROUND: Antimicrobial resistance (AMR) in Gram-negative bacteria-causing bloodstream infections (BSIs), such as Klebsiella pneumoniae and non-typhoidal Salmonella (NTS), is a major public health concern. Nonetheless, AMR surveillance remains scarce in sub-Saharan Africa, where BSI treatment is largely empirical. The aim of the study was to determine the distribution and AMR patterns of BSI-causing NTS, K. pneumoniae, and other Gram-negative bacteria in Ghana. METHODS: A cross-sectional study was conducted between April and December 2021 at eleven sentinel health facilities across Ghana as part of a pilot study on the feasibility and implementation of the human sector AMR surveillance harmonized protocol in sub-Saharan Africa. Gram-negative bacteria recovered from blood specimens of febrile patients were identified using MALDI-TOF and evaluated for antimicrobial resistance using the BD Phoenix M50 analyzer and Kirby-Bauer disc diffusion. The Department of Medical Microbiology at the University of Ghana served as the reference laboratory. RESULTS: Out of 334 Gram-negative blood isolates, there were 18 (5.4%) NTS, 85 (25.5%) K. pneumoniae, 88 (26.4%) Escherichia coli, 40 (12.0%) Acinetobacter baumannii, 25 (7.5%) Pseudomonas aeruginosa, and 77 (23.1%) other Gram-negative bacteria. As a composite, the isolates displayed high resistance to the antibiotics tested-amoxicillin (89.3%), tetracycline (76.1%), trimethoprim-sulfamethoxazole (71.5%), and chloramphenicol (59.7%). Resistance to third-generation cephalosporins [ceftriaxone (73.7%), cefotaxime (77.8%), and ceftazidime (56.3%)] and fluoroquinolones [ciprofloxacin (55.3%)] was also high; 88% of the isolates were multidrug resistant, and the rate of extended-spectrum beta-lactamase (ESBL) production was 44.6%. Antibiotic resistance in K. pneumoniae followed the pattern of all Gram-negative isolates. Antibiotic resistance was lower in NTS blood isolates, ranging between 16.7-38.9% resistance to the tested antibiotics. Resistance rates of 38.9%, 22.2%, and 27.8% were found for cefotaxime, ceftriaxone, and ceftazidime, respectively, and 27.8% and 23.8% for ciprofloxacin and azithromycin, respectively, which are used in the treatment of invasive NTS. The prevalence of multidrug resistance in NTS isolates was 38.9%. CONCLUSIONS: Multicenter AMR surveillance of Gram-negative blood isolates from febrile patients was well-received in Ghana, and the implementation of a harmonized protocol was feasible. High resistance and multidrug resistance to first- or second-choice antibiotics, including penicillins, third-generation cephalosporins, and fluoroquinolones, were found, implying that these antibiotics might have limited effectiveness in BSI treatment in the country. Continuation of AMR surveillance in Gram-negative blood isolates is essential for a better understanding of the extent of AMR in these pathogens and to guide clinical practice and policymaking.

Review of Israel's action and response during the COVID-19 pandemic and tabletop exercise for the evaluation of readiness and resilience-lessons learned 2020-2021.

Background: Reevaluating response plans is essential to ensuring consistent readiness and resilience to the COVID-19 pandemic. The "During Action Review" and Tabletop (DART) methodology provides a retrospective and prospective assessment to inform the adaptive response. Israel introduced COVID-19 vaccinations in December 2020 and was the first country to implement booster vaccination to address waning immunity and surges caused by new variants. We assessed Israel's readiness and resilience related to COVID-19 response while capturing the pre-vaccination and vaccination periods. Methods: A DART analysis was conducted between December 2020 and August 2021 among experts involved in the management of the COVID-19 pandemic in Israel. During the retrospective stage, a role-based questionnaire and discussions were undertaken in a participant-led review of the response, focusing on epidemiology and surveillance, risk communication, and vaccines. The prospective stage included tabletop exercises to evaluate short to long-term simulated scenarios. Results: Participants emphasized the pivotal role of Israel globally by sharing experiences with the pandemic, and vaccination. Perceived strengths included multi-sectoral collaboration between the Ministry of Health, healthcare providers, academia, military, and others, stretching capacities, expanding laboratory workload, and establishing/maintaining surveillance. The vaccine prioritization plan and strong infrastructure, including computerized databases, enabled real-life assessment of vaccine uptake and impact. Challenges included the need to change case definitions early on and insufficient staffing. Quarantine of patients and contacts was particularly challenging among underprivileged communities. Risk communication approaches need to focus more on creating norms in behavior. Trust issues and limited cooperation were noted, especially among ethnic and religious minorities. To ensure readiness and resiliency, participants recommended establishing a nationally deployed system for bringing in and acting upon feedback from the field, especially concerning risk communication and vaccines. Conclusion: Our study appraised strengths and weaknesses of the COVID-19 pandemic response in Israel and led to concrete recommendations for adjusting responses and future similar events. An efficient response comprised multi-sectoral collaboration, policy design, infrastructure, care delivery, and mitigation measures, including vaccines, while risk communication, trust issues, and limited cooperation with minority groups were perceived as areas for action and intervention.

Determinants of Direct Costs of HIV-1 Outpatient Care in Israel.

HIV-1 patients place an economic burden on the health system. The objectives of this study were to estimate the direct HIV-1 costs and cost-related factors of HIV-1 patients in Israel and identify cost predictors. We conducted a retrospective study of randomly selected HIV-1 patients aged ≥18 who visited a large outpatient clinic in 2015 and/or 2019. Yearly costs of physician and nurse visits, antiretroviral therapy (ART) and laboratory tests were calculated in USD using the 2020 purchasing power parities. Associations between disease characteristics and costs were analyzed using univariate and multivariable analysis. The median (IQR) total direct costs per patient per year were USD 12,387 (9813-14,124) and USD 12,835 (11,651-13,970) in 2015 (n = 284) and 2019 (n = 290), respectively. ART accounted for approximately 77% of all direct costs, followed by laboratory tests (20%) and medical visits (3%) in both studied years. Being female (USD +710), first yearly viral load <50 c/mL (+$1984) and ≥20 years with HIV-1 (USD +1056) were independently associated with higher costs. In conclusion, HIV-1 cost was stable in the studied period. Viral load and time since diagnosis were the major determinants associated with HIV-1 costs. ART and laboratory tests accounted for 97% of the costs. Therefore, these factors should be considered when planning future expenditures.

Organizational Commitment Is Negatively Associated with Burnout Among Nephrology Nurses.

This study examines the association between burnout and organizational commitment in nephrology nurses working in hemodialysis. A cross-sectional study of all nurses working in a hospital hemodialysis unit was conducted. Low to medium level of burnout and a high level of organizational commitment were documented. A significant negative correlation was found between burnout and organizational commitment. Burnout was significantly higher among nurses who had made a career shift in the past, and lower levels of burnout were documented among married nurses. In a multivariate analysis, lower levels of burnout and a higher number of children were significantly associated with higher organizational commitment. Burnout is a negative independent predictor for organizational commitment. Inter ventions focused on reducing burnout among nurses should be implemented to improve organizational commitment.

A nationwide analysis of population group differences in the COVID-19 epidemic in Israel, February 2020-February 2021.

BACKGROUND: Social inequalities affect the COVID-19 burden and vaccine uptake. The aim of this study was to explore inequalities in the incidence and mortality rate of SARS-CoV-2 infection and vaccine uptake in various sociodemographic and population group strata in Israel. METHODS: We analysed nationwide publicly available, aggregated data on PCR-confirmed SARS-CoV-2 infections and COVID-19 deaths between March 2020 and February 2021, as well as the first three months of COVID-19 immunisation according to sociodemographics, including population group and residential socioeconomic status (SES). We computed incidence and mortality rates of COVID-19. Comparisons between towns with predominantly Arab, ultra-Orthodox Jewish (the minorities), general Jewish populations, and according to SES, were conducted using generalised linear models with negative binomial distribution. FINDINGS: Overall, 774,030 individuals had SARS-CoV-2 infection (cumulative incidence 84•5 per 1,000 persons) and 5687 COVID-19 patients had died (mortality rate 62•8 per 100,000 persons). The highest mortality rate was found amongst the elderly. Most (>75%) individuals aged 60 years or above have been vaccinated with BNT162b2 vaccine. The risk of SARS-CoV-2 infection was higher in towns with predominantly Arab and ultra-Orthodox Jewish populations than in the general Jewish population, and in low SES communities. COVID-19 mortality rate was highest amongst Arabs. Conversely, vaccine uptake was lower amongst Arab and ultra-Orthodox Jewish populations and low SES communities. INTERPRETATION: Ethnic and religious minorities and low SES communities experience substantial COVID-19 burden, and have lower vaccine uptake, even in a society with universal accessibility to healthcare. Quantifying these inequalities is fundamental towards reducing these gaps, which imposes a designated apportion of resources to adequately control the pandemic. FUNDING: No external funding was available for this study.

Too Much Cancer Care?: Nurses' Perspectives on the Unnecessary Use of Oncology Services.

BACKGROUND: "Unnecessary use of health services" refers to care that does not add value for patients and can lead to physical, emotional, and economical harm. High rates of overuse have been reported within oncology, and patients experience its consequences. OBJECTIVE: The aim of this study was to explore perceptions and experiences of oncology nurses regarding unnecessary use of oncology services. METHODS: In-depth, semistructured interviews were conducted with a convenience sample of 20 oncology nurses currently practicing in Israel. Interviews were recorded, transcribed, and analyzed thematically. RESULTS: Themes included perceptions of unnecessary use of health services in cancer (causes and effects of unnecessary use, current and proposed solutions) and negative effects of unnecessary cancer care on patients, families, providers, and the system, including decreased quality of life, increased suffering, and emotional effects on patients and families. Causes were seen on provider, family, and patient levels, such as difficulty for providers to "give up," lack of registered nurses' authority, and family and patient demands. Multidisciplinary care provision, nurses' role, and the patient-provider relationship were seen as existing facilitators minimizing unnecessary use. Future improvement can be achieved by strengthening relationships, providing support to healthcare providers, and improving communication. CONCLUSIONS: Nurses perceive unnecessary use of health services as a result of multiple, interlinked and complex causes, but few targeted interventions exist. Future research should explore quantifying unnecessary use to determine an accurate representation of the issue. IMPLICATIONS FOR PRACTICE: Solutions should include engaging patients and families, involving nurses, and fostering multidisciplinary collaborative teamwork to positively affect care and treatment decision-making processes.

Understanding Physicians' Perceptions of Overuse of Health Services in Oncology.

Overuse rates in oncology are high, but areas of possible improvement exist for reducing it and improving quality of care. This study explores perceptions and experiences of oncologists in Israel regarding overuse of health services within oncology. In-depth, semistructured interviews were conducted focusing on causes of overuse, facilitators for reduction, and suggestions for improvement. Interviews were audio recorded, transcribed, coded, and thematically analyzed. Physicians reported patient-level causes including "well-informed" and "demanding" patients; physician-level causes including desire to satisfy patients, lack of confidence, time, and skills; and system-level causes like ease of access, and lack of alignment and coordination. Physicians can reduce overuse through patient dialogue, building trust and solidifying patient-physician relationships, and further reduce overuse with better teamwork. Improvements can be made through educational initiatives, and bottom-up solutions. Policy makers and decision makers should develop appropriate interventions addressing health service overuse, including improving patient education and instilling confidence and knowledge in physicians.

Exploring community healthcare providers' perceptions on antimicrobial resistance.

OBJECTIVES: Antimicrobial resistance (AMR) is a threat to global health, making previously curable diseases disabling or incurable. Human misuse of antimicrobials exacerbates the issue. As stewards to the public and prescribers of antimicrobials, healthcare providers are vital to reducing AMR, thus their perceptions and experiences around the issue must be explored. This study aimed to understand the perceptions of community nurses and physicians regarding the causes of AMR as well as barriers and facilitators to addressing it. METHODS: In-depth, semi-structured interviews were conducted to understand the perceptions of nurses and physicians on these issues. RESULTS: Overall, participants expressed that both environmental and human causes at various levels contribute to AMR. Whilst most themes were discussed by both healthcare practitioner groups, nurses more frequently mentioned patient causes and patient education compared with physicians. Participants also reflected on facilitators to reduce AMR, including guidelines, patient and provider education, and top-down and bottom-up initiatives. Identified barriers included patient demands, physician pressures and fears, and systemic overworking of physicians. CONCLUSION: This study demonstrated numerous factors underpinning AMR and many barriers to addressing it, hence a multifaceted approach is required. This work also offers insight on how different groups can be utilised or will react to interventions.

Nurses' Perceptions on the Overuse of Health Services: A Qualitative Study.

PURPOSE: To examine whether nurses in Israel think there is overuse of health services, the reasons behind the issue, and ways to reduce the overuse. DESIGN: This was a qualitative study using semistructured interviews. A convenience sample of community care nurses from health clinics across Israel was interviewed. Interviews focused on common areas of overuse, outcomes of overuse, causes of overuse, and potential ways to address the issue. Interviews were recorded, transcribed, and analyzed thematically. FINDINGS: Overuse of antibiotics, imaging, blood tests, and prenatal surveillance were cited as main areas of health service overuse. Participants stated that negative outcomes of overuse could be seen at patient, health system, and population levels. Factors influencing overuse included patient satisfaction, physician fears, and insecurities. Potential interventions included improving physicians' diagnostic confidence, increasing appointment times, providing patients with more treatment information, and implementing a unified computerized system across medical institutions. CONCLUSIONS: Nurses mentioned physicians and patients as main actors in influencing overuse; hence, those populations should be researched further. The health system was identified as the responsible party to address the issue. Health system leaders must consider potential barriers, and investigate interventions that match current culture and context within the health system. CLINICAL RELEVANCE: Nurses can play an essential role in limiting overuse and mitigating subsequent harms to patients.