Search

Copyright of Notfall & Rettungsmedizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Cathal O’Cionnaith,1 Anne PF Wand,1– 3 Carmelle Peisah3,4 1Older Persons Mental Health Service, Jara Unit, Concord Centre for Mental Health, Concord Repatriation General Hospital, Concord, NSW, Australia; 2Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; 3Discipline of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; 4Capacity Australia, Crows Nest, NSW, AustraliaCorrespondence: Anne PF WandOlder Persons Mental Health Service, Jara Unit, Concord Centre for Mental Health, Concord Repatriation General Hospital, 109 Hospital Road, Concord, NSW, 2139, AustraliaTel +61297678940Fax +61297678944Email a.wand@unsw.edu.auPurpose: The purpose of this case series is to illustrate the complexity of considerations across health (physical and mental), ethical, human rights and practical domains when an older adult with chronic symptoms of mental illness refuses treatment for a serious medical comorbidity. A broad understanding of these considerations may assist health care professionals in navigating this challenging but common aspect of clinical practice.Case Presentation: Three detailed case reports are described. Participants were older adults with an acute presentation of a chronic mental illness, admitted to a specialized older persons mental health inpatient unit (OPMHU) in an Australian metropolitan hospital. Significant comorbid medical issues were detected or arose during the admission and the patient refused the recommended medical intervention. Data extracted from patients’ medical records were analyzed and synthesized into detailed case reports using descriptive techniques. Each patient was assessed as lacking capacity for healthcare and treatment consent and did not have relatives or friends to assist with supported decision-making. Multifaceted aspects of decision-making and management are highlighted.Conclusion: There are multiple complex issues to consider when an older adult with chronic symptoms of mental illness refuses treatment for serious comorbid medical conditions. In addition to optimizing management of the underlying mental illness (which may be impairing capacity to make healthcare decisions), clinicians should adopt a role of advocacy for their patients in considering the potential impact of ageism and stigma on management plans and inequities in physical healthcare. Consultation with specialist medical teams should incorporate multifaceted considerations such as potentially inappropriate treatment and optimum setting of care. Equally important is reflective practice; considering whether treatment decisions may infringe upon human rights or cause trauma.Keywords: treatment refusal, human rights, capacity, ageism, psychiatric

Treatment discontinuation within Early Intervention Services (EIS) for psychosis poses a significant challenge to achieving better outcomes in the early stages of psychotic disorders. Prevalence and predictors of early disengagement from EIS located in low- and middle-income countries (LMICs) remain poorly investigated. We aimed to examine the rates and predictors of disengagement from the Ribeirão Preto Early Intervention Program for Psychosis (Ribeirão Preto-EIP) in Brazil. We conducted a retrospective cohort study using data from patients referred to the Ribeirão Preto-EIP between January 01, 2015, and December 31, 2018. Exclusion criteria were individuals with a single consultation, a diagnosis other than a psychotic disorder, and documented cases of death. Our sample comprised 234 patients, with an overall median follow-up time of 14.2 months. Early treatment disengagement was observed in 26.5 % (n=62), with a median time to disengagement of 5.25 months. Univariable analysis identified non-white skin color (HR=2.10, 95 %CI 1.26–3.49), positive THC screening (HR=2.22, 95 %CI 1.23–4.01), and substance-induced psychosis (HR=2.15, 95 %CI 1.10–4.21) as significant predictors. In multivariable analysis, only non-white skin color remained a significant predictor of early disengagement (HR=1.87, 95 %CI 1.08–3.27). The observed rates of early disengagement in our sample are similar to those reported in wealthy countries, but higher than previously reported for LMICs. Non-white skin color predicted early disengagement in our sample, probably due to social disadvantages. Our data highlights the need for enhanced research elucidating the specific features of EIS in LMICs. • One-fourth of patients disengaged earlier than recommended. • Those who disengaged had a median follow-up of 13.5 months shorter. • The main predictor of early disengagement was non-white skin color. [ABSTRACT FROM AUTHOR]

Background: Patients with anorexia nervosa (AN) often refuse treatment despite their extremely low nutritional status. This study investigated the methods of assessing the mental capacity of patients with anorexia nervosa (AN) who refuse treatment by physicians in Japan, the United Kingdom (UK), and the United States (USA). It also identified the key points of the assessment. Methods: A questionnaire survey using a case vignette was conducted among physicians (Japan, n = 53; UK, n = 85; USA, n = 85) who treat eating disorders. Results: A total of 23% of physicians in Japan, 32% in the UK, and 35% in the USA reported that they believe patients with AN lack the capacity to make appropriate decisions. Physicians who considered patients with AN to have an impaired mental capacity placed significantly more emphasis on the level of psychopathological values, which are values caused by AN (and can be changed by recovery) that affect the ability to be rational, when assessing the mental capacity of these patients. Conversely, physicians who considered patients with AN to have full mental capacity placed significantly more weight on the ability to express a choice or preference. Conclusions: It may be necessary to add the level of psychopathological values to the assessment of the mental capacity in relation to obesity fears and emotional disturbances of Patients with AN because emotions caused by psychopathological values strongly influence decision-making. By considering the level of psychopathological values, it may be feasible to reflect the actual situation during the assessment of the mental capacity of those who refuse AN treatment, thus making it more likely to overcome ethical dilemmas. Plain English summary: This study investigated the method of assessing the mental capacity of anorexia nervosa (AN) patients who refuse treatment in Japan, the United Kingdom, and the United States. Approximately one-third of clinicians who assessed patients with AN declared that those patients showed impaired decision-making capacity when refusing treatment. Clinicians who considered patients with AN to have impaired decision-making ability tended to focus on the level of psychopathological values when assessing their mental capacity. [ABSTRACT FROM AUTHOR]

Background: This study investigated the attitudes of physicians in Japan, the United Kingdom (UK), and the United States (US) toward refusal of treatment for anorexia nervosa. Methods: A questionnaire survey was administered to physicians treating patients with eating disorder (Japan, n = 55; UK, n = 84; US, n = 82) to evaluate their treatment strategies for fictitious cases of refusal of treatment for anorexia nervosa. Results: For acute patients, 53 (96.3%) physicians in Japan, 65 (77.4%) in the UK, and 54 (65.9%) in the US chose compulsory treatment if the patient's family requested treatment, while 46 (83.6%) physicians in Japan, 53 (63.1%) in the UK, and 47 (57.3%) in the US chose compulsory treatment if the family left the decision to the patient. For severe and enduring anorexia nervosa, 53 (96.3%) physicians in Japan, 62 (73.8%) in the UK, and 57 (69.5%) in the US chose compulsory treatment if the patient's family requested treatment, while 38 (69.1%) physicians in Japan, 56 (66.7%) in the UK, and 55 (67.1%) in the US chose compulsory treatment if the family left the decision to the patient. Conclusions: Physicians in all three countries tended to choose compulsory treatment irrespective of disease duration or whether the patient's family requested treatment or not. This may indicate that medical practitioners value the ethical obligation of beneficence, giving priority to the protection of life. Attitudes toward refusal of treatment during a life crisis tend to vary among medical professionals, particularly if the patient's family does not request treatment. Plain English summary: This study aimed to investigate the attitudes of physicians in Japan, the UK, and the US toward refusal of treatment for anorexia nervosa. Physicians in all three countries received an anonymous questionnaire comprising four fictitious cases for which they had to respond whether they would choose compulsory inpatient treatment or not. The study revealed that in all three countries, compulsory treatment tended to be the prevalent choice in cases of life-threatening malnutrition, regardless of the patient's age or duration of illness. Moreover, in all the three countries, treatment tended to be forced if a family member requested treatment, and this trend was particularly strong in Japan. The influence of family request was stronger for acute AN in the U.K. and the U.S., and for SE-AN in Japan. [ABSTRACT FROM AUTHOR]

Background: In 2016, the Act on Decisions on Life‐Sustaining Treatment for Patients in Hospice and Palliative Care was implemented in Korea, providing a broad framework for end‐of‐life decision‐making for the first time and making advance directives legally recognized documents. This Act can correct long‐standing under‐recognition of patients as valid decision makers for their own treatment choices. However, limited recognition of patient self‐determination, rigid legal forms for documenting patient wishes, and the roles of family under the Act may pose challenges both to patients and nurses. Aim: This paper critiques whether this newly introduced system of advance directives can truly guarantee protection of the patient's interests and respect for patient autonomy in real life​, and discusses ethical and legal issues regarding the Act. Source of evidence: We reviewed the current system of advance directives by raising three questions: (1) Do advance directives reflect a competent person's voluntary and informed choice?, (2) Are advance directives applicable in diverse clinical situations?, and (3) Does the Korean advance directive system ensure that such directives are honored in reality? Conclusion: Although the Act is an important first step in respecting patient autonomy in end‐of‐life decision‐making, it remains inadequate as it fails to provide thorough guidance in terms of the quality of writing process, applicability, and the guaranteed effects of advance directives. Implications for nursing and health policy: As nurses are best situated for addressing these limitations due to their roles and competencies in clinical practice, expanding the roles of nurses in every stage of advance directive practice could help achieve the original purpose of advance directives. This calls for a policy that promotes an expanded role of nurses to improve the quality of advance directive practice. [ABSTRACT FROM AUTHOR]

Objective: The development of new injectable antiretroviral therapy facilitates treatment for Human immunodeficiency virus (HIV) positive individuals who lack capacity to consent, posing a safety risk to both themselves and the wider community. We consider pathways to enforce treatment and propose an algorithm to determine the most appropriate legal instrument for application. Conclusion: Legislative safeguards in mental health and guardianship legislation provide oversight and protection for those who suffer from illness and require coercive treatment. These frameworks have utility in the treatment of HIV patients who lack capacity to consent to treatment. [ABSTRACT FROM AUTHOR]

BackgroundThe COVID-19 pandemic has resulted in treatment interruption for chronic diseases. The scale of COVID-19 in Japan has varied greatly in terms of the scale of infection and the speed of spread depending on the region. This study aimed to examine the relationship between local infection level and treatment interruption among Japanese workers.MethodsCross-sectional internet survey was conducted from December 22 to 26, 2020. Of 33,302 participants, 9,510 (5,392 males and 4,118 females) who responded that they required regular treatment were included in the analysis. The infection level in each participant's prefecture of residence was assessed based on the incidence rate (per 1,000 population) and the number of people infected. Age-sex and multivariate adjusted odds ratios (ORs) of regional infection levels associated with treatment interruption were estimated by multilevel logistic models, nested by prefecture of residence. The multivariate model was adjusted for sex, age, marital status, equivalent household income, educational level, occupation, self-rated health status and anxiety.ResultsThe ORs of treatment interruption for the lowest and highest levels of infection in the region were 1.32 [95 % confidence interval (CI) were 1.09–1.59] for the overall morbidity rate (per 1,000) and 1.34 (95 % CI 1.10–1.63) for the overall number of people infected. Higher local infection levels were linked to a greater number of workers experiencing treatment interruption.ConclusionsHigher local infection levels were linked to more workers experiencing treatment interruption. Our results suggest that apart from individual characteristics such as socioeconomic and health status, treatment interruption during the pandemic is also subject to contextual effects related to regional infection levels. Preventing community spread of COVID-19 may thus protect individuals from indirect effects of the pandemic, such as treatment interruption.

nema

• In the Americas, structural barriers to treatment are more common in LMICs than HICs. • 43% of those that did not access treatment did not perceive treatment need. • Severity is correlated to higher structural but lower attitudinal barriers. • There are few country-specific variations in the region, mostly from Argentina. Mental health treatment is scarce and little resources are invested in reducing the wide treatment gap that exists in the Americas. The regional barriers are unknown. We describe the barriers for not seeking treatment among those with mental and substance use disorders from six (four low- and middle-income and two high-income) countries from the Americas. Regional socio-demographic and clinical correlates are assessed. Respondents (n = 4648) from seven World Mental Health surveys carried out in Argentina, Brazil, Colombia, Mexico, Peru, and the United States, who met diagnostic criteria for a 12-month mental disorder, measured with the Composite International Diagnostic Interview, and who did not access treatment, were asked about treatment need and, among those with need, structural and attitudinal barriers. Country-specific deviations from regional estimates were evaluated through logistic models. In the Americas, 43% of those that did not access treatment did not perceive treatment need, while the rest reported structural and attitudinal barriers. Overall, 27% reported structural barriers, and 95% attitudinal barriers. The most frequent attitudinal barrier was to want to handle it on their own (69.4%). Being female and having higher severity of disorders were significant correlates of greater perceived structural and lower attitudinal barriers, with few country-specific variations. Only six countries in the Americas are represented; the cross-sectional nature of the survey precludes any causal interpretation. Awareness of disorder or treatment need in various forms is one of the main barriers reported in the Americas and it specially affects persons with severe disorders. [ABSTRACT FROM AUTHOR]

Economic motivations are key drivers of human behavior. Unfortunately, they are largely overlooked in literature related to medical decisionmaking, particularly with regard to end-of-life care. It is widely understood that the directions of a proxy acting in bad faith can be overridden. But what of cases in which the proxy or surrogate appears to be acting in good faith to effectuate the patient's values, yet doing so directly serves the decision-maker's financial interests? Such situations are not uncommon. Many patients care as deeply about economic wellbeing of their families as they do for their own lives and health. This brief work examines three scenarios that raise ethical issues regarding the role of pecuniary motives in making critical medical decisions. Each scenario presents a potential financial conflict of interest between an incapacitated patient and a third-party decision-maker and offers a framework for integrating ethical and legal concerns into clinical care. It is our hope that this work prepares physicians for unexpected ethical conflicts of interest and enables them to further the interests of his or her patients. [ABSTRACT FROM AUTHOR]

Objective: U.S. opioid overdoses increased nearly sixfold from 1999 to 2018, and greater than 1% of all emergency medical services (EMS) encounters now involve naloxone administration. While "treat and release" protocols may have low short-term mortality, the risk of subsequent non-fatal overdoses is not known. This study compares the risk of repeat overdose encounters between patients transported to an emergency department (ED) and those who refused transport after prehospital naloxone administration. Methods: All EMS charts within a large single-tier fire-based urban EMS system between January 1 and August 31, 2018 were reviewed if either naloxone administration or a clinical impression related to opioid overdose was documented. Charts were excluded if there was no documented evidence of an opioid toxidrome (respiratory depression or altered mental status), if there was another clear explanation for the symptoms (e.g., hypoglycemia), or if naloxone was not administered. Ten percent of charts were reviewed by a second author to assess reliability. Cox regression (survival analysis) was used to estimate the risk of a subsequent EMS encounter with naloxone administration following an index encounter with naloxone administration. Results: Of the 2143 charts reviewed, 1311 unique patients with 1600 overdose encounters involving naloxone administration were identified. Inter-rater reliability for chart inclusion was strong [κ = 0.83 (95% CI: 0.72–0.90)]. Police/bystanders administered naloxone in 208/1600 (13.0%) encounters. A substantial proportion of encounters resulted in transport refusal (674/1600, 42.1%). The final Cox model included only refusal vs. acceptance of transport to an ED during the index EMS encounter. Patient age, gender, and naloxone administration prior to EMS arrival were not statistically significant in univariate or multivariable analyses, nor were they significant confounders. Refusal of transport was associated with a hazard ratio of 1.66 (95% CI: 1.23–2.23) for subsequent EMS encounters with naloxone administration. Conclusions: Non-transport after prehospital naloxone administration is associated with an increased risk of subsequent non-fatal overdose requiring EMS intervention. Limitations include the use of a single EMS agency as patients may have had uncaptured overdose encounters in neighboring municipalities. [ABSTRACT FROM AUTHOR]

Objective: To address frequently asked questions regarding the use of the Guardianship Act, the Mental Health Act and the Public Health Act within New South Wales EDs and present an algorithm to guide the use of this legislation. Methods: An ED‐specific algorithm was developed for the use of the three pieces of legislation. Then an emergency psychiatrist and an emergency physician reviewed the algorithm with ED staff to understand its usefulness and where further detail was required. Frequently asked questions were collated. Results: Frequently asked questions are addressed with reference to the algorithm. Conclusion: This paper offers an algorithm that can be easily followed for use in EDs across New South Wales. [ABSTRACT FROM AUTHOR]

Background: Despite some insurance plans now paying for home-based palliative care, recent reports have suggested that insurance coverage for palliative care may be insufficient in expanding patient access to home-based palliative care. Aim: To identify patients' and caregivers' perceived barriers to home-based palliative care and their recommendations for overcoming these barriers. Design: We conducted a qualitative study using semi-structured individual interviews. Our interview protocol elicited participants' perspectives on home-based palliative care services; positive and negative aspects of the palliative program explanation; and suggestions for improving messaging around home-based palliative care. Setting/Participants: Twenty-five participants (patients, proxies, and their caregivers) who were eligible for a randomized controlled trial of home-based palliative care were interviewed by telephone. Results: Themes related to home-based palliative care referral barriers included reluctance to have home visits, enrollment timing, lack of palliative care knowledge, misconceptions about palliative care, and patients' self-perceived health condition. Themes related to recommendations for overcoming these obstacles included ensuring that palliative care referrals come from healthcare providers or insurance companies and presenting palliative care services more clearly. Conclusion: Findings reinforce the need for additional palliative care education among patients with serious illness (and their caregivers) and the importance of delivering palliative care information and referrals from trusted sources. [ABSTRACT FROM AUTHOR]

The ethical challenges of pediatric cancer care across Arab countries are not well addressed, despite medical advancements and increased awareness of children’s rights. The ethical challenges related to pediatric cancer in Saudi Arabia were investigated by surveying 400 respondents at King Abdulaziz Medical City in Riyadh, Jeddah, and Dammam, Saudi Arabia, from four groups: pediatricians, medical students, nurses, and parents of children with cancer. Respondents’ characteristics were surveyed across three outcomes: awareness of care, knowledge, and parent consent/child assent, developed from a systematic review and a qualitative analysis. A majority of respondents (89.0%) considered pediatric cancer different from adult cancer. Families considered alternative treatment, according to 64.3% of respondents, while 88.0% emphasized understanding the family’s needs and values. Furthermore, 95.8% of respondents believed physicians should offer time for pedagogy, 92.3% viewed parental consent as essential, and 94.5% thought that sufficient discussion about the plan and type of treatment should precede consent. However, child assent showed lower levels of agreement, with only 41.3% and 52.5% agreeing with getting child assent and having a discussion. Finally, 56% agreed that parents might refuse suggested treatment, while only 24.3% agreed that the child could refuse it. In all these ethical considerations, nurses and physicians showed significantly more positive results compared with other groups.

Choriocarcinoma is characterized as the most aggressive malignant alternation of gestational trophoblastic neoplasm; however, this illness is a curable malignancy. Although a rarity, this disease affects a female patient's life and causes a fatal condition. Choriocarcinoma is a life-threatening disease since it is initially insidious and can rapidly lead to masive hemorrhage, even death. Choriocarcinoma should be suspected in childbearing-age women with the high-risk scores according to FIGO. The study aims to report a severe case of widespread metastatic choriocarcinoma to optimize the treatment with multiagent chemotherapy and a multidisciplinary cooperation at our center. A G1P0 20-year-old woman was referred to the hospital for suspicion of metastatic choriocarcinoma after self-stopping chemotherapy because of the COVID-19 pandemic. During hospitalization, the tumor metastasized and presented profuse intraabdominal hemorrhage. The patient underwent immediate surgical intervention to control bleeding, and a definitive diagnosis was accurately established by the histopathological examination. After surgery, the EMA/CO regimen was administered as the first line of treatment, despite the patient being in a coma and requiring a ventilator machine. After 6 cycles of the EMA/CO regimen, her serum β-hCG level decreased to 8 mUI/mL, however, her β-hCG concentration was not down to a negative value. Thus, the patient received paclitaxel/cisplatin alternating with paclitaxel/etoposide (TP/TE regimen) for complete remission following 2 cycles. The delays in choriocarcinoma treatment are prognostic factors for worse outcomes, whereas chemotherapy may be considered a suitable treatment even in a patient's coma, thus improving a prognosis substantially.

Objectives: End-stage renal disease is a health concern around the world. Kidney transplant substantially improves survival compared with dialysis. Although kidney transplant is the better choice for treatment of end-stage renal disease, most patients refuse this option. In this study, we aimed to find the most common reasons why patients did not undergo a kidney transplant., Materials and Methods: We conducted a cross-sectional study involving 263 patients on chronic hemodialysis in hemodialysis centers in Shiraz, Iran, in 2024. We collected data via structured interviews, which had questions on demographics, disease characteristics, dialysis details, and reasons for transplant refusal. P < .05 was considered significant., Results: In our study cohort, mean age was 60.2 ± 16.8 years and 57.8% were male patients. The most prevalent reason for refusing kidney transplant was patient-centric barriers for kidney transplant (47.7%); difficulties with the transplant process included financial concern (33.7%), unacceptability of outcomes (30.2%), and worries about the unpredictability of transplant outcome (24.1%). The mean age of patients on the kidney transplant waiting list was 51.7 ± 16.4 years, and mean age of those who declined a kidney transplant was 60.2 ± 16.8 years (P < .001). Among patients on the waiting list, 68.7% were married compared with 81.7% of patients who declined a kidney transplant (P = .011)., Conclusions: Addressing financial concerns by possibly improving insurance coverage, enhancing patient education on transplant benefits and risks, and providing psychological support can potentially increase acceptance rates. Tailored interventions focusing on individual patient concerns and improving communication between health care providers and patients are essential.

Bariatric surgery has become a leading treatment for obesity, with techniques such as Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) demonstrating notable success in sustained weight loss and improved quality of life. Technological advancements and improved techniques have enhanced the safety of these procedures. The surgical procedures of Jehovah's Witnesses, who refuse blood transfusions as part of their beliefs, pose unique challenges and have rarely been addressed in the context of bariatric surgery. This report aimed to investigate the safety of bariatric surgery in patients who refuse blood transfusion, with an established protocol to minimize the risk of bleeding. We examined the prospectively collected data of Jehovah's Witness patients who underwent bariatric surgery from 2019 to 2023. The surgeries were conducted following a protocol that included specific measures to prevent bleeding. Data were reviewed for demographics, anthropometrics, comorbidities, preoperative medications, operative time, blood loss, length of hospital stay, hemoglobin level, drainage volume, tranexamic acid use, and postoperative 30-day complications. Eleven Jehovah's Witness patients underwent bariatric surgery, including 10 LSG and 1 LRYGB. A patient with iron deficiency anemia underwent intravenous iron treatment before the surgery. There were no intraoperative complications or major postoperative complications. All patients maintained stable hemodynamics postoperatively. Only one patient encountered nausea-vomiting, classified as a minor complication. One patient experienced a small amount of hemorrhagic drainage, which transitioned to serous after tranexamic acid infusion. Bariatric surgery can be performed safely with established protocols in patients who refuse blood transfusions., (© 2024. The Author(s).)

AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient's court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient's choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.

Patients who discharge themselves against medical advice comprise 1%-2% of hospital admissions. Discharge against medical advice (DAMA) is defined as when a hospitalised patient chooses to leave the hospital before the treating medical team recommends discharge. The act of DAMA impacts on both the patient, the staff and their ongoing care. Specifically, this means that the patient's medical problems maybe inadequately assessed or treated. Patients who decide to DAMA tend to be young males, from a lower socioeconomic background and with a history of mental health or substance misuse disorder. DAMA has an associated increased risk of morbidity and mortality. In this review of studies across Western healthcare settings, specifically adult medical inpatients, we will review the evidence and seek to address the causes, consequences and possible corrective measures in this common scenario.

Vitamin K is an essential dietary cofactor required for the synthesis of active forms of vitamin K-dependent procoagulant proteins. Vitamin K deficiency, particularly late-onset deficiency occurring between 1 week and 6 months of age, can cause a life-threatening bleeding disorder. An exclusively breastfed, full-term, 6-week-old infant male presented with severe haemorrhagic shock and multi-system organ failure related to caregiver refusal of intramuscular vitamin K after birth. Coagulation studies were normalised within 8 hours of intramuscular vitamin K administration. An increasing number of caregivers are refusing intramuscular vitamin K which has led to a rise in the incidence of vitamin K deficiency bleeding. Health policy organisations around the world emphasise the benefits of intramuscular vitamin K and risks of refusal, particularly in exclusively breastfed infants who are at higher risk due to low vitamin K levels in breast milk. This case highlights the multi-system severity of this life-threatening yet preventable disorder., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To review and synthesise the contemporary qualitative evidence, relating to the individual, healthcare professional and system‐level barriers and facilitators to injectable therapies in people with type 2 diabetes, and evaluate (using an intersectional approach to explore the diverse perspectives of different identities) whether views have changed with treatment and guideline advancements. Methods: A meta‐ethnography approach used. Eight databases searched from the years 2006 (GLP‐1 analogues introduced) to February 2021. Study selection (using a pre‐defined inclusion criteria), quality appraisal and data extraction, conducted independently by two reviewers. Results: Screened 7143 abstracts, assessed 93 full‐text papers for eligibility and included 42 studies—using data from 818 individuals with type 2 diabetes and 160 healthcare professionals. Studies covered a diverse range of views from healthcare professionals and individuals, including those relating to older adults and people from ethnic migrant backgrounds, and 10 studies rated moderate to strong research value. Key themes abstracted: barriers (physical/psychological/social) and facilitators (motivation/capability/opportunity). Conclusions: The first synthesis of contemporary qualitative data to adopt an intersectionality approach and explore diverse views relating to barriers and facilitators that influence engagement with injectable treatments for type 2 diabetes. A model is presented to help patients, health practitioners and policy makers identify barriers and facilitators and understand the complex interplay of physical, psychological and social factors involved when prescribing injectable therapies. Despite advances in injectable treatments and guidelines, findings highlight the many barriers that still exist and show how strongly held culturally‐specific health beliefs of people from diverse socio‐economic and ethnic backgrounds can become substantial obstacles to treatment. [ABSTRACT FROM AUTHOR]

Issues: Early discharges, also known as 'against medical advice' discharges, frequently occur in inpatient withdrawal management settings and can result in negative outcomes for patients. The purpose of this scoping review is to identify what is known about predictors of and reasons for the early discharge among adults accessing inpatient withdrawal management settings.Approach: MEDLINE, CINAHL, PsycINFO, ASSIA and EMBASE were searched, resulting in 2587 articles for screening. Title and abstract screening and full-text review were completed by two independent reviewers. Results were synthesised in quantitative and qualitative formats.Key Findings: Sixty-two studies were included in this scoping review. All studies focused on predictors of early discharge, except one which only described reasons for the early discharge. Forty-eight percent of studies involved retrospective review of health records data. The most frequently examined variables were demographics. Variables related to the treatment setting, such as referral source and treatment received, were examined less frequently but were more consistently associated with early discharge compared to demographics. Only six studies described patient reasons for the early discharge, which were retrieved via clinical documentation. The most common reasons for early discharge were dissatisfaction with treatment and family issues.Implications and Conclusions: Most demographic variables do not consistently predict early discharge, and reasons for early discharge are not well understood. Future studies should focus on the predictive value of non-patient-level variables, or conduct analyses to account for predictors of early discharge among different subgroups of people (e.g. by gender or ethnicity). Qualitative research exploring patient perspectives is needed. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To compile the instruments validated in Brazil for assessing adherence of people living with HIV to antiretroviral therapy. METHODS: Scoping review using the Web of Science, Scopus, Medline (via PubMed), Embase, BDENF, CINAHL and Lilacs databases. In addition, the Preprints bioRxiv, Google Scholar and OpenGrey servers were checked. There was no language restriction for the search, and it considered articles published from the year 1996 onwards. RESULTS: Three publications were included in the qualitative synthesis. Following were the instruments identified "Questionário para Avaliação da Adesão ao Tratamento Antirretroviral" (Questionnaire for Assessment of Adherence to Antiretroviral Treatment) developed in Porto Alegre (RS) and published in 2007; the "Escala de autoeficácia para adesão ao tratamento antirretroviral em crianças e adolescentes com HIV/Aids" (Self-efficacy Scale for Adherence to Antiretroviral Treatment in Children and Adolescents with HIV/Aids) developed in São Paulo (SP) and published in 2008; and the "WebAd-Q, um instrumento de autorrelato para monitorar a adesão à terapia antirretroviral em serviços de HIV/Aids no Brasil" (WebAd-Q, a self-report instrument to monitor adherence to antiretroviral therapy in HIV/Aids services in Brazil) developed in São Bernardo do Campo (SP) and published in 2018. The instruments were validated in Brazil, and presented statistically acceptable values for psychometric qualities. CONCLUSION: The instruments to assess adherence of people living with HIV to antiretroviral therapy are validated strategies for the Brazilian context. However, their (re) use in different settings and contexts of the nation should be expanded. The use of these instruments by health professionals can improve the understanding of factors that act negatively and positively on antiretroviral therapy adherence, and the proposition of strategies intended to consolidate good adherence and intervene in the treatment of people with low therapeutic engagement. [ABSTRACT FROM AUTHOR]

It is unknown if changes in the rate of discharges against medical advice (DAMA) are related to the implementation of the Medicare Hospital Readmissions Reduction Program (HRRP). We performed an interrupted time series analysis of monthly DAMA rates per 1,000 discharges of all enrolled individuals 18–64 years old with a hospitalization between January 1, 2006, and December 31, 2015, in a commercially insured population. We performed a segmented linear regression with two interruptions: (1) April 2010 to coincide with the passage of the HRRP and (2) October 2012 to coincide with the implementation of HRRP penalties. There were 1,087,812 discharges representing 668,823 individuals over 120 months. The downward trend in monthly DAMA rates was reversed significantly after April 2010 with a sustained 0.1 increase in the monthly rate that continued after the implementation of penalties in October 2012. Allowing for the two interruptions, there was a statistically significant positive trend (0.10; 0.06–0.13, p <.01) in April 2010. Relative to the first interruption, there was no statistically significant change in the slope in October 2012; the estimated slope was −0.04 (−0.08 to 0.002). Monthly DAMA rates increased in anticipation of and after HRRP implementation, suggesting a potential relationship between the HRRP and DAMA. [ABSTRACT FROM AUTHOR]

Background: Patient suitability has been suggested to predict treatment non-attendance but information on its effect is limited.Aim: To study the prediction of the Suitability for Psychotherapy Scale (SPS), on occurrence of treatment non-attendance.Methods: Altogether 326 outpatients, with depressive or anxiety disorder, were randomized to short-term psychodynamic psychotherapy (SPP), long-term psychodynamic psychotherapy (LPP), and solution-focused therapy (SFT). SPS was based on seven components from three suitability domains: nature of problems, ego strength, and self-observing capacity. Treatment non-attendance was defined as refusal of engaging therapy and of premature termination. The Cox model and logistic regression were used.Results: Treatment non-attendance was significantly more common in LPP patients with poor SPS (RR = 2.76, 95% CI = 1.45-5.26). This was mainly due to poor flexibility of interaction, poor self-concept, and poor reflective ability. Premature termination in SFT showed a similar trend but due to other SPS components: absence of a circumscribed problem, poor modulation of affects, and poor response to trial interpretation. On the contrary, individuals with good values of SPS were more prone to premature termination in SPP.Limitations: The prediction of suitability on refusal could only be studied in the LPP group due to few refusals in the short-term therapy groups. The sample consisted of patients who participated in a trial. Thus the findings may not be directly generalized to unselected patients in the public mental health setting.Conclusions: Poor suitability, apparently, predicts non-attendance in LPP and SFT, but not in SPP. More studies on large cohorts are needed. [ABSTRACT FROM AUTHOR]

IntroductionOver the past decade, there has been a sharp increase in the number of newly identified synthetic drugs. These new drugs are often derivatives of previously abused substances but have unpredictable toxicity. One of these drugs is gacyclidine, a derivative of phencyclidine (PCP). Gacyclidine has been studied as a neuroprotective agent in trauma and as a therapy of soman toxicity. There are no previous reports of its use as a drug of abuse.Case reportsDuring a two-month period in the summer of 2013, a series of patients with severe agitation and end-organ injury were identified in an urban academic Emergency Department (ED). A urine drug of abuse screen was performed on all patients, and serum samples were sent for comprehensive toxicology analysis. A total of five patients were identified as having agitation, rhabdomyolysis, and elevated troponin (Table 1). Three of the five patients reported use of methamphetamine, and all five patients had urine drug screens positive for amphetamine. Comprehensive serum analysis identified methamphetamine in three cases, cocaine metabolites in one case, and a potential untargeted match for gacyclidine in all five cases. No other drugs of abuse were identified.DiscussionThis is the first series of cases describing possible gacyclidine intoxication. The possible source of the gacyclidine is unknown but it may have been an adulterant in methamphetamine as all patients who were questioned reported methamphetamine use. These cases highlight the importance of screening for new drugs of abuse when patients present with atypical or severe symptoms. Gacyclidine has the potential to become a drug of abuse both by itself and in conjunction with other agents and toxicity from gacyclidine can be severe. It is the role of the medical toxicology field to identify new agents such as gacyclidine early and to attempt to educate the community on the dangers of these new drugs of abuse.

Cancer patients are interested in complementary and alternative therapies. Providing complementary therapies to them should be based on the four principles of medical ethics. Ignoring these principles creates many ethical challenges in treating these patients. Shared decision-making between physician and patient is essential for the choice of complementary therapies. The use of complementary medicine that does not have the evidence on effectiveness causes that shared decision-making is not based on precise information, and therefore, patient autonomy is not achieved. When the conventional treatment of a cancer patient is replaced by a treatment for which there is no evidence of effectiveness, the principle of beneficence is violated. Failure to follow the basic standards of care in the provision of complementary medicine causes the patient to face profound side effects, indicating a lack of compliance with the principle of nonmaleficence. In the moral analysis of two patients’ treatment, we encounter violations of the principles of medical ethics. The traditional doctor must fully observe the principles of medical ethics in caring for their patients. The need for this is especially significant in patients with complex and severe disease.

Background: Completion of surgical resection and adjuvant/neoadjuvant treatments (chemotherapy, radiation, and endocrine therapy) is necessary to achieve optimal outcomes in invasive breast cancer. The objective of this study was to determine the characteristics of patients refusing treatment and to analyze the impact of refusal on survival.Study Design: A retrospective cohort study of invasive breast cancer cases diagnosed 2004-2016 was performed utilizing the National Cancer Database.Results: Of 2 058 568 cases comprising the study cohort, .6% refused recommended surgery, 14.1% refused chemotherapy, 5.5% refused radiation, and 6.3% refused endocrine therapy. Patients refusing therapy were older and more likely uninsured; they did not live farther from the treating hospital. Racial disparities were also associated with refusal. Surgery refusal had the highest hazard ratio for mortality (2.7; 95% CI: 2.5-3.0, P < .001) compared to chemotherapy (1.3; 95% CI: 1.3-1.4, P < .001), radiation (1.8; 95% CI: 1.7-1.9, P < .001), and endocrine therapy (1.5; 95% CI: 1.4-1.6, P < .001) independent of race, insurance, receptor status, and stage.Conclusion: This study demonstrates significant associations with refusal of breast cancer treatment and quantifies the impact on mortality, which may help to identify at-risk groups for whom interventions could prevent increases in mortality associated with declining treatment. [ABSTRACT FROM AUTHOR]

In South Korea, the legal and cultural environment keeps terminally ill patients from making an informed refusal to a treatment the discontinuation of which can cause death. Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life allows several forms of informed refusal, but it is not enough. There is no explicit guarantee, at least under this law, of the right to refuse a treatment given during a period that has not reached an endof-life process prescribed in the law. Dori, which the family of a terminal patient feels obligated to follow, makes them commit to doing what they believe is right as a family member without asking the patient's intention. Because it reduces the family's motivation to have a difficult talk about death and end-of-life with the patient, the patient is deprived of an opportunity to make a decision based on accurate information. In making a decision for the patient while patient is excluded, the family often ends up choosing a safe decision that puts physical survival first. In conclusion, the culture and the culturally influenced law are making it impractical for terminal patients to make an informed refusal. [ABSTRACT FROM AUTHOR]

Objectives: Significant number older patients with acute coronary syndrome (ACS) cannot undergo coronary angiography (CAG) due to various comorbidities. Patient's refusal of invasive procedures is common among old patients and has not been thoroughly investigated in the context of ACS. We wanted to assess CAG refusal rate and its impact on all-cause mortality in older patients with non-ST elevation acute myocardial infarction. Methods: In this retrospective study, patients over 75 years of age admitted with acute non-ST elevation ACS were included in the study. Patients were divided into three groups based on the treatment strategy; Group 1: Those who underwent CAG; Group 2: Refused; and Group 3: Deemed unsuitable for procedure due to severe comorbidities. The primary outcomes were to assess the patient refusal rate and its impact on all-cause mortality. Results: The study included 201 elderly patients. Eighty-two (41%) patients did not undergo CAG and of those, 48 (24%) had severe comorbidities, and 34 (17%) refused the procedure. The in-hospital mortality for patients who underwent, refused, or could not undergo CAG was 5.0%, 0%, and 16.7% (p<0.01); 30-day mortality 8.5%, 9.1%, and 25% (p=0.01); and long-term mortality was 20.2%, 35.3%, and 47.9% (p<0.01), respectively. The median follow-up was 12 months. Hazard ratio of treatment refusal for longterm mortality was 1.97 (1.02-3.87, 95% CI). Conclusion: Substantial number of elderly patients with ACS refuses to undergo CAG and this leads to increased mortality. Factors affecting patient behavior and the decision-making process should be explored. [ABSTRACT FROM AUTHOR]

Background: For patients with breast cancer who decline recommended treatments, available data examining survival outcomes are sparse. We compared overall survival and relapse‐free survival outcomes between patients with breast cancer who declined recommended primary treatments and those who received recommended primary treatments. Methods: Using data from the BreastSurgANZ Quality Audit database, a retrospective cohort study was performed for patients diagnosed with breast carcinoma (stage 0–IV) between 2001 and 2014 who were treated in our integrated cancer centre. A propensity score‐matched analysis was performed to compare overall survival and relapse‐free survival between patients who either declined or received the standard recommended treatment. Results: A total of 56/912 (6.1%) patients declined one or more recommended therapies. Five‐year overall survival for those who declined or received treatment as recommended was 81.8% versus 88.9% (P = 0.17), respectively. Ten‐year survival was 61.3% versus 67.8% (P = 0.22), respectively. For patients who declined treatments, 5‐year relapse‐free survival was 72.4%, compared to 87.4% for those who received them (P = 0.005). Ten‐year relapse‐free survival was 61.0% versus 80.6% (P = 0.002), respectively. On adjusted Cox regression analysis, treatment refusal was associated with poorer relapse‐free survival (adjusted hazard ratio 2.76 (95% confidence interval 1.52–5.00), P < 0.001). Conclusion: In conclusion, patients who declined recommended treatment for breast cancer had poorer relapse‐free survival compared to those who received them. These data may help clinicians assist patients with breast cancer in their decision‐making. [ABSTRACT FROM AUTHOR]

Copyright of Notfall & Rettungsmedizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Notfall & Rettungsmedizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Psycho-Oncologie is the property of PiscoMed Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Aim: To review the experience of a dedicated paediatric multidisciplinary lipid clinic in the management of familial hypercholesterolaemia (FH) by studying the demographics, clinical presentations as well as statin therapy and outcomes. Methods: Retrospective database review of all patients under 18 years old seen in the lipid clinic at an Australian tertiary paediatric hospital between April 1999 and August 2017. Outcome measures collected included patient demographics, family history, lipid profile, age at treatment commencement, treatment outcomes and complications. Results: One hundred and eight patients (53 males) were seen in the lipid clinic. Eighty‐five had low‐density lipoprotein cholesterol (LDL‐C) levels at or above the 75th percentile for sex prior to treatment. Of these, 75 had a first‐degree relative with hypercholesterolaemia and/or early cardiac death. Four patients had clinical manifestations. Thirty‐two patients (14 males) were started on statin therapy for likely FH. LDL‐C levels reduced by 2.4 mmol/L (1.4 to 2.7) in boys and 1.9 mmol/L (0.8 to 2.8) in girls at 12 month follow‐up. Five patients reported side effects requiring adjustment in therapy. Main reasons for not starting statin therapy in eligible patients were parental refusal and/or lost to follow up (77%). Conclusion: A dedicated multidisciplinary lipid clinic is helpful for streamlining and monitoring management of paediatric FH. Clinical manifestations of FH are rare in children and may represent more severe form of FH or other lipid disorder. Statin therapy is efficacious and well tolerated but current recommended targets of treatment are difficult to attain. Greater awareness and coordinated services are required to overcome poor family engagement. [ABSTRACT FROM AUTHOR]

Background: This study sought to provide a comprehensive understanding of cancer treatment refusal based on the experiences of patients, caregivers, and health care providers. Methods: In this qualitative research study, we enrolled 21 cancer patients, their caregivers, and health care providers. We conducted in-depth interviews of the participants to obtain the necessary data about treatment refusal. The data were coded, and data analysis was performed via the inductive analysis method. Results: There were three main categories in this study: “coexistence of hope and denial”, “treatment complexity and repeated complications”, and “treatment is in vain”. The first main category had five subcategories: ‘lack of symptoms, a way to denial’; ‘misconception’; ‘hope’; ‘hiding the disease’; and ‘insistence on maintaining one’s lifestyle’. Subcategories of the second main category included: ‘fear: shared experience’; ‘sign and symptom exacerbation; end of denial’; ‘duality in life quality’; ‘side-effects: a barrier to treatment’; ‘side-effect reliever’; and ‘tendency for alternative medicine’. Subcategories of the third category included: ‘degenerative course of cancer’; ‘acceptance of death’; and ‘remorsefulness: the shared experience’. Conclusion: In this study, participants provided different explanations for forgoing or avoiding treatment. During the initial cancer stages, denial was an effective factor for patients to not seriously consider the appropriate diagnostic and therapeutic interventions. As the disease advanced, alternative treatments and complications were the main factors for treatment refusal. Identification of the main motives for treatment refusal during the course of the disease would be effective for cancer management.

Introduction: Considering the global prevalence of coronavirus disease 2019 (COVID-19), a vaccine is being developed to control the disease as a complementary solution to hygiene measures—and better, in social terms, than social distancing. Given that a vaccine will eventually be produced, information will be needed to support a potential campaign to promote vaccination.Objective: The aim of this study was to determine the variables affecting the likelihood of refusal and indecision toward a vaccine against COVID-19 and to determine the acceptance of the vaccine for different scenarios of effectiveness and side effects.Materials and Methods: A multinomial logistic regression method based on the Health Belief Model was used to estimate the current methodology, using data obtained by an online anonymous survey of 370 respondents in Chile.Results: The results indicate that 49% of respondents were willing to be vaccinated, with 28% undecided or 77% of individuals who would potentially be willing to be inoculated. The main variables that explained the probability of rejection or indecision were associated with the severity of COVID-19, such as, the side effects and effectiveness of the vaccine; perceived benefits, including immunity, decreased fear of contagion, and the protection of oneself and the environment; action signals, such as, responses from ones' family and the government, available information, and specialists' recommendations; and susceptibility, including the contagion rate per 1,000 inhabitants and relatives with COVID-19, among others. Our analysis of hypothetical vaccine scenarios revealed that individuals preferred less risky vaccines in terms of fewer side effects, rather than effectiveness. Additionally, the variables that explained the indecision toward or rejection of a potential COVID-19 vaccine could be used in designing public health policies.Conclusions: We discovered that it is necessary to formulate specific, differentiated vaccination-promotion strategies for the anti-vaccine and undecided groups based on the factors that explain the probability of individuals refusing or expressing hesitation toward vaccination.

BackgroundRoutine follow-up care is recommended to promote the well-being of cancer survivors, but financial difficulties may interfere. Rural-urban disparities in forgoing healthcare due to cost have been observed in the general population; however, it is unknown whether this disparity persists among survivors. The purpose of this study was to examine rural-urban disparities in forgoing healthcare after cancer due to cost.MethodsWe analyzed data from 7,804 cancer survivors in the 2006 to 2010 National Health Interview Survey. Logistic regression models, adjusting for sociodemographic and clinical characteristics, were used to assess rural-urban disparities in forgoing medical care, prescription medications, and dental care due to cost, stratified by age (younger: 18-64, older: 65+).ResultsCompared with urban survivors, younger rural survivors were more likely to forgo medical care (P < 0.001) and prescription medications (P < 0.001) due to cost; older rural survivors were more likely to forgo medical (P < 0.001) and dental care (P = 0.05). Rural-urban disparities did not persist among younger survivors in adjusted analyses; however, older rural survivors remained more likely to forgo medical [OR = 1.66, 95% confidence interval (CI) = 1.11-2.48] and dental care (OR = 1.54, 95%CI = 1.08-2.20).ConclusionsAdjustment for health insurance and other sociodemographic characteristics attenuates rural-urban disparities in forgoing healthcare among younger survivors, but not older survivors. Financial factors relating to healthcare use among rural survivors should be a topic of continued investigation.ImpactAddressing out-of-pocket costs may be an important step in reducing rural-urban disparities in healthcare, especially for older survivors. It will be important to monitor how healthcare reform efforts impact disparities observed in this vulnerable population.

BackgroundDelays and failures in initiation of antiretroviral therapy (ART) among treatment eligible patients may compromise the effectiveness of HIV care in Africa. An accurate understanding, however, of the pace and completeness of ART initiation and mortality during the waiting period is obscured by frequent losses to follow-up.MethodsWe evaluated newly ART-eligible HIV-infected adults from 2007 to 2011 in a prototypical clinic in Mbarara, Uganda. A random sample of patients lost to follow-up was tracked in the community to determine vital status and ART initiation after leaving the original clinic. Outcomes among the tracked patients were incorporated using probability weights, and a competing risks approach was used in analyses.ResultsAmong 2633 ART-eligible patients, 490 were lost to follow-up, of whom a random sample of 132 was tracked and 111 (84.0%) had outcomes ascertained. After incorporating the outcomes among the lost, the cumulative incidence of ART initiation at 30, 90, and 365 days after eligibility was 16.0% [95% confidence interval (CI): 14.2 to 17.7], 64.5% (95% CI: 60.9 to 68.1), and 81.7% (95% CI: 77.7 to 85.6). Death before ART was 7.7% at 1 year. Male sex, higher CD4 count, and no education were associated with delayed ART initiation. Lower CD4 level, malnourishment, and travel time to clinic were associated with mortality.ConclusionsUsing a sampling-based approach to account for losses to follow-up revealed that both the speed and the completeness of ART initiation were suboptimal in a prototypical large clinic in Uganda. Improving the kinetics of ART initiation in Africa is needed to make ART more in real-world populations.

Objectives: To determine the burden and etiological factors of leave against medical advice (LAMA) in Indian children.Methodology: In this prospective study, legal guardians of 528 patients who took the decision of LAMA were interviewed (using structured question answers based multi-option) and data were captured over a period of 16 months. The resultant database was analyzed using standard statistical methods.Results: About 6.12% of childhood LAMA cases were dealt out of total pediatric admission including newborns. Neonatal preponderance noted in cases of LAMA from intensive care unit (ICU; 57.14%, p < 0.05). The overall male (n = 293) to female (n = 235) ratio in this study was 1.25:1. Number of LAMA patients was higher from rural area (83.33%), mostly admitted in ICU (93.65%, Pearson's chi-squared test, p < 0.05). Higher proportion (29.47%) of patients with infection availed LAMA from neonatal age group but overall LAMA patients fall under category of respiratory disorders (22.35%). Interest of the domestics issues other than suffering child was considered primary during LAMA for those admitted in ward as compared with ICU patients [odds ratio (OR): 1.73, CI: 1.02-2.94, p < 0.05]. ICU patients were reportedly to be taken to private health care facility (OR: 1.93, CI: 1.06-3.49, p < 0.05). Duration of stay before taking LAMA from ward was <7 days (85.59%, OR: 0.19, CI: 0.11-0.35, p < 0.05). Upper-lower socio-economic class attributed financial constraint as the main reason for LAMA (Pearson's chi-squared test, Chi-square value: 152.23, p < 0.05).Conclusions: This study tried to elucidate the determinants of childhood LAMA in rural Indian setting. [ABSTRACT FROM AUTHOR]

Refusal of care is a frequent occurrence in geriatric medicine, especially among people with neurocognitive diseases, particularly in the advanced stages. These refusals of care are a daily burden, not only for the patients themselves, but also for their carers and caregivers. Although they can be prevented, the absence of a single, simple strategy for overcoming them is a real challenge for professionals and carers alike. Their management calls for an approach that is essentially non-pharmacological, always interdisciplinary, humanistic and ethically grounded., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Transcultural nursing recognises the significance of cultural backgrounds in providing patients with quality care. This study investigates the opinions of master's students in nursing and midwifery regarding the attitudes of Jehovah's Witnesses towards refusing blood transfusions., Methods: 349 master's students in nursing and midwifery participated in a quantitative study and were surveyed via the Web to evaluate their awareness of the stance of Jehovah's Witnesses on blood transfusions and the ethical and legal dilemmas associated with caring for Jehovah's Witness (JW) patients., Results: The study yielded three significant findings. It unequivocally demonstrates that nursing and midwifery students possess inadequate knowledge regarding Jehovah's Witnesses' stance on blood transfusions and their acceptance of specific blood products and medical procedures. Despite being cognisant of the ethical and legal dilemmas of caring for JW patients, students lack an understanding of patients' autonomy to reject blood transfusions and their need for bloodless medicine. Students also articulated educational needs regarding cultural competencies regarding the Jehovah's Witnesses' beliefs on blood transfusions and non-blood management techniques., Conclusions: Healthcare professionals need the knowledge and skills necessary to provide holistic, patient-centred and culturally sensitive care. This study emphasises the urgent need for university curricula and nursing postgraduate training to include modules on transcultural nursing and strategies for minimising blood loss., (© 2024. The Author(s).)

raumatic brain injury (TBI) is a significant global health concern, particularly affecting young individuals, and is a leading cause of mortality and morbidity worldwide. Despite improvements in treatment infrastructure, many TBI patients choose discharge against medical advice (DAMA), often declining necessary surgical interventions. We aimed to investigate the factors that can be associated with DAMA in TBI patients that were recommended to have surgical treatment. This study was conducted at single tertiary university center (2008-2018), by retrospectively reviewing 1510 TBI patients whom visited the emergency room. We analyzed 219 TBI surgical candidates, including 50 declining surgery (refused group) and the others whom agreed and underwent decompressive surgery. Retrospective analysis covered demographic characteristics, medical history, insurance types, laboratory results, CT scan findings, and GCS scores. Statistical analyses identified factors influencing DAMA. Among surgical candidates, 169 underwent surgery, while 50 declined. Age (60.8 ± 17.5 vs. 70.5 ± 13.8 years; p < 0.001), use of anticoagulating medication (p = 0.015), and initial GCS scores (9.0 ± 4.3 vs. 5.3 ± 3.2; p < 0.001) appeared to be associated with refusal of decompressive surgery. Based on our analysis, factors influencing DAMA for decompressive surgery included age, anticoagulant use, and initial GCS scores. Contrary to general expectations and some previous studies, our analysis revealed that the patients' medical conditions had a larger impact than socioeconomic status under the Korean insurance system, which fully covers treatment for TBI. This finding provides new insights into the factors affecting DAMA and could be valuable for future administrative plans involving national insurance., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Patients who leave against medical advice (AMA) face increased risks of negative health outcomes, presenting a challenge for healthcare systems. This study examines demographic and hospital course factors associated with patients leaving AMA after an upper extremity (UE) orthopaedic procedure., Methods: We analyzed 262,912 patients who underwent UE orthopaedic procedures between 2011 and 2020, using the Healthcare Cost and Utilization Project database. We then compared demographic and hospital course factors between patients who left AMA and those who did not leave AMA., Results: Of 262,912 UE orthopaedic patients, 0.45% (1,173) left AMA. Those more likely to leave AMA were aged 30 to 49 (OR, 5.953, P < 0.001), Black (OR, 1.708, P < 0.001), had Medicaid (OR, 3.436, P < 0.001), and were in the 1st to 25th income percentile (OR, 1.657, P < 0.001). Female patients were less likely to leave AMA than male patients (OR, 0.647, P < 0.001). Patients leaving AMA had longer stays (3.626 versus 2.363 days, P < 0.001) and longer recovery times (2.733 versus 1.977, P < 0.001)., Conclusion: We found that male, Black, younger than 49 years old, Medicaid-insured, and lowest income quartile patients are more likely to leave AMA after UE orthopaedic treatment., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Slippery slope argumentation features prominently in debates over assisted suicide. The jurisdiction of Oregon features prominently too, especially as regards parliamentary scrutiny of assisted suicide proposals. This paper examines Oregon's public data (including certain official pronouncements) on assisted suicide in light of the two basic versions of the slippery slope argument, the empirical and moral-logical versions. Oregon's data evidences some normatively interesting shifts in its assisted suicide practice which in turn prompts consideration of two elements of moral-logical slippage that are not widely discussed. One is slippage from an initial autonomy-based public justification for assisted suicide which does not include burden-based concerns within its operative account of voluntariness to an evolved public justification that does. The other is an expansion of a terminal illness ground to include chronic illnesses effectively rendered terminal via a refusal of treatment.