case study of patient joe

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• Published: 14 March 2012

The split brain: A tale of two halves

• David Wolman 1  

Nature volume  483 ,  pages 260–263 ( 2012 ) Cite this article

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• Neurosurgery

Since the 1960s, researchers have been scrutinizing a handful of patients who underwent a radical kind of brain surgery. The cohort has been a boon to neuroscience — but soon it will be gone.

In the first months after her surgery, shopping for groceries was infuriating. Standing in the supermarket aisle, Vicki would look at an item on the shelf and know that she wanted to place it in her trolley — but she couldn't. “I'd reach with my right for the thing I wanted, but the left would come in and they'd kind of fight,” she says. “Almost like repelling magnets.” Picking out food for the week was a two-, sometimes three-hour ordeal. Getting dressed posed a similar challenge: Vicki couldn't reconcile what she wanted to put on with what her hands were doing. Sometimes she ended up wearing three outfits at once. “I'd have to dump all the clothes on the bed, catch my breath and start again.”

In one crucial way, however, Vicki was better than her pre-surgery self. She was no longer racked by epileptic seizures that were so severe they had made her life close to unbearable. She once collapsed onto the bar of an old-fashioned oven, burning and scarring her back. “I really just couldn't function,” she says. When, in 1978, her neurologist told her about a radical but dangerous surgery that might help, she barely hesitated. If the worst were to happen, she knew that her parents would take care of her young daughter. “But of course I worried,” she says. “When you get your brain split, it doesn't grow back together.”

In June 1979, in a procedure that lasted nearly 10 hours, doctors created a firebreak to contain Vicki's seizures by slicing through her corpus callosum, the bundle of neuronal fibres connecting the two sides of her brain. This drastic procedure, called a corpus callosotomy, disconnects the two sides of the neocortex, the home of language, conscious thought and movement control. Vicki's supermarket predicament was the consequence of a brain that behaved in some ways as if it were two separate minds.

After about a year, Vicki's difficulties abated. “I could get things together,” she says. For the most part she was herself: slicing vegetables, tying her shoe laces, playing cards, even waterskiing.

But what Vicki could never have known was that her surgery would turn her into an accidental superstar of neuroscience. She is one of fewer than a dozen 'split-brain' patients, whose brains and behaviours have been subject to countless hours of experiments, hundreds of scientific papers, and references in just about every psychology textbook of the past generation. And now their numbers are dwindling.

Through studies of this group, neuroscientists now know that the healthy brain can look like two markedly different machines, cabled together and exchanging a torrent of data. But when the primary cable is severed, information — a word, an object, a picture — presented to one hemisphere goes unnoticed in the other. Michael Gazzaniga, a cognitive neuroscientist at the University of California, Santa Barbara, and the godfather of modern split-brain science, says that even after working with these patients for five decades, he still finds it thrilling to observe the disconnection effects first-hand. “You see a split-brain patient just doing a standard thing — you show him an image and he can't say what it is. But he can pull that same object out of a grab-bag,” Gazzaniga says. “Your heart just races!”

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Michael Gazzaniga reflects on five decades of split-brain research

Work with the patients has teased out differences between the two hemispheres, revealing, for instance, that the left side usually leads the way for speech and language computation, and the right specializes in visual-spatial processing and facial recognition. “The split work really showed that the two hemispheres are both very competent at most things, but provide us with two different snapshots of the world,” says Richard Ivry, director of the Institute of Cognitive and Brain Sciences at the University of California, Berkeley. The idea of dichotomous consciousness captivated the public, and was greatly exaggerated in the notion of the 'creative right brain'. But further testing with split-brain patients gave a more-nuanced picture. The brain isn't like a computer, with specific sections of hardware charged with specific tasks. It's more like a network of computers connected by very big, busy broadband cables. The connectivity between active brain regions is turning out to be just as important, if not more so, than the operation of the distinct parts. “With split-brain patients, you can see the impact of disconnecting a huge portion of that network, but without damage to any particular modules,” says Michael Miller, a psychologist at the University of California, Santa Barbara.

David Roberts, head of neurosurgery at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, sees an important lesson in split-brain research. He operated on some of the cohort members, and has worked closely with Gazzaniga. “In medical school, and science in general, there is so much emphasis on large numbers, labs, diagnostics and statistical significance,” Roberts says — all crucial when, say, evaluating a new drug. But the split-brain cohort brought home to him how much can be gleaned from a single case. “I came to learn that one individual, studied well, and thoughtfully, might enable you to draw conclusions that apply to the entire human species,” he says.

Today, the split-brain patients are getting on in years; a few have died, one has had a stroke and age in general has made them all less fit for what can be taxing research sessions of sitting, staring and concentrating. The surgery, already quite rare, has been replaced by drug treatments and less drastic surgical procedures. Meanwhile, imaging technologies have become the preferred way to look at brain function, as scientists can simply watch which areas of the brain are active during a task.

But to Miller, Ivry, Gazzaniga and others, split-brain patients remain an invaluable resource. Imaging tools can confirm, for example, that the left hemisphere is more active than the right when processing language. But this is dramatically embodied in a split-brain patient, who may not be able to read aloud a word such as 'pan' when it's presented to the right hemisphere, but can point to the appropriate drawing. “That gives you a sense of the right hemisphere's ability to read, even if it can't access the motor system to produce speech,” Ivry says. “Imaging is very good for telling you where something happens,” he adds, “whereas patient work can tell you how something happens.”

A cable, cut

Severing the corpus callosum was first used as a treatment for severe epilepsy in the 1940s, on a group of 26 people in Rochester, New York. The aim was to limit the electrical storm of the seizure to one side of the brain. At first, it didn't seem to work. But in 1962, one patient showed significant improvement. Although the procedure never became a favoured treatment strategy — it's invasive, risky, and drugs can ease symptoms in many people — in the decades since it nevertheless became a technique of last resort for treating intractable epilepsy.

To Roger Sperry, then a neurobiologist and neuropsychologist at the California Institute of Technology, and Gazzaniga, a graduate student in Sperry's lab, split-brain patients presented a unique opportunity to explore the lateralized nature of the human brain. At the time, opinion on the matter was itself divided. Researchers who studied the first split-brain patients in the 1940s had concluded that the separation didn't noticeably affect thought or behaviour. (Gazzaniga and others suspect that these early sections were incomplete, which might also explain why they didn't help the seizures.) Conversely, studies conducted by Sperry and colleagues in the 1950s revealed greatly altered brain function in animals that had undergone callosal sections. Sperry and Gazzaniga became obsessed with this inconsistency, and saw in the split-brain patients a way to find answers.

The duo's first patient was a man known as W. J., a former Second World War paratrooper who had started having seizures after a German soldier clocked him in the head with the butt of a rifle. In 1962, after W.J.'s operation, Gazzaniga ran an experiment in which he asked W.J. to press a button whenever he saw an image. Researchers would then flash images of letters, light bursts and other stimuli to his left or right field of view. Because the left field of view is processed by the right hemisphere and vice versa, flashing images quickly to one side or the other delivers the information solely to the intended hemisphere (see 'Of two minds').

For stimuli delivered to the left hemisphere, W.J. showed no hang-ups; he simply pressed the button and told the scientists what he saw. With the right hemisphere, W.J. said he saw nothing, yet his left hand kept pressing the button every time an image appeared. “The left and right didn't know what the other was doing,” says Gazzaniga. It was a paradigm-blasting discovery showing that the brain is more divided than anyone had predicted 1 .

Suddenly, the race was on to delve into the world of lateralized function. But finding more patients to study proved difficult. Gazzaniga estimates that at least 100 patients, and possibly many more, received a corpus callosotomy. But individuals considered for the operation tend to have other significant developmental or cognitive problems; only a few have super-clean cuts and are neurologically healthy enough to be useful to researchers. For a while, Sperry, Gazzaniga and their colleagues didn't know if there was ever going to be anyone else like W.J..

But after contacting neurosurgeons, partnering with epilepsy centres and assessing many potential patients, they were able to identify a few suitable people in California, then a cluster from the eastern part of the United States, including Vicki. Through the 1970s and the early 1980s, split-brain research expanded, and neuroscientists became particularly interested in the capabilities of the right hemisphere — the one conventionally believed to be incapable of processing language and producing speech.

Gazzaniga can tick through the names of his “endlessly patient patients” with the ease of a proud grandparent doing a roll call of grandchildren — W.J., A.A., R.Y., L.B., N.G.. For medical confidentiality, they are known in the literature by initials only. (Vicki agreed to be identified in this article, provided that her last name and hometown were not published.)

On stage last May, delivering a keynote address at the Society of Neurological Surgeons' annual meeting in Portland, Oregon, Gazzaniga showed a few grainy film clips from a 1976 experiment with patient P.S., who was only 13 or 14 at the time. The scientists wanted to see his response if only his right hemisphere saw written words.

In Gazzaniga's video, the boy is asked: who is your favourite girlfriend, with the word girlfriend flashed only to the right hemisphere. As predicted, the boy can't respond verbally. He shrugs and shakes his head, indicating that he doesn't see any word, as had been the case with W.J.. But then he giggles. It's one of those tell-tale teen giggles — a soundtrack to a blush. His right hemisphere has seen the message, but the verbal left-hemisphere remains unaware. Then, using his left hand, the boy slowly selects three Scrabble tiles from the assortment in front of him. He lines them up to spell L-I-Z: the name, we can safely assume, of the cute girl in his class. “That told us that he was capable of language comprehension in the right hemisphere,” Gazzaniga later told me. “He was one of the first confirmation cases that you could get bilateral language — he could answer queries using language from either side.”

The implications of these early observations were “huge”, says Miller. They showed that “the right hemisphere is experiencing its own aspect of the world that it can no longer express, except through gestures and control of the left hand”. A few years later, the researchers found that Vicki also had a right-hemisphere capacity for speech 2 . Full callosotomy, it turned out, resulted in some universal disconnections, but also affected individuals very differently.

In 1981, Sperry was awarded a share of the Nobel Prize in Physiology or Medicine for the split-brain discoveries. (“He deserved it,” Gazzaniga says.) Sperry died in 1994, but by that point, Gazzaniga was leading the charge. By the turn of the century, he and other split-brain investigators had turned their attention to another mystery: despite the dramatic effects of callosotomy, W.J. and later patients never reported feeling anything less than whole. As Gazzaniga wrote many times: the hemispheres didn't miss each other.

Gazzaniga developed what he calls the interpreter theory to explain why people — including split-brain patients — have a unified sense of self and mental life 3 . It grew out of tasks in which he asked a split-brain person to explain in words, which uses the left hemisphere, an action that had been directed to and carried out only by the right one. “The left hemisphere made up a post hoc answer that fit the situation.” In one of Gazzaniga's favourite examples, he flashed the word 'smile' to a patient's right hemisphere and the word 'face' to the left hemisphere, and asked the patient to draw what he'd seen. “His right hand drew a smiling face,” Gazzaniga recalled. “'Why did you do that?' I asked. He said, 'What do you want, a sad face? Who wants a sad face around?'.” The left-brain interpreter, Gazzaniga says, is what everyone uses to seek explanations for events, triage the barrage of incoming information and construct narratives that help to make sense of the world.

The split-brain studies constitute “an incredible body of work”, said Robert Breeze, a neurosurgeon at the University of Colorado Hospital in Aurora, after listening to Gazzaniga's lecture last year. But Breeze, like many other neuroscientists, sees split-brain research as outdated. “Now we have technologies that enable us to see these things” — tools such as functional magnetic resonance imaging (fMRI) that show the whereabouts of brain function in great detail.

Miller, however, disagrees. “These kinds of patients can tell us things that fMRI can never tell us,” he says.

Subject of interest

Seated at a small, oval dining-room table, Vicki faces a laptop propped up on a stand, and a console with a few large red and green buttons. David Turk, a psychologist at the University of Aberdeen, UK, has flown in for the week to run a series of experiments.

Vicki's grey-white hair is pulled back in a ponytail. She wears simple white sneakers and, despite the autumn chill, shorts. She doesn't want to get too warm: when that happens she can get drowsy and lose focus, which can wreck a whole day of research.

During a break, Vicki fetches an old photo album. In one picture, taken soon after her surgery, she is sitting up in the hospital bed. Her hair is starting to grow back as black stubble and she and her daughter have wide smiles. Another page of the album has a slightly faded printout of a 1981 paper from The Journal of Neuroscience glued into it: the first published report involving data gleaned from Vicki, in which researchers describe how she, like P.S., had some capacity for language in her right hemisphere 4 .

I have a hard time saying it's all over.

When pressed to share the most difficult aspect of her life in science, the perpetually upbeat Vicki says that it would have to be an apparatus called the dual Purkinje eye tracker. This medieval-looking device requires the wearer to bite down on a bar to help keep the head still so that researchers can present an image to just the left or right field of view. It is quite possible that Vicki has spent more of her waking hours biting down on one of those bars than anyone else on the planet.

Soon, it is time to get back to work. Turk uses some two-sided tape to affix a pair of three-dimensional glasses onto the front of Vicki's thin, gold-rimmed bifocals. The experiment he is running aims to separate the role of the corpus callosum in visual processing from that of deeper, 'subcortical' connections unaffected by the callosotomy. Focusing on the centre of the screen, Vicki is told to watch as the picture slowly switches between a house and different faces — and to press the button every time she sees the image change. Adjusting her seat, she looks down the bridge of her nose at the screen and tells Turk that she's ready to begin.

Deep connections

Other researchers are studying the role of subcortical communication in the coordinated movements of the hands. Split-brain patients have little difficulty with 'bimanual' tasks, and Vicki and at least one other patient are able to drive a car. In 2000, a team led by Liz Franz at the University of Otago in New Zealand asked split-brain patients to carry out both familiar and new bimanual tasks. A patient who was an experienced fisherman, they found, could pantomime tying a fishing line, but not the unfamiliar task of threading a needle. Franz concluded that well-practised bimanual skills are coordinated at the subcortical level, so split-brain people are able to smoothly choreograph both hands 5 .

Miller and Gazzaniga have also started to study the right hemisphere's role in moral reasoning. It is the kind of higher-level function for which the left hemisphere was assumed to be king. But in the past few years, imaging studies have shown that the right hemisphere is heavily involved in the processing of others' emotions, intentions and beliefs — what many scientists have come to understand as the 'theory of mind' 6 . To Miller, the field of enquiry perfectly illustrates the value of split-brain studies because answers can't be found by way of imaging tools alone.

In work that began in 2009, the researchers presented two split-brain patients with a series of stories, each of which involved either accidental or intentional harm. The aim was to find out whether the patients felt that someone who intends to poison his boss but fails because he mistakes sugar for rat poison, is on equal moral ground with someone who accidentally kills his boss by mistaking rat poison for sugar 7 . (Most people conclude that the former is more morally reprehensible.) The researchers read the stories aloud, which meant that the input was directed to the left hemisphere, and asked for verbal responses, so that the left hemisphere, guided by the interpreter mechanism, would also create and deliver the response. So could the split-brain patients make a conventional moral judgement using just that side of the brain?

No. The patients reasoned that both scenarios were morally equal. The results suggest that both sides of the cortex are necessary for this type of reasoning task.

But this finding presents an additional puzzle, because relatives and friends of split-brain patients do not notice unusual reasoning or theory-of-mind deficits. Miller's team speculates that, in everyday life, other reasoning mechanisms may compensate for disconnection effects that are exposed in the lab. It's an idea that he plans to test in the future.

As the opportunities for split-brain research dwindle, Gazzaniga is busy trying to digitize the archive of recordings of tests with cohort members, some of which date back more than 50 years. “Each scene is so easy to remember for me, and so moving,” he says. “We were observing so many astonishing things, and others should have the same opportunity through these videos.” Perhaps, he says, other researchers will even uncover something new.

Other split-brain patients may become available — there is a small cluster in Italy, for instance. But with competition from imaging research and many of the biggest discoveries about the split brain behind him, Gazzaniga admits that the glory days of this field of science are probably gone. “It is winding down in terms of patients commonly tested.” Still, he adds: “I have a hard time saying it's all over.”

And maybe it's not — as long as there are scientists pushing to tackle new questions about lateralized brain function, connectivity and communication, and as long as Vicki and her fellow cohort members are still around and still willing participants in science. Her involvement over the years, Vicki says, was never really about her. “It was always about getting information from me that might help others.”

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Split-brain experiments Michael Gazzaniga and split-brain patient J.W. in experiments shot in the 1990s showing some of the lateralized nature of brain function.

Split-brain work in the 1970s A video featuring Michael Gazzaniga and early split-brain experiments in animals and people.

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Dissecting the right brain 2005-Jul-13

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Wolman, D. The split brain: A tale of two halves. Nature 483 , 260–263 (2012). https://doi.org/10.1038/483260a

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Published : 14 March 2012

Issue Date : 15 March 2012

DOI : https://doi.org/10.1038/483260a

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The Case of Joe

The Case of Joe: Ethical End of Life Decisions

“Give me something. I want to die.”

“Joe” is a 62-year-old building contractor who has been in an ICU for the past 10 weeks. He had gone to his community hospital for bypass surgery (CABG) and aortic valve repair (AVR), and things didn’t go well post-op. His sternal wound became infected with Methicillin-resistant Staphylococcus Aureus (MRSA). Sepsis led to acute hypoxic respiratory failure, a tracheotomy, profound hearing loss, and then acute renal failure ameliorated somewhat by hemodialysis.

The complexity and severity of Joe’s post-operative condition has resulted in transfer to our larger tertiary facility for the past 6 weeks. He now has been weaned off the vent to a few hours of room air, but the care team is not as optimistic as Joe’s family remains. Per chart notes, he is not improving sufficiently to warrant hope for recovery. The best that can be hoped for now, says his critical care physician, is discharge to a long-term acute care hospital (L-TACH). The prognosis does not include any likelihood of return to baseline, or to home. The situation is dire, and Joe seems to “get it.”

On the Saturday of Joe’s tenth week in ICU, he mouths a message to his nurse, and then to the physician who is summoned, and then to an ethics consultant also. “Stop everything. Give me something. I want to die.”

Joe repeats his request with family at the bedside. In later conversation with the ethics consultant, they express frustration with Joe for wanting to “quit.” “That’s not Joe. He’s stubborn. Never quits. He’s been through worse than this, and then went back to work. He must be depressed or not thinking clearly now.”

Is he depressed and not thinking clearly? Psychiatry is consulted to assess Joe’s decisional capacity. He has been informed already that, “We can’t give you something to die. That’s not legal, not in this state.” Although that answer seems to frustrate Joe, he continues to ask that “everything stop.”

No more aggressive treatment. Stop the antibiotics. No more vent. “I want to die.” Joe is deemed to have decisional capacity, per Psych. Ethics thinks so too. The wife, a sister, and two adult children–one of them a nurse in our facility–claim otherwise. “You don’t know Joe. This isn’t him. He isn’t thinking clearly. He’s actually getting better. He can breathe off the vent. His color is much better compared to a week ago. Can you at least not pull the plug for a few days, maybe a week, to give this a chance?” What now should be done for Joe – and his family?

Written by: Tarris Rosell, PhD, DMin

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Article Contents

Answer to part 1, answer to part 2, answer to part 3, answer to part 4, answer to part 5.

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Educational Case: A 57-year-old man with chest pain

Contributed equally.

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Nikhil Aggarwal, Subothini Selvendran, Vassilios Vassiliou, Educational Case: A 57-year-old man with chest pain, Oxford Medical Case Reports , Volume 2016, Issue 4, April 2016, Pages 62–65, https://doi.org/10.1093/omcr/omw008

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This is an educational case report including multiple choice questions and their answers. For the best educational experience we recommend the interactive web version of the exercise which is available via the following link: http://www.oxfordjournals.org/our_journals/omcr/ec01p1.html

A 57 year-old male lorry driver, presented to his local emergency department with a 20-minute episode of diaphoresis and chest pain. The chest pain was central, radiating to the left arm and crushing in nature. The pain settled promptly following 300 mg aspirin orally and 800 mcg glyceryl trinitrate (GTN) spray sublingually administered by paramedics in the community. He smoked 20 cigarettes daily (38 pack years) but was not aware of any other cardiovascular risk factors. On examination he appeared comfortable and was able to complete sentences fully. There were no heart murmurs present on cardiac auscultation. Blood pressure was 180/105 mmHg, heart rate was 83 bpm and regular, oxygen saturation was 97%.

What is the most likely diagnosis?

An ECG was requested and is shown in figure 1.

How would you manage the patient? (The patient has already received 300 mg aspirin).

30 minutes later the patient's chest pain returned with greater intensity whilst waiting in the emergency department. Now, he described the pain as though “an elephant is sitting on his chest”. The nurse has already done an ECG by the time you were called to see him. This is shown in figure 2.

ECG on admission.

ECG 30 minutes after admission.

What would be the optimal management for this patient?

He was taken to the catheterization lab where the left anterior descending coronary artery (LAD) was shown to be completely occluded. Following successful percutaneous intervention and one drug eluding stent implantation in the LAD normal flow is restored (Thrombosis in myocardial infarction, TIMI = 3). 72 hours later, he is ready to be discharged home. The patient is keen to return to work and asks when he could do so.

When would you advise him that he could return to work?

One week later, he receives a letter informing him that he is required to attend cardiac rehabilitation. The patient is confused as to what cardiac rehabilitation entails, although he does remember a nurse discussing this with him briefly before he was discharged. He phones the hospital in order to get some more information.

Which of the following can be addressed during cardiac rehabilitation?

A - Acute coronary syndrome

Although the presentation could be attributable to any of the above differential diagnoses, the most likely etiology given the clinical picture and risk factors is one of cardiac ischemia. Risk factors include gender, smoking status and age making the diagnosis of acute coronary syndrome the most likely one. The broad differential diagnosis in patients presenting with chest pain has been discussed extensively in the medical literature. An old but relevant review can be found freely available 1 as well as more recent reviews. 2 , 3

C - Atorvastatin 80 mg, Clopidogrel 300 mcg, GTN 500 mcg, Ramipril 2.5 mg,

In patients with ACS, medications can be tailored to the individual patient. Some medications have symptomatic benefit but some also have prognostic benefit. Aspirin 4 , Clopidogrel 5 , Atenolol 6 and Atorvastatin 7 have been found to improve prognosis significantly. ACE inhibitors have also been found to improve left ventricular modeling and function after an MI. 8 , 9 Furthermore, GTN 10 and morphine 11 have been found to be of only significant symptomatic benefit.

Oxygen should only to be used when saturations <95% and at the lowest concentration required to keep saturations >95%. 12

There is no evidence that diltiazem, a calcium channel blocker, is of benefit. 13

His ECG in figure 1 does not fulfil ST elevation myocardial infarction (STEMI) criteria and he should therefore be managed as a Non-STEMI. He would benefit prognostically from beta-blockade however his heart rate is only 42 bpm and therefore this is contraindicated. He should receive a loading dose of clopidogrel (300 mg) followed by daily maintenance dose (75 mg). 14 , 15 He might not require GTN if he is pain-free but out of the available answers 3 is the most correct.

D - Proceed to coronary angiography

The ECG shows ST elevation in leads V2-V6 and confirms an anterolateral STEMI, which suggests a completely occluded LAD. This ECG fulfils the criteria to initiate reperfusion therapy which traditionally require one of the three to be present: According to guidance, if the patient can undergo coronary angiography within 120 minutes from the onset of chest pain, then this represents the optimal management. If it is not possible to undergo coronary angiography and potentially percutaneous intervention within 2 hours, then thrombolysis is considered an acceptable alternative. 12 , 16

≥ 1 mm of ST change in at least two contiguous limb leads (II, III, AVF, I, AVL).

≥ 2 mm of ST change in at least two contiguous chest leads (V1-V6).

New left bundle branch block.

GTN and morphine administration can be considered in parallel but they do not have a prognostic benefit.

E - Not before an exercise test

This patient is a lorry driver and therefore has a professional heavy vehicle driving license. The regulation for driving initiation in a lorry driver following a NSTEMI/ STEMI may be different in various countries and therefore the local regulations should be followed.

In the UK, a lorry driver holds a category 2 driving license. He should therefore refrain from driving a lorry for at least 6 weeks and can only return to driving if he completes successfully an exercise evaluation. An exercise evaluation is performed on a bicycle or treadmill. Drivers should be able to complete 3 stages of the standard Bruce protocol 17 or equivalent (e.g. Myocardial perfusion scan) safely, having refrained from taking anti-anginal medication for 48 hours and should remain free from signs of cardiovascular dysfunction during the test, notably: angina pectoris, syncope, hypotension, sustained ventricular tachycardia, and/or electrocardiographic ST segment shift which is considered as being indicative of myocardial ischemia (usually >2 mm horizontal or down-sloping) during exercise or the recovery period. 18

For a standard car driving license (category 1), driving can resume one week after successful intervention providing that no other revascularization is planned within 4 weeks; left ventricular ejection fraction (LVEF) is at least 40% prior to hospital discharge and there is no other disqualifying condition.

Therefore if this patent was in the UK, he could restart driving a normal car one week later assuming an echocardiogram confirmed an EF > 40%. However, he could only continue lorry driving once he has passed the required tests. 18

E - All of the above

Cardiac rehabilitation bridges the gap between hospitals and patients' homes. The cardiac rehabilitation team consists of various healthcare professions and the programme is started during hospital admission or after diagnosis. Its aim is to educate patients about their cardiac condition in order to help them adopt a healthier lifestyle. This includes educating patients' about their diet, exercise, risk factors associated with their condition such as smoking and alcohol intake and finally, about the medication recommended. There is good evidence that adherence to cardiac rehabilitation programmes improves survival and leads to a reduction in future cardiovascular events.​ 19 , 20

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• Peer Review: Split-brain patient 'Joe' being tested with stimuli presented in different visual fields

Peer Review

Split-brain patient 'joe' being tested with stimuli presented in different visual fields.

The material is a short YouTube video featuring a case study regarding a split brain patient, named Joe, who was studied by Michael Gazzaniga. In the video, Michael Gazzaniga (a student of Roger Sperry) discusses the effects of severing the corpus callosum and tests "Joe" on visual stimuli to illustrate these effects.

The video could be used as a demonstration for an introductory psychology course, neuroscience course, or biopsychology course that covers topics in brain anatomy, language, or lateralization of cortical processes.

This material is useful for anyone studying the brain and how incoming information is processed. Specific classroom uses included the following.

• Brief video demonstration in class to supplement lecture material.

• Brief video demonstration to supplement homework or textbook reading.

Major learning goals include the following.

• To learn how the contralateral system of vision works, as well as the effects from severing the corpus callosum.

• To observe the behavioral outcomes resulting from damage to interhemispheric communication.

• To identify consequences of brain lateralization.

• To describe aspects of the case study involving a split-brain patient.

Content Quality

• This video demonstrates one of the seminal findings in brain anatomy and lateralization. It does so simply, such that introductory students would not need a substantive background in psychology or biology to understand its lessons. It is authentic and accurate, as it shows the original researcher testing one of his original subjects. Since it is short, it can easily supplement an in class or at home assignment, lecture, or reading.

• The content provided is accurate, with much of the information provided by a leading researcher in Cognitive Neuroscience.

Potential Effectiveness as a Teaching Tool

• The video of what “Joe” sees versus what he reports and draws helps users understand some differences between the hemispheres and the importance of the corpus callosum. This is difficult to understand for most students – the visuals, along with the descriptions make this information more accessible.

• The material contains no descriptions of objectives, prerequisite knowledge, concept reinforcement, learning effectiveness, and/or assessment of student learning outcomes. Instructors would need to develop this information in order to effectively integrate the video into class activities or assignments.

Ease of Use for Both Students and Faculty

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Case Study: A Patient with Asthma, Covid-19 Pneumonia and Cytokine Release Syndrome Treated with Corticosteroids and Tocilizumab

Gunter k schleicher.

1 Department of Critical Care and Pulmonology, Wits Donald Gordon Medical Centre, Johannesburg, South Africa

Warren Lowman

2 Pathcare/Vermaak Laboratories, Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Guy A Richards

3 Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

INTRODUCTION

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the novel coronavirus first detected in Wuhan, China, that causes coronavirus disease 2019 (Covid-19) and pneumonia. Covid-19 pneumonia is defined by a positive result for SARS-CoV-2 on a reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay of a specimen collected from the upper or lower respiratory tract together with radiological features of pneumonia and clinical features of hypoxaemia and dyspnoea. Although more than 80% of patients with Covid-19 infection have mild disease and make a full recovery, a significant proportion of patients progress to pneumonia, and about half of these cases will develop severe acute respiratory syndrome (ARDS). Initial reports from China suggested that age >65 years and medical comorbidities are risk factors for poor outcomes.( 1 ) The need for ICU admission and mechanical ventilation once ARDS develops is associated with a high mortality, ranging from 39% to 72%.( 2 , 3 ) Current guidelines recommend that corticosteroids or immunosuppressive therapy should not be used in patients with Covid-19 pneumonia unless there are other indications, such as shock, asthma or exacerbation of chronic obstructive pulmonary disease.( 4 ) However, the role of systemic corticosteroids is currently being re-evaluated in mechanically ventilated adults with ARDS, with some guidelines now suggesting their use.( 5 )

We describe a case of a patient with Covid-19 infection, progressive pneumonia, development of a hyperinflammatory state and cytokine release syndrome (CRS) who was successfully treated with steroids and tocilizumab.

CASE REPORT

In January 2020, a 53-year-old gentleman with a background of asthma on long-term low dose inhaled corticosteroid inhaler had an acute exacerbation of his asthma in February 2020 triggered by a viral upper respiratory tract infection and acute sinusitis and was managed with bronchodilator nebulization and a 7-day course of oral prednisone 30 mg daily. He made an uneventful recovery and proceeded to travel to Austria on 29 February 2020. During his stay in Austria, he had contact with a Covid-19 positive individual and started developing upper respiratory symptoms on 7 March. On his return to South Africa on 8 March he had a fever, sore throat, dry cough, severe wheezing and worsening dyspnoea. At that stage a commercial test for Covid-19 PCR was not yet available to the private pathology laboratories and blood tests showed a normal full blood count and a C-reactive protein (CRP) of 16 mg/L. He was advised to self-isolate at home and was managed telephonically with bronchodilator nebulization, oral prednisone 30 mg daily for 5 days and paracetamol. By 11 March he was not feeling any better and had ongoing fever and cough. The Covid-19 PCR test had become available at that stage and his initial test with a private pathology laboratory was negative.

Over the next 3 days his symptoms worsened, and on 16 March he was admitted to hospital to an isolation ward where blood tests showed a lymphopaenia and a rising CRP ( Table 1 ). A high-resolution CT scan of his chest showed bilateral asymmetrical peripheral ground glass infiltrates in a subsegmental distribution, particularly in the lower zones. A repeat Covid-19 PCR swab on this occasion was positive and he was diagnosed with Covid-19 pneumonia. His oxygen saturation was 86% on room air. He was haemodynamically stable and was kept in strict isolation, and treatment was commenced with supplemental oxygen via a nasal cannula, paracetamol, chloroquine, azithromycin and lopinavir/ritonavir. In keeping with national and international guidelines recommending against the use of systemic corticosteroids, prednisone was discontinued.

Laboratory and pathology results during hospital admission and post discharge

Arrows indicate treatment with tocilizumab 400 mg IV.

Over the next 5 days his clinical condition worsened despite antiviral therapy. His biomarkers, including lymphopaenia, CRP, pro-B-type natriuretic peptide (Pro-BNP), lactate dehydrogenase (LDH), D-dimers and ferritin all increased significantly ( Table 1 ). His hypoxaemia worsened and he had increased bilateral chest infiltrates on follow-up radiology ( Figure 1 ). His PaO2:FiO2 ratio decreased to 250. He was diagnosed as having Covid-19 hyperinflammatory syndrome, CRS and ARDS. After a discussion with the team he was treated with tocilizumab 800 mg IV, given as two doses of 400 mg 24 h apart on 23 and 24 March, as well as methylprednisolone 40 mg IV daily for 5 days. Chloroquine dose was reduced, and azithromycin and lopinavir/ritonavir were discontinued in view of QT prolongation (QTc > 500 ms).

Portable chest radiographs on 17 and 20 March 2020 showing progressive bilateral pulmonary infiltrates

Within 24 h following the tocilizumab infusion, there was an improvement in his fever, biomarkers ( Table 1 ) and hypoxaemia. Mechanical ventilation was avoided and he was monitored for another 6 day in the isolation unit. His saturations on room air improved to 90%. He was discharged home on 27 March, where he continued to make an uneventful recovery. Follow-up blood tests as an outpatient showed normalization of his lymphocyte count and CRP ( Table 1 ). His saturations on room air improved to 92%. A repeat nasopharyngeal and throat swab test for Covid-19 on 31 March was negative.

It has been postulated that there are three distinct but overlapping phases and pathological subsets of Covid-19 infection and subsequent Covid-19 disease in humans, the first two triggered by the virus itself and the third, by the host response.( 6 ) Treatment recommendations differ depending on the stage of the Covid-19 disease: the viral response phase (about 1–6 days after start of symptoms), the pneumonic phase (about days 6–10) which may progress to acute lung injury and ARDS, and the hyperinflammatory phase which typically occurs after day 8 in a minority of patients. This last phase is associated with worsening ARDS, multi-organ dysfunction syndrome (MODS), coagulation abnormalities, myocarditis and death. Patients progressing to this last severe phase of Covid-19 have clinical and laboratory evidence of an exaggerated inflammatory response, similar to the CRS, with persistent fever, worsening ARDS, elevated inflammatory markers and proinflammatory cytokines and MODS.

The Covid-19 virus binds to alveolar epithelial cells, activating the innate and adaptive immune systems resulting in the release of pro-inflammatory cytokines. This can lead to the CRS which is characterised by a hyperinflammatory state with raised inflammatory cytokines and biomarkers such as interleukin (IL)-2, IL-6, IL-7, granulocyte-colony stimulating factor, macrophage inflammatory protein 1-α, tumour necrosis factor-α, CRP, ferritin, Pro-BNP and D-dimer.( 7 ) The clinical picture is one of progressive ARDS and fulminant MODS.

Although corticosteroids are not routinely recommended for the treatment of Covid-19-associated lung injury, CRS immunosuppression with corticosteroids and other therapies is likely to be beneficial. Although there are currently no controlled clinical trials on the use of corticosteroids in Covid-19 patients, several published reports of corticosteroid therapy in severe Covid-19 have shown a shorter duration of supplemental oxygen use, improved radiographic findings and lower mortality in patients with ARDS.( 8 , 9 )

Tocilizumab, an IL-6 receptor blocker registered for CRS treatment, is being investigated for the treatment of patients with severe Covid-19, CRS and elevated IL-6 levels. IL-6 plays an important role in CRS and tocilizumab binds specifically to both soluble and membrane-bound IL-6 receptors (sIL-6R and mIL-6R), inhibiting sIL-6R and mIL-6R-mediated signalling. Small observational studies support the concept that tocilizumab may be an effective drug for patients with severe Covid-19 and respiratory failure requiring mechanical ventilation.( 10 , 11 ) In a study of 21 patients with Covid-19-related ARDS who received tocilizumab, the ICU mortality was less than 5%, all surviving patients became apyrexial within 72 h, pulmonary infiltrates on follow-up CT scan improved in 90%, hypoxaemia resolved in the majority and 90.5% of patients were discharged from the ICU after a median of 13.5 days.( 12 ) A large randomised, double-blind, placebo-controlled phase 3 clinical trial to evaluate the safety and efficacy of tocilizumab plus standard of care in hospitalised adult patients with severe Covid-19 pneumonia and ARDS has been being initiated.( 13 )

Currently, tocilizumab is available in South Africa for patients with severe Covid-19 and ARDS under the Monitored Emergency use of Unregistered and Investigational Interventions framework.( 14 ) This requires the treating physician to consult with an expert panel prior to enrolment, detailed patient data collection and ensuring that the patient meets the strict inclusion and exclusion criteria. Other immune modulating agents under investigation include siltuximab (IL-6 inhibitor), bevacizumab (vascular endothelial growth factor inhibitor), convalescent plasma from patients who have recovered from SARS-CoV-2 infection and intravenous immune globulin (Polygam).( 15 , 16 )

This case study also highlights some of the many controversies and complications in managing patients with severe Covid-19:

• • The use of inhaled or oral corticosteroids as a risk factor for severe Covid-19 is not certain. Individuals taking long-term corticosteroids for chronic conditions such as asthma, allergies and arthritis may be unable to mount an appropriate immune response and are generally considered high risk for severe disease if infected with Covid-19.( 17 ) Corticosteroids can also result in increased viral replication and prolonged viral shedding. Even a short course of oral corticosteroids in the preceding month for an asthma exacerbation, such as in this case study, is a risk factor for ARDS and mechanical ventilation.( 18 ) Conversely, in vitro studies with ciclesonide showed antiviral activity against Covid-19, and there have been reports of clinical effectiveness of inhaled ciclesonide in the treatment of Covid-19.( 19 ) Studies are currently underway to investigate whether inhaled ciclesonide alone, or in combination with hydroxychloroquine, could eradicate SARS-CoV-2 from respiratory tract earlier in patients with mild Covid-19.( 20 )
• • Diagnosis of SARS-CoV-2 pneumonia is not always straightforward. Currently, the gold standard in clinical practice is the detection of Covid-19 RNA by RT-PCR in respiratory tract specimens. Nasopharyngeal and throat swabs are recommended over expectorated or induced sputum. Lower respiratory tract specimens, such as tracheal aspirates or bronchoalveolar lavage in intubated patients may have higher viral loads and be more likely to yield positive tests (up to 95% sensitive) but come with a higher risk of transmission of infection to health-care workers.( 21 ) False-negative tests from upper respiratory specimens have been documented, as with this case study. If initial testing is negative in a patient with risk factors for infection and clinical or radiological features are highly suggestive of Covid-19 or determining the presence of infection is important for further management and infection control, repeat testing is recommended.
• • Chloroquine, azithromycin and lopinavir/ritonavir can all cause QT prolongation and ventricular arrhythmia, in particular drug-induced torsades de pointes and sudden cardiac death.( 22 ) Patients treated with any combination of these drugs should have 12–24 hourly ECG with QTc monitoring. If QTc >500 ms (as in the case study), or QTc increases >60 ms from baseline after initiating drug therapy, discontinue azithromycin and lopinavir/ritonavir, and consider reducing dose of chloroquine. Frequent monitoring of QTc is mandatory and chloroquine should also be discontinued if QTc remains >500 ms. The risk of serious ventricular arrhythmia may be reduced by performing a screening ECG prior to initiation of therapy, inquiring about a personal or family history of QT interval prolongation or sudden unexplained cardiac death, avoiding exposure to other medications known to affect QT interval, and aggressively treating hypocalcaemia, hypokalaemia and hypomagnesaemia. Hypokalaemia is especially common in patients with Covid-19 and is associated with a poorer prognosis.( 23 ) The correction of hypokalaemia can be challenging due to continuous renal loss of potassium resulting from the degradation of angiotensin converting enzyme 2 by binding of SAR-CoV-2.

This case study of severe Covid-19 pneumonia and CRS illustrates some of the diagnostic and therapeutic challenges and controversies regarding the management of this novel and complex infection. Meticulous monitoring for and early treatment of the hyperinflammatory phase of the disease may be crucial in preventing progression to severe ARDS, MODS and death.

ACKNOWLEDGEMENTS

We thank Dr L. Brannigan for his assistance with the management of this patient, and Dr E. Boschoff for the radiographs.

The Naive Bayes Classifier

• First Online: 30 July 2023

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The Naive Bayes Classifier makes a so-called conditional independence assumption that is almost always wrong.

This incorrect assumption earns the classifier the designation “naive.” The assumption greatly simplifies calculations; the naive Bayes classifier is very fast. The assumption trades off increased bias with reduced variance making the classifier surprisingly successful. The Naive Bayes classifier often benefits from smoothing. We discuss Laplace smoothing and the m-estimator. Somewhat cheekily, we use the Naive Bayes classifier to determine whether the movie “Shakespeare in Love” would be classified as a history, tragedy, or comedy, had the movie been written by Shakespeare. Our case study is about an open-ended survey question where respondents give advice to “Patient Joe” in a hypothetical situation. We classify the text answers into one of four classes.

Pretending to be an idiot may lead to a worthwhile tradeoff

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For readers familiar with parallel coordinate plots: a hammock plot uses bars instead of lines and optionally adds labels as shown here.

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Published on 19.6.2024 in Vol 12 (2024)

Effect of Implementing an Informatization Case Management Model on the Management of Chronic Respiratory Diseases in a General Hospital: Retrospective Controlled Study

Authors of this article:

• Yi-Zhen Xiao 1 , MBBS ; 
• Xiao-Jia Chen 1 , MBBS ; 
• Xiao-Ling Sun 1 , MBBS ; 
• Huan Chen 1 , MM ; 
• Yu-Xia Luo 1 , MBBS ; 
• Yuan Chen 1 , MBBS ; 
• Ye-Mei Liang 2 , MM

1 Department of Pulmonary and Critical Care Medicine, Yulin First People’s Hospital, , Yulin, , China

2 Department of Nursing, Yulin First People’s Hospital, , Yulin, , China

Corresponding Author:

Ye-Mei Liang, MM

Background: The use of chronic disease information systems in hospitals and communities plays a significant role in disease prevention, control, and monitoring. However, there are several limitations to these systems, including that the platforms are generally isolated, the patient health information and medical resources are not effectively integrated, and the “Internet Plus Healthcare” technology model is not implemented throughout the patient consultation process.

Objective: The aim of this study was to evaluate the efficiency of the application of a hospital case management information system in a general hospital in the context of chronic respiratory diseases as a model case.

Methods: A chronic disease management information system was developed for use in general hospitals based on internet technology, a chronic disease case management model, and an overall quality management model. Using this system, the case managers provided sophisticated inpatient, outpatient, and home medical services for patients with chronic respiratory diseases. Chronic respiratory disease case management quality indicators (number of managed cases, number of patients accepting routine follow-up services, follow-up visit rate, pulmonary function test rate, admission rate for acute exacerbations, chronic respiratory diseases knowledge awareness rate, and patient satisfaction) were evaluated before (2019‐2020) and after (2021‐2022) implementation of the chronic disease management information system.

Results: Before implementation of the chronic disease management information system, 1808 cases were managed in the general hospital, and an average of 603 (SD 137) people were provided with routine follow-up services. After use of the information system, 5868 cases were managed and 2056 (SD 211) patients were routinely followed-up, representing a significant increase of 3.2 and 3.4 times the respective values before use ( U =342.779; P <.001). With respect to the quality of case management, compared to the indicators measured before use, the achievement rate of follow-up examination increased by 50.2%, the achievement rate of the pulmonary function test increased by 26.2%, the awareness rate of chronic respiratory disease knowledge increased by 20.1%, the retention rate increased by 16.3%, and the patient satisfaction rate increased by 9.6% (all P <.001), while the admission rate of acute exacerbation decreased by 42.4% (P <.001) after use of the chronic disease management information system.

Conclusions: Use of a chronic disease management information system improves the quality of chronic respiratory disease case management and reduces the admission rate of patients owing to acute exacerbations of their diseases.

Introduction

Chronic obstructive pulmonary disease (COPD) and asthma are examples of common chronic respiratory diseases. The prevalence of COPD among people 40 years and older in China is estimated to be 13.7%, with the total number of patients reaching nearly 100 million. The lengthy disease cycle, recurrent acute exacerbations, and low control rate were found to have a significant impact on the prognosis and quality of life of middle-aged and older patients with COPD [ 1 , 2 ]. Therefore, to decrease the morbidity and disability rates and enhance the quality of life of all patients with chronic respiratory diseases, it is crucial to investigate effective prevention and treatment methods and establish a life cycle management model for chronic respiratory diseases.

Since the development of information technology, the internet and medical technology have been applied to the management of chronic diseases [ 3 ]. The chronic disease information systems adopted in hospitals and communities, along with mobile medical apps, can enhance the self-management capabilities of patients and play a significant role in disease prevention, control, and monitoring [ 4 - 9 ]. However, the existing platforms are generally isolated, the patient health information and medical resources are not effectively integrated, and the Internet Plus Healthcare technology model is not implemented throughout the patient consultation process [ 3 , 9 ].

Yulin First People’s Hospital developed a chronic disease management information system based on the hospital information system (HIS) to fully and effectively utilize the medical resources in hospitals and to better support and adapt the system to the needs of patients with chronic diseases. In this study, we evaluated the impact of the use of this system on the efficacy of case management for patients with chronic respiratory diseases.

Chronic Respiratory Diseases Case Management Model Prior to Implementation of the Chronic Disease Management Information System

Yulin First People’s Hospital is a public grade-3 general hospital with 2460 open beds, a specialty clinic in the Department of Pulmonary and Critical Care Medicine, and 180 beds in the Inpatient Department. Chronic respiratory diseases case management was initiated in 2019, which did not involve the use of an information system and was implemented by a chronic respiratory diseases case management team led by two nurses qualified as case managers, one chief physician, two supervisor nurses, and one technician. Under this system, patients with COPD, bronchial asthma, bronchiectasis, pulmonary thromboembolism, lung cancer, and lung nodules were managed using the traditional inpatient-outpatient-home chronic respiratory diseases case management model, including 1024 cases managed from 2019 to 2020. Except for medical prescriptions and electronic medical records, the patient case management information such as the basic information form, follow-up form, patient enrollment form, inpatient follow-up register, patient medication and inhalation device use records, smoking cessation and vaccination records, and pulmonary rehabilitation and health education records was managed using Microsoft Excel forms that were regularly printed for filing.

Establishment of a Management Information System for Chronic Diseases

The information carrier forming the basis of the management information system is constituted by the model of internet technology, chronic disease case management models, and overall quality management. The key technology is to establish a scientific, refined, and feasible follow-up pathway according to the methods and procedures of chronic disease case management based on the guidelines for the diagnosis and treatment of single chronic diseases. The closed-loop management of the clinical pathway was conducted in accordance with the Deming cycle (plan-do-check-act), and dynamic monitoring of single-disease health-sensitive and quality-sensitive indicators was carried out. The successfully developed system was installed on the hospital server to connect personal terminals (medical terminals and customer apps) to the existing HIS, which includes electronic medical records and medical advice.

Using the single-disease path assessment or plan scale as a framework, the system can automatically collect and integrate the majority of the medical information of patients with chronic respiratory diseases and provide these patients with inpatient, outpatient, and home intelligent medical services. Patients with chronic diseases who enroll in use of the system can use the app to schedule appointments for medical guidance, payment, and result queries; receive health guidance information; perform self-health assessments; write a treatment diary; and obtain medical communication materials.

The medical terminal consists of five functional modules: user entry, data statistics and query, quality control, knowledge base, and module management. As the core of the system, the user entry module can manage case information in seven steps: enrollment, assessment, planning, implementation, feedback, evaluation, and settlement [ 10 - 14 ]. Each step has a corresponding assessment record scale as well as the health-sensitive and quality-sensitive indicators. The structure of the HIS-based chronic disease management information system is shown in Figure 1 .

Implementation of the Chronic Disease Information Management System

Using the chronic disease management information system, two full-time case managers oversaw the case management of 2747 patients diagnosed with six diseases among chronic respiratory diseases between 2021 and 2022. The operation process was broken down into enrollment, assessment, planning, implementation, evaluation, feedback, and settlement stages.

Case managers entered the system through the medical app, selected a disease and an enrolled patient from the list of patients (the system automatically captures the patient’s name and ID number according to the International Classification of Diseases [ ICD ] code) in accordance with the chronic respiratory diseases diagnostic criteria to sign the enrollment contract and determine the relationship between the personal information and data [ 15 - 19 ].

The system can be seamlessly integrated with multiple workstations on the HIS to automatically capture the basic information, electronic medical records, medical advice, and inspection materials, and can generate questionnaires or assessment scales for patients with chronic respiratory diseases such as the COPD Assessment Test, Asthma Control Test, modified Medical Research Council scale, form for lung function test results, inhalation device technique evaluation form, 6-minute walk test record, rehabilitation assessment form, health promotion form, and nutritional assessment form. The above materials can be added or removed based on the requirements for individual patients.

The case managers drafted the follow-up plan based on the patient assessment criteria and included the patients on the 1-, 3-, 6-, and 12-month follow-up lists. If the patient satisfied the self-management and indicator control requirements after follow-up, they could be settled and included in the annual follow-up cohort. Case managers can set up follow-up warning and treatment, involving the return visit plan, health education, follow-up content, pathway, and time, and notify the patients and nurses on day 7 and at months 1, 3, 6, and 12 after discharge. The nurses should promptly deal with patients who miss their scheduled follow-up visit.

Implementation

During the inpatient or outpatient care, supervising physicians, nurses, and patients collaborated with each other to implement the treatment. Case managers monitored the patients, evaluated them, documented the results, interpreted various test indicators, and provided health guidance. The chronic disease management information system acquired the corresponding data for chronic disease–sensitive indicators from outpatient and inpatient orders and medical records automatically. The chronic respiratory diseases management team reviewed the patients’ conditions and the dynamics of chronic disease–sensitive indicators to make accurate decisions based on the current situation. The outpatient physicians obtained the single-disease package advice and personalized prescriptions to modify the diagnosis and treatment scheme.

Case managers highlighted evaluation and health education. First, they assessed and examined the content of the previous education and recorded and analyzed the patients’ conditions, medication, diet, nutrition, rehabilitation exercises, and self-management. Second, they prepared the personalized health education plan, return visit plan, and rehabilitation plan, and used standardized courseware, educational videos, and health prescriptions to provide the patients with one-on-one health guidance. Finally, they sent the management tasks and educational contents to the phones of the patients for consolidating the learning in the hospital, as an outpatient, and at home.

Patients can access their biochemical, physical, and chemical data as well as chronic disease–sensitive indicators in the hospital, as an outpatient, and at home for self-health management. Case managers can also perform online assessment, appraisal, and guidance via telephone, WeChat, and the chronic disease information system and record the data. Client mobile terminals can receive SMS text message alerts and the main interface of the chronic disease information system would display reminders of follow-up and return visits within ±7 days.

If a patient was out of contact for 3 months, died, or refused to accept the treatment, case managers could settle the case.

Evaluation of the Effect of Implementing the Chronic Disease Management Information System

Evaluation method.

In accordance with case quality management indicators [ 20 ], two full-time case managers collected and evaluated data in the process of the follow-up procedure. To reduce the potential for evaluation bias, the case managers consistently communicated and learned to standardize the evaluation method. The cases were divided based on different chronic respiratory diseases case management models (ie, before and after use of the chronic disease information system). The following case management quality indicators were evaluated under the noninformation system management model (2019‐2020) and under the chronic disease management information system model (2021‐2022): number of managed cases, number of patients accepting routine follow-up services, follow-up visit rate, pulmonary function test rate, admission rate for acute exacerbations, chronic respiratory diseases knowledge awareness rate, and patient satisfaction. Excel sheets were used to acquire data prior to incorporation of the chronic disease management information system into the new information system.

Evaluation Indicators

The annual number of cases was calculated as the sum of the number of newly enrolled patients and the number of initially enrolled patients. The number of cases was calculated as the sum of the number of cases in different years. The number of routine follow-up visits represents the number of patients who completed the treatment plan. The follow-up visit rate was calculated as the number of completed follow-up visits in the year divided by the number of planned follow-up visits in the same year. The pulmonary function test rate was calculated as the number of pulmonary function tests completed for patients scheduled for follow-up during the year divided by the number of pulmonary function tests for patients scheduled for follow-up during the year. The admission rate for acute exacerbations was calculated as the number of recorded patients admitted to the hospital due to acute exacerbations divided by the total number of patients recorded. The chronic respiratory diseases knowledge awareness rate was determined by the number of people having sufficient knowledge divided by the total number of people tested. This knowledge indicator was based on the self-prepared chronic respiratory diseases knowledge test scale, which consists of 10 items determined using the Delphi method (following expert consultation) through review of the literature, including common symptoms, disease hazards, treatment medication, diet, living habits, exercise, negative habits affecting the disease, regular review items, effective methods for cough and sputum removal, appointments, and follow-ups. The content of the questionnaire was refined by disease type, and the reviewers included 11 personnel with the title of Deputy Chief Nurse or above in the Internal Medicine Department of the hospital. The expert authority coefficients were 0.85 and 0.87 and the coordination coefficients were 0.50 and 0.67 for the two rounds of review, respectively; the χ 2 test showed a statistically significant value of P =.01. Patient satisfaction was assessed with a self-made questionnaire that showed good internal reliability (Cronbach α=0.78) and content validity (0.86). The questionnaire items included the reminder of return visits, practicability of health education content, and service attitude of medical staff; the full-time case managers surveyed the patients (or their caregivers) at the time of return visits after the third quarter of each year. Satisfaction items were rated using a 5-point Likert scale with a score of 1‐5, and a mean ≥4 points for an individual indicated satisfaction. Patient satisfaction was then calculated as the number of satisfied patients divided by the total number of managed patients.

Statistical Analysis

SPSS 16.0 software was used for data analysis. The Mann-Whitney U test was performed to compare continuous variables between groups and the χ 2 test was performed to compare categorical variables between groups. P <.05 indicated that the difference was statistically significant.

Ethical Considerations

The study was conducted in accordance with the principles of the Declaration of Helsinki. This study received approval from the Ethics Committee of Yulin First People’s Hospital (approval number: YLSY-IRB-RP-2024005). The study did not interfere with routine diagnosis and treatment, did not affect patients’ medical rights, and did not pose any additional risks to patients. Therefore, after discussion with the Ethics Committee of Yulin First People’s Hospital, it was decided to waive the requirement for informed consent from patients. Patients’ personal privacy and data confidentiality have been upheld throughout the study.

Characteristics of Patient Populations Before and After Implementation of the Information System

There was no significant difference in age and gender distributions in the patient populations that received care before and after implementation of the chronic disease management information system ( Table 1 ).

Comparison of Workload Before and After Implementation of the Information Management System

Before use of the system, 1808 cases were managed, with a mean of 603 (SD 137) cases having routine follow-up visits. After use of the system, 5868 cases were managed, with a mean of 2056 (SD 211) routine follow-up visits. Therefore, the number of managed cases and the number of follow-up visits significantly increased by 3.2 and 3.4 times, respectively, after use of the system (U =342.779; P< .001).

Comparison of Quality Indicators of Managed Cases Before and After Implementation of the Information System

The quality indicators in the two groups are summarized in Table 2 . Compared with the corresponding indicators before use of the system, the follow-up visit rate increased by 50.2%, the pulmonary function test rate increased by 26.2%, the chronic respiratory diseases knowledge awareness rate increased by 20.1%, the retention rate increased by 16.3%, and the patient satisfaction increased by 9.6%; moreover, the admission rate for acute exacerbations decreased by 42.4%.

a CRD: chronic respiratory disease.

Principal Findings

The main purpose of this study was to build a chronic disease management information system and apply it to the case management of chronic respiratory diseases. Our evaluation showed that the chronic disease management information system not only improves the efficiency and quality of case management but also has a benefit for maintaining the stability of the condition for patients with respiratory diseases, reduces the number of acute disease exacerbations, increases the rate of outpatient return, and improves patients’ adherence with disease self-management. Thus, a chronic disease management information system is worth popularizing and applying widely.

Value of the HIS-Based Chronic Disease Management Information System

Chronic diseases constitute a significant public health issue in China. Public hospitals play important roles in the health service system, particularly large-scale public hospitals with the most advanced technologies, equipment, and enormous medical human resources, which can greatly aid in the diagnosis and treatment of diseases and also serve as important hubs for the graded treatment of chronic diseases. Moreover, a significant number of patients with chronic diseases visit large hospitals, making them important sources of big data on chronic diseases [ 21 ]. Adoption of an HIS-based chronic disease management information system can make full use of and exert the advantages of large-scale public hospitals in terms of labor, technology, and equipment in the diagnosis, treatment, and prevention of chronic diseases; enhance the cohesiveness of the case management team in chronic disease management; and achieve prehospital, in-hospital, and posthospital continuity of care for patients with chronic diseases. Overall, use of a chronic disease management information system can enhance the quality and efficiency of chronic disease management and lay a good foundation for teaching and research on chronic diseases.

Improved Efficiency of Case Management

China was relatively late in applying case management practices, and chronic disease management has traditionally been primarily conducted offline [ 14 , 20 ] or supplemented by management with apps and WeChat [ 7 , 8 ]. Traditional case management methods require case managers to manually search, record, store, query, count, and analyze information. This manual process necessitates substantial time and makes it challenging to realize a comprehensive, systematic, and dynamic understanding of patient information, resulting in a small number of managed cases and follow-up visits. With the application of information technology, use of an HIS-based chronic disease monitoring and case management system can automatically extract and integrate patient information, thereby increasing the efficiency of chronic disease management and reduce costs [ 4 , 22 ]. In this study, two case managers played leading roles both before and after implementation of the information system; however, compared with the situation before the use of the system, the numbers of both managed cases and of follow-up visits increased, reaching 3.2 and 3.4 times the preimplementation values, respectively. The information system can automatically obtain a patient’s name and ID number based on the ICD code, which can expand the range of enrollment screening and appoint the register of patients as planned. In addition, the information system can automatically obtain outpatient, inpatient, and home medical information for the postillness life cycle management of patients. Moreover, the intuitive, clear, and dynamic indicator charts on the system can save a significant amount of time for diagnosis and treatment by medical staff, while the paperless office and online data-sharing functions can essentially solve the problem of managing files by case managers to ultimately enhance efficiency.

Improved Quality of Case Management

According to evidence-based medicine, the seven steps of case management represent the optimal clinical pathway [ 10 - 14 , 22 ]. In this study, the concept of an Internet-Plus medical service was introduced; that is, the chronic disease management information system was established based on the HIS data and case management model [ 22 ] and the function of a mobile medical terminal app was incorporated in the system [ 6 , 7 ]. Compared with the noninformation system case management model, this system has several advantages. First, owing to the swift management mode, it can overcome the limitations of time and space [ 4 - 8 ]. Second, multichannel health education and communication can enhance patients’ knowledge and skills, as well as their compliance with self-management, based on diversified forms of image data such as graphics and audio [ 6 , 22 ]. Third, the use of intelligent management can remind doctors and patients to complete management work and follow-up visits as planned, and to perform intelligent pushes of patient outcome indicators to improve confidence in the treatment [ 22 ]. Fourth, this system enables information sharing and big data analysis, as well as multidisciplinary diagnosis and treatment based on the matching of doctor-patient responsibility management, which can be more conducive to the precise health management of patients.

Compared with the traditional case management model, information-based case management significantly increased the follow-up visit rate, lung function test rate, chronic respiratory diseases knowledge awareness rate of patients, patient satisfaction rate, and retention rate. Among these indicators, the follow-up visit rate and lung function test rate represent aspects related to the patients’ own management of their condition [ 1 ]. The results of this study are consistent with previous findings related to information-based management of chronic diseases in China, demonstrating that such a management system was more conducive to planned, systematic, and personalized education and follow-up by the case management team, thereby promoting the virtuous cycle of compliance with self-management and reducing the number of acute exacerbations among patients with chronic respiratory diseases, ultimately enhancing the precision of medical resource allocation and hospital management [ 22 , 23 ].

Helping Patients With COPD Maintain Stability of Their Condition

The admission rate for acute exacerbations serves as a common indicator of the quality of the treatment of chronic respiratory diseases [ 23 ]. The deployment of a clinical pathway–based hospital case management information system significantly reduced the admission rate for acute exacerbations and enhanced the quality of treatment for chronic respiratory diseases, indicating its high clinical significance. There are several reasons for these observed benefits. First, home care and self-management are essential in the management of chronic respiratory diseases. The information-based case management model improved the patients’ knowledge and skills along with their compliance with self-management. Consequently, the standardized self-management process helped to reduce the number of acute exacerbations of chronic respiratory diseases and thus lowered the admission rate. Second, the information-based case management model increased the regular return rate, which allowed the medical staff to identify the potential risk factors for acute exacerbations in a timely manner, deal with them when they occur, and prepare personalized treatment plans and precise health management schemes. This consequently enabled adjustment of treatment schemes in real time, reduced the number of admissions due to acute exacerbations, and lowered the readmission rate. For hospitals interested in implementing a similar model, we suggest first conducting a detailed review of the current situation prior to making adequate changes based on the relevant disease and patient populations.

Consequently, the HIS-based case information management model could improve efficiency, enhance the quality of case management, and aid in stabilizing the conditions of patients with chronic respiratory diseases. In contrast to the hospital case management information system reported by Yuan et al [ 22 ], the system described in this study includes a personal terminal app. Previous studies confirmed that a stand-alone mobile health app could improve patient compliance and disease control [ 6 - 8 ]; thus, whether this system can be used to manage specialized disease cohorts for patients with chronic diseases remains to be determined. In this study, the effect on the retention rate of patients was confirmed; however, the overall operational indicators for the diagnosis and treatment of chronic diseases should be further determined.

With the advancement of information technology, the internet and medical technology have been applied to the management of chronic diseases. As an information-based platform for the case management of patients with chronic respiratory diseases, a newly developed chronic disease management information system was introduced in this study. This system is capable of designing the follow-up time registration, follow-up content, approaches, methods, quality control, and feedback process for a single chronic respiratory disease via the single-disease clinical pathway following the case management process (enrollment, assessment, planning, implementation, feedback, and evaluation). Use of this system can encourage patients with chronic respiratory diseases to adhere to regular follow-up and form an outpatient-inpatient-home chronic disease management strategy. This can help in reducing the admission rate for acute exacerbations, increase the return visit rate, and improve the correctness and compliance of home self-management of patients with chronic respiratory diseases. Owing to these benefits, wide adoption of such information systems for the management of chronic diseases can offer substantial economic and social value.

Acknowledgments

We are particularly grateful to all the people who provided help with our article. This study was supported by a grant from Yulin City Science and Technology Planning Project (20202002).

Data Availability

The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors' Contributions

YML, YZX, XLS, and YXL designed this study. XLS and XJC wrote the draft of the paper. YML, YZX, and YC contributed final revisions to the article. XJC, HC, and YC collected the data. XJC, YML, YXL, and HC performed the statistical analysis. YML received funding support. All authors read and approved the final draft of the article.

Conflicts of Interest

None declared.

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Abbreviations

Edited by Christian Lovis; submitted 15.06.23; peer-reviewed by Kuang-Ming Kuo; final revised version received 14.04.24; accepted 17.04.24; published 19.06.24.

© Yi-Zhen Xiao, Xiao-Jia Chen, Xiao-Ling Sun, Huan Chen, Yu-Xia Luo, Yuan Chen, Ye-Mei Liang. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 19.6.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Medical Informatics, is properly cited. The complete bibliographic information, a link to the original publication on https://medinform.jmir.org/ , as well as this copyright and license information must be included.

Nurix Therapeutics: Protein Deg Specialist's Latest Data Establishes Bull Case

• Nurix Therapeutics raised $209m in its IPO in July 2020, focusing on protein degradation in drug development, primarily in the blood cancer space.
• Protein degradation involves marking proteins for destruction by the proteasome using bifunctional small molecules.
• Nurix's lead proprietary candidate NX-5948 showed promising results in a Phase 1a clinical study for CLL patients in data released this week, triggering a surge in the company's share price.
• Management hopes to guide its lead candidate into a pivotal study next year, opening up a potentially compelling market opportunity.
• More data - in NHL and immuno-oncology - will arrive this year, and Nurix continues to collaborate with three major Pharma companies - Gilead, Sanofi, and Pfizer. The bull run can therefore be sustained.

Overview: Nurix and The Protein Deg Field Of Drug Development

San Francisco-based biotech company Nurix Therapeutics ( NASDAQ: NRIX ) completed its Initial Public Offering ("IPO") in July 2020, raising ~$209m via the issuance of ~11m shares priced at $11 per share.

Nurix' area of expertise is a field of drug development known as "protein degradation". The company explains the mechanism of action ("MoA") of this approach in its 2023 annual report / 10K submission - I'll quote from this document to try to provide a brief overview.

The traditional approach to discovering treatments for disease has involved the development of small molecule drugs that bind to a protein’s surface and modulate its activity. However, the vast majority of the body’s proteins do not have distinct active sites that can be targeted using traditional discovery methods. One of the most exquisitely ordered cellular systems governing cellular proteins is the ubiquitin proteasome system ("UPS"). The UPS is responsible for regulating and maintaining normal protein levels in the cell. An important class of enzymes called E3 ligases mediate this process with a high degree of specificity by recognizing individual proteins and catalyzing the attachment of ubiquitin protein tags to their surface. Proteins marked with chains of ubiquitin are then shuttled to the proteasome for degradation and removal from the cell. Targeted protein degradation is accomplished by using bifunctional small molecules, which are composed of an E3 ligase binding element, or harness, linked to a target protein binding element.

An even briefer explanation is that protein degrading drugs "force a handshake" between a disease causing protein and an ubiquitin E3 ligase, which results in the protein being marked for destruction by the proteasome - the "cell's trash compactor".

While the MoA sounds straightforward and ingenious, progress has been slow to date. While it is now recognised that lenalidomide and pomalidomide, marketed and sold as Revlimid and Pomalyst by Bristol-Myers Squibb ( BMY ) and indicated for multiple myeloma, are types of protein degrader drug, and there are multiple companies developing protein degraders, including Arvinas ( ARVN ), C4 Therapeutics ( CCCC ), Foghorn Therapeutics ( FHTX ), Kymera Therapeutics ( KYMR ), and Pharma giants including BMY, Novartis ( NVS ), and Boehringer Ingelheim, the next commercially approved protein degrading drug is likely still a few years away.

Nurix Has Deep Pocketed Partners - But Proprietary Drug's Promise Drives Valuation

Nurix has partnerships in place with three large Pharmas - Gilead Sciences ( GILD ), Sanofi ( SNY ), and Pfizer ( PFE ) - according to the company:

In aggregate, we have received $413.0 million in non-dilutive financing from our collaborators to date, and as of February 29, 2024, we are eligible to receive up to $7.6 billion in potential future fees and milestone payments, as well as royalties on future product sales. We retain certain options for co-development, co-commercialization and profit sharing in the United States for multiple drug candidates, pursuant to these collaborations.

Development milestone payments, often referred to as "biobucks", are rarely realised in full, however, and it is not uncommon for Pharmas to terminate deals due to a lack of progress, or insufficient safety / efficacy credentials.

As such, arguably the most valuable asset in Nurix' pipeline (diagram below) is its lead proprietary candidate NX-5948.

Nurix pipeline (presentation)

As we can see above, NX-5948 targets Bruton's Tyrosine Kinase ("BTK"), a B-cell signalling protein, and a well validated target in the field of hematological cancer treatment, as Nurix states in its 2023 10K submission:

The first generation BTK inhibitor Imbruvica, or ibrutinib, is approved for the treatment of Chronic Lymphocytic Lymphoma ("CLL"), Waldenstrom’s macroglobulinemia (WM), and chronic graft versus host disease (GVHD). Second generation BTK inhibitors include Calquence, or acalabrutinib, which is approved for use in CLL and mantle cell lymphoma ("MCL"), and Brukinsa, or zanubrutinib, which is approved for use in CLL, MCL, WM and marginal zone lymphoma (MZL).

Imbruvica - market and sold by AbbVie ( ABBV ) - revenues topped $5bn per annum for many years, before price controls and newer therapies checked sales, while Calquence revenues topped $2.5bn last year.

On June 16th, Nurix shared findings from a Phase 1a clinical study of NX-5948, which triggered a surge in the company's share price from ~$15 per share, to ~$18.5 per share (at the time of writing).

Digging Into The Data

The headline news was that NX-5948 achieved an objective response rate of 69.2% in a population of 26 patients with CLL. While there were no complete responses ("CR") observed, i.e. the complete disappearance of the cancer, 18 partial responses ("PR") were noted, with 6 Stable Disease ("SD"), and only 2 Progressive Disease.

The data was especially impressive given that patients had received a median of four prior lines of therapy, which included, according to a press release :

prior covalent BTK inhibitors (96.8%), prior BCL2 inhibitors (90.3%), and prior non-covalent BTK inhibitors (25.8%)

The press release also discusses two specific patient cases as follows:

one patient who entered the study with CLL with CNS involvement after having undergone three prior therapies, including treatment with a BTK inhibitor. After daily treatment with 100 mg, and later 300 mg, of NX-5948, the patient exhibited a deepening response approaching complete response criteria by 36 weeks, with elimination of malignant cells in the cerebrospinal fluid ("CSF") by 24 weeks. Another case report presented by the company involved a patient who had received eleven prior lines of therapy, including all available BTK inhibitors (ibrutinib, acalabrutinib, zanubrutinib, and pirtobrutinib). After daily treatment with 200 mg of NX-5948, the patient achieved a response by week 8 which deepened over time and was ongoing with over 6 months of follow up.

From a safety perspective, the data also appears encouraging. Across the overall patient population, which included 31 patients with CLL, and 48 with NHL/WM, instances of grade 3 or higher treatment related adverse events ("TRAE") were not common, with the most observed being neutropenia, which occurred in 15% of patients. Nurix observed that there was "no increased safety signal at higher doses", which is another promising sign.

Looking Ahead - Plans For A Pivotal Study

Nurix management has already outlined plans to select two dose levels from the Phase 1a study and expand the study into a Phase 1b portion with 80 - 160 CLL / small lymphocytic lymphoma ("SLL") patients.

This portion of the study would also include a combo study of NX-5948 plus one of either venetoclax - AbbVie's >$2bn per annum selling Venclexta, obinutuzumab, Roche's ( OTCQX:RHHBY ) ~$1bn per annum selling Gazyva, or rituximab - Rituxan, sold by various Pharma companies, earning ~$4bn per annum.

Following this, the plan is to initiate "pivotal" - i.e. generating data than can be used to support a formal regulatory approval request - clinical trials for NX-5948 as a third-line therapy in patients who have failed to respond to treatment with current approved BTK and BCL2 inhibitors, and as a first / second line therapy, both as monotherapy and in "fixed duration combination".

Management says it hopes to initiate such a study in 2025, which puts the company ahead of most of the rest of the pack chasing a first approval for a next-generation protein degrading drug.

For example, Kymera has one asset in Phase 2 studies; however, this candidate is directed against autoimmune diseases, not cancers. It's two oncology candidates directed against STAT3 and MDM2 are currently in Phase 1 studies.

Foghorn's lead candidate, FHD-286, is in a Phase 1 study in acute myeloid lymphoma, while C4 Therapeutics lead candidate, CFT7455, targeting the protein IKZF1/3, and indicated for multiple myeloma ("MM") / Non-Hodgkin's Lymphoma ("NHL"), is also in a Phase 1 study.

Research suggests that none of these companies have yet generated results as impressive as Nurix', or opened up a clear path to approval, as Nurix appears to be on the verge of doing. Arvinas has reached the Phase 3 study stage with its breast cancer drug Vepdegestrant, alongside development partner Pfizer (PFE). Phase 1 studies demonstrated a ORR of 42%.

Analysis - Following Phase 1 Data Readout, Is Nurix Stock A Buy?

It's important to emphasise that despite its latest data release, Nurix has many hurdles still to overcome on the road to a potential approval. The data gathered was from 26 patients only, and the expansion arm will potentially include four times as many patients.

We do not yet have any NHL/WM efficacy data, either, although this has been promised for the second half of 2024. This ought to be an intriguing catalyst - if positive, the data will reinforce the positive CLL data and open up a larger market opportunity, but if negative, it may cast doubt over the data presented last week.

Nevertheless, combined with the safety data, and even in the absence of CRs - perhaps they will arrive in due course - Nurix' Phase 1 results for NX-5984 seem undeniably impressive. The drug already has Fast Track Designation from the FDA, and appears to be able to successfully treat patients who failed to respond to treatment with current standard of care BTK inhibitors, plus the responses appear to be durable. This was a hard to treat patient population, yet NX-5984 performed well.

At the end of Q1 2024, Nurix reported a loss from operations of $(41.4m), versus $(400.7m) in the prior year, collaboration revenues of $17m, and a cash position of ~$251m.

Nurix' other BTK drug, NK-2127 had been subject to an FDA clinical hold, pending transition to a new manufacturing process, but that hold was lifted in March, and Phase 1 studies of that drug, which has a slightly differentiated MoA, targeting BTK/IKZF, are ongoing.

The drug achieved an ORR of 41% in 13 patients with CLL / SLL according to data presented last year, quoted in Nurix' investor presentation . Data from immuno-oncology candidate NX-1607 has also been promised for this year, presenting another intriguing catalyst.

Nurix has collaboration partners with deep pockets besides, in Gilead, which extended its agreement in April this year, paying $15m to do so, Sanofi, and Pfizer. The Sanofi partnership includes discovery of autoimmune targets, giving Nurix some exposure to that potentially lucrative field of development.

Protein degradation is arguably an over-looked field of development. While the market - and large pharmas - are increasingly investing in the likes of antibody drug conjugates ("ADCs") and radiopharmaceuticals, work on protein deg candidates has largely been carried out under the radar.

While slow progress has negatively impacted the share prices of e.g. Foghorn ad C4, both of whose share prices are down >70% on a five-year basis / since IPO, Nurix trades at a premium to its IPO, and we can make the case this is well-deserved as there are credible reasons to believe the company is on track to secure a drug approval, and potentially challenge standards of care in first, second, and third line setting, opening up a billion, or perhaps even double-digit billion revenue opportunity long term.

As mentioned, there are many hurdles to overcome before the market opportunity can be brought up, but there are equally plenty of reasons to believe that the upcoming data catalysts - in NHL for NX-5984, and immuno-oncology for NX-1607, can help sustain the momentum that has seen Nurix stock gain >75% year-to-date.

With its market cap of ~$1bn at the time of writing, Nurix is worth substantially less than Arvinas' $1.7bn, and Kymera's $1.9bn, but it would not surprise me if Nurix' valuation rises to those kinds of levels if its data readouts continue to impress, especially in NHL - thankfully, we won't have to wait too long to find out.

If you like what you have just read and want to receive at least 4 exclusive stock tips every week focused on Pharma, Biotech and Healthcare, then join me at my marketplace channel, Haggerston BioHealth . Invest alongside the model portfolio or simply access the investment bank-grade financial models and research. I hope to see you there.

This article was written by

Edmund Ingham is a biotech consultant. He has been covering biotech, healthcare, and pharma for over 5 years, and has put together detailed reports of over 1,000 companies. He leads the investing group Haggerston BioHealth .

Analyst’s Disclosure: I/we have no stock, option or similar derivative position in any of the companies mentioned, but may initiate a beneficial Long position through a purchase of the stock, or the purchase of call options or similar derivatives in NRIX over the next 72 hours. I wrote this article myself, and it expresses my own opinions. I am not receiving compensation for it (other than from Seeking Alpha). I have no business relationship with any company whose stock is mentioned in this article.

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• Open access
• Published: 15 June 2024

Cultural competences among future nurses and midwives: a case of attitudes toward Jehovah’s witnesses’ stance on blood transfusion

• Jan Domaradzki   ORCID: orcid.org/0000-0002-9710-832X 1   na1 ,
• Katarzyna Głodowska   ORCID: orcid.org/0000-0001-8887-3364 1 ,
• Einat Doron   ORCID: orcid.org/0009-0002-4807-3471 2 ,
• Natalia Markwitz-Grzyb   ORCID: orcid.org/0009-0004-8126-838X 1 &
• Piotr Jabkowski   ORCID: orcid.org/0000-0002-8650-9558 3   na1  

BMC Medical Education volume  24 , Article number:  663 ( 2024 ) Cite this article

148 Accesses

Metrics details

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.

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.

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.

Peer Review reports

Transcultural nursing entails nurses’ ability to approach each patient in a culturally sensitive and inclusive manner. It emphasises the need to consider patients’ cultural backgrounds, including values and norms, religious beliefs, traditional customs and lifestyles, as an essential part of quality care [ 1 , 2 ], and has a central role in the healthcare domain, requiring nurses to embody cultural competence as an integral aspect of their daily practice [ 3 ]. The concept of cultural competence itself, which originated in social work, was developed in the 1970s by Madeleine Leininger, who emphasised that healthcare should include multiple aspects of culture, as they influence the way a person or a group perceives health and disease, approaches healthcare and copes with illness or death [ 4 , 5 , 6 ]. Cultural competence therefore entails a process that involves a heightened self-awareness, an appreciation of diversity and the acquisition of knowledge concerning cultural strengths [ 7 ]. Nurses conceptualise cultural competence as the capacity to understand cultural distinctions and the continuous process of effectively engaging with diverse individuals, helping them deliver quality care to a culturally diverse population [ 5 , 6 ]. Culturally competent nurses show sensitivity to issues of culture, religion, race, ethnicity, gender and sexual orientation, highlighting their ability to communicate, perform cultural assessments and acquire knowledge related to diverse health practices.

Culturally competent nurses display a nuanced understanding of diverse cultural practices, enabling them to discern distinct patterns and formulate individualised care plans tailored to meet both healthcare goals and the individual needs of every patient [ 8 ]. While the overarching goal of transcultural nursing is to foster the values, knowledge and skills required for the provision of culturally different and sensitive care within a culturally diverse environment [ 2 , 9 ], it is an integral part of holistic nursing which aims at addressing patients’ physical, psychological, emotional, spiritual and social needs, and underscores the imperative of individualised care [ 10 ]. In pursuing holistic care, nurses must meticulously consider cultural variations in their care plans, ensuring a thorough and culturally competent approach [ 8 ]. Appreciating patients’ cultural perspectives is paramount in delivering effective care and navigating intricate ethical scenarios, particularly within diverse cultural backgrounds [ 5 , 6 ]. A detailed understanding of patients’ cultural backgrounds ensures a holistic and culturally competent approach to nursing care.

Given their prominence as the largest group of healthcare professionals, nurses are crucial in addressing global health challenges and disparities. The evolving landscape of global healthcare needs adjustments in nursing practice, positioning nurses at the forefront of addressing cultural backgrounds and global events that affect patients’ needs [ 11 ]. Nurses must be prepared to discern global healthcare issues and cultivate skills to attain cultural competences [ 12 , 13 ].

While there are many groups of patients whose cultural background, religious beliefs or traditional customs are an essential part of their identity and may therefore influence their health and medical behaviour, psychological reaction to illness, treatment preferences and communication with the healthcare team, one notable example is Jehovah’s Witnesses (JWs), a Christian denomination founded in 1872 in the United States by Charles Taze Russell. Although JWs represent a religious minority in Poland, they have been enormously successful and, according to the Central Statistical Office, there are currently more than 114,000 JWs in Poland, making them the third largest religious group in Poland after Roman Catholics and Orthodox Christians [ 14 ].

One of the central beliefs adopted by JWs is their refusal to accept allogenic blood transfusions, even in cases in which the outcome may be death [ 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. While JWs argue that there are also some medical grounds for refusing blood, this refusal is based on religious grounds and is the result of their interpretation of several verses in the Bible ( Genesis 9:4; Leviticus 17:10; Deuteronomy 12:23; Acts 15:28–29) [ 22 ]. JWs therefore refuse transfusions of whole blood (including pre-operative autologous donation, i.e. auto-transfusion) and its four primary components (red cells, white cells, platelets and unfractionated plasma). In 2000, however, JWs were informed that ambiguity in the Bible meant that the use of blood fractions is not absolutely prohibited and that they may accept them as a matter of personal choice. JWs may consequently accept such derivatives of primary blood components as albumin solutions, cryoprecipitate, clotting factor concentrates and immunoglobulins [ 23 , 24 ]. At the same time, although JWs reject allogeneic blood transfusions and pre-operative autologous transfusions, many other medical procedures are permitted and are left to the discretion of individual members, including blood donation, autologous transfusions, intra-operative blood salvage, dialysis, aphaeresis and cardiac bypass or organ transplants (on condition it is performed on a bloodless basis) [ 23 , 24 ].

Many clinicians, including physicians (e.g. cardiac surgeons, obstetricians and anaesthesiologists), nurses and midwives who treat their patients with blood products [ 23 , 24 , 25 , 26 , 27 , 28 ], either whole blood transfusions or blood component therapy (e.g. red cell concentrates, fresh frozen plasma, platelet concentrates or cryoprecipitate) [ 29 , 30 ] therefore face a challenging ethical and medico-legal dilemma: whether to respect patients’ autonomy and right to follow their religious beliefs, albeit this may result in death, or to remain faithful to the doctor’s duty to preserve life even against patients’ own wishes [ 16 , 17 , 18 , 19 , 26 , 31 ]. Although there is no official data, according to some estimates, up to one thousand JWs die in the United States each year due to their refusal of blood transfusions [ 32 , 33 , 34 ].

Since JWs carry a ready-made document regarding health care, a No Blood card, i.e. a declaration of the person’s resolution against blood transfusions, signed by the person and confirmed by two witnesses, which is compatible with the requirements of the Civil Code and is binding on an attending doctor. According to Polish law, any JW patients who have procedures performed on them that involve a blood transfusion against their will have the right to initiate any of three types of proceedings: criminal, civil or disciplinary [ 35 , 36 , 37 , 38 ].

If a JW patient refuses a blood transfusion, healthcare professionals must provide comprehensive information regarding treatment methods available with blood substitutes and other alternative methods used during surgical procedures. Since JWs reject pre-operative autologous blood donation, they may, for instance, be offered bloodless medical care, i.e. transfusion-free health care that uses neither allogeneic blood transfusion nor blood products during medical procedures and surgeries but instead uses blood conservation techniques and various blood transfusion alternatives, such as extra-corporeal circulation combined with recovery of patients’ blood from the surgical field in a closed circuit [ 39 , 40 , 41 ].

While earlier studies in Poland have focused on the moral (ethical) dilemmas and legal aspects of providing care to JW patients [ 35 , 36 , 37 , 38 ], there remains a shortage of research on the awareness among (future) healthcare professionals of JWs’ refusal of blood transfusions. This study, therefore, seeks to explore nursing and midwifery master’s students’ views on JWs’ attitudes towards blood transfusions, including (1) their awareness regarding JWs’ stance on blood transfusion, (2) students’ opinions on the ethical and legal dilemmas related to caring for JW patients, (3) students’ educational needs for non-blood management techniques, and (4) factors associated with future nurses’ and midwifes’ perception of JWs’ refusal of blood transfusion.

Study design

This research was part of a larger project aimed at assessing healthcare professionals’ attitudes towards JWs’ refusal of blood transfusions [ 42 ], but it was designed to explore the views of nursing and midwifery master’s students. It includes data from a self-administered, anonymised Web survey about future healthcare professionals’ awareness of JWs’ stance and the ethical and legal dilemmas related to their refusal of blood transfusions.

Research tool

A modified version of a previously developed questionnaire that assessed the knowledge and attitudes of Polish nurses towards JWs’ stance in refusing blood transfusions was used [ 42 ]. The development of the questionnaire followed the guidelines of the European Statistical System [ 43 ]. It was constructed after the published literature had been reviewed [ 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 31 , 35 , 36 , 37 , 38 ], and a focus group discussion with four research experts (a nurse, a medical sociologist and two Jehovah’s Witnesses) was carried out. They discussed the list of questions regarding critical issues related to JWs’ stance on refusing blood transfusions and decided which issues to address. A preliminary questionnaire was pre-tested on ten nursing students via a communication platform used at the Poznan University of Medical Sciences for educational purposes (Microsoft Teams), which resulted in reformulating the three questions. It was then re-evaluated by the same experts: a nurse, a sociologist and two JWS.

The final version of the questionnaire consisted of 25 questions divided into four sections. The first dealt with students’ demographic data. The second section addressed students’ knowledge and awareness of JWs’ stance in refusing blood transfusions. The third section included questions about students’ opinions on the bioethical and legal dilemmas related to JWs’ stance in refusing blood transfusions. The last section referred to students’ educational needs regarding bloodless medicine , i.e., non-blood management strategies to minimise blood loss during surgery and obviate the need for blood transfusions (Supplementary material).

Participants and setting

Nursing and midwifery master’s students were targeted for recruitment. The rationale behind choosing such students was two-fold: firstly, after completing the first stage of studies (3 years), which ends with a Bachelor’s Degree in Nursing or Midwifery, they are already qualified healthcare professionals and during the second stage (2 years), i.e. master’s studies, the vast majority already worked professionally in a variety of healthcare facilities; secondly, as qualified nurses and midwives who already worked in the profession, they were liable to face bioethical and legal dilemmas related to caring for a JW patient who refuses a blood transfusion in a life-threatening situation.

The inclusion criteria were: (1) being a nursing or midwifery master’s student, (2) being enrolled in the Poznań University of Medical Science (PUMS), (3) being willing to participate in the study, and (4) providing written informed consent before completing the survey.

Data collection

The study was conducted between October and November 2023 among master’s students of nursing and midwifery at PUMS. Students were recruited during regular classes.

Before completing the survey, all students were informed by two members of the research team (JD and KG) about the study’s aim, as well as its voluntary, anonymous, confidential and non-compensatory character. They were also instructed about their right to abandon the survey without consequences. After informed consent was obtained from all students who agreed to complete the survey, all participants received a QR code and, once they had scanned it with their smartphones, they received access to the questionnaire posted on a Web platform. Completing the questionnaire took between 8 and 10 min.

Ethical issues

This study followed the principles of the Declaration of Helsinki [ 44 ]. Ethics and research governance approval were also obtained from the Poznan University of Medical Sciences Bioethics Committee (KB – 760/22). All participants provided written informed consent before completing the survey.

Data analysis

All analyses were conducted using the R Project for Statistical Computing [ 45 ], where we utilised various open-source R packages such as tidyverse [ 46 ], flextable [ 47 ] and ggplot [ 48 ] for tasks including data manipulation, statistical analysis and data visualisation.

We conducted a comprehensive analysis to examine potential statistical differences among the socio-demographic categories of students participating in the survey. Firstly, we implemented a descriptive analysis, offering insights into the variability and tendencies of the data. We also employed graphical representations of data, such as density curves, histograms and correlation plots, to depict the observed patterns visually. Finally, to rigorously assess the differences between various categories of survey participants, we applied formal statistical tests. A two-tail t-test for the mean and a chi-square test were employed to scrutinise the differences in variable distributions, ensuring a robust evaluation of the statistical significance of variations observed. Comparisons of 95% confidence intervals for the mean values were also undertaken to bolster the reliability of the findings. The analytical procedures chosen were paramount in providing a thorough and systematic exploration of the data, enabling a nuanced comprehension of potential distinctions between student groups and augmenting the scientific rigour of our study.

The main goal of our analysis was to assess the students’ knowledge of JWs’ stance in refusing blood transfusions. Respondents were presented with dozens of statements, some intentionally false, describing reasons for refusing an allogenic blood transfusion and medical procedures and the blood products accepted and those JWs would refuse. In total each respondent determined the truth of 51 sentences, based on which we built three indices of knowledge covering distinct aspects of JWs’ stance in refusing blood transfusions. While Index 1 measured the general knowledge of JWs’ stance in refusing blood transfusions; Index 2 measured knowledge regarding blood products approved by JWs; and Index 3 measured knowledge regarding medical procedures accepted by JWs. Note that each index consists of 17 statements formulated as a priori in a questionnaire to measure the students’ knowledge (consult Supplementary Materials for details). For each respondent the value of each index ranged from 0 (if none of the sentences were indicated correctly) to 17 (if the respondent indicated all the sentences correctly).

Of the 349 students approached, 302 (86.5%) participated in the study by completing the questionnaire (Table  1 ). Forty-seven students who refused to participate did so because they were either absent during the classes, lacked interest in the study or were unwilling to discuss their opinions. The feedback on surveys from the nursing students (NSs) was 145/188 (77.12%), and from the midwifery students (MSs) 157/161 (97.51%).

The sample comprised 145 NSs (48%) and 157 MSs (52%), all of Polish origin. While women predominated over men in the student body (95.7% vs. 4.3%), this disproportion results from the fact that both courses are strongly gendered in Poland. In 2021 women accounted for 73.76% of all medical and healthcare students in the country and this disproportion was even higher among nursing and midwifery students (89% and 99.54% respectively) [ 49 ].

Less than one-third (32.8%) of students claimed religion played any significant role in their life (32.4% NSs and 33.2% MSs) and 67.2% declared it was of little or no importance (67.6% NSs and 66.9% MSs).

A considerable number of respondents were professionally active (63.9%). The proportion of NSs working in their profession, however, was double that of MSs (86.2% vs. 43.3%, p  <  0.001). 18.9% of respondents said that they had prior professional experience with patients who refused allogeneic blood transfusions because of their religious beliefs (17.2% and 20.4% MS).

Our analysis began by assessing the student’s knowledge of JWs’ stance in refusing blood transfusions. Figure  1 presents the distribution of the scores and correlation plots between the indices of students’ knowledge of JWs’ stance on blood transfusions. The results showed that the students scored highest on Index 1, with a mean score of 12.4, indicating that they had the greatest knowledge of JWs’ position on blood transfusion, on average correctly answering over 12 out of 17 statements. The highest mean score for Index 1 was followed by Index 2, with a mean score of 10.9, and Index 3, with the lowest mean score of 8.4, reflecting less knowledge about specific blood products and accepted medical procedures respectively. The correlations between all three indices were also generally low, highlighting the distinct nature of the domains of knowledge. In fact, Pearson’s linear correlation between Index 1 and Index 2 was − 0.14 ( p  = 0.019), indicating a significant, albeit only slightly negative relationship. The correlation between Index 1 and Index 3 was 0.26 ( p  < 0.001), indicating a significant but moderately positive relationship. The weakest Pearson correlation of 0.06 was between Index 2 and Index 3 ( p  = 0.28), indicating almost no relationship. In conclusion, while students have a good knowledge of the JW position on blood transfusion, their knowledge of specific blood products and accepted medical procedures is limited, suggesting the need for increased educational efforts to improve students’ overall understanding of medical practices accepted by the JW.

Histograms and correlation plots for indexes of students’ knowledge on JWs’ stand toward blood transfusions

While the overall mean scores provide a general overview, specific group comparisons highlight nuanced differences. Table  2 compares the mean values of the indices measuring students’ knowledge of JWs’ stand on blood transfusions in groups delimited by selected socio-demographic characteristics.

The results show that midwifery students have greater knowledge regarding JWs’ concerns about blood transfusion but poorer knowledge of blood products and medical procedures accepted by JWs. The differences between the two categories of students are only significant, however, for the third index (the mean for nurses is 9.3, while for midwifery students it is 7.6, with p  < 0.001), possibly indicating nurses’ deeper understanding of the issue of medical procedures. The participants’ employment status also plays a role, as those not currently working tended to have slightly lower mean scores (7.6 vs. 8.8, p  < 0.001) in knowledge related to blood products and medical procedures accepted by JWs. Participants who attached little or no importance to religion and those who had never experienced a refusal also tended to have slightly lower knowledge scores in their awareness of medical the procedures accepted by JWs. The differences, however, remain negligible at p  < 0.05.

Figure  2 outlines students’ perception of the bioethical and legal dilemmas surrounding the refusal of blood transfusion in JW patients in total and broken down into two groups of students, i.e., MSs and NSs. The majority of students experience bioethical dilemmas as most of them disagree with the right of JW parents to refuse blood transfusion for JW children (73.2% overall, with nurses tending to agree more often than midwifery students: 77.9% vs. 68.8%) and showed a limited understanding of JWs’ position on their choice of treatment methods (63.9% in total: 66.2 for nursing students and 61.8 for midwifery students), as well as agreeing that JWs should have the right to refuse blood transfusions on religious grounds in life-threatening circumstances (45.7% in general, with nursing students more likely to agree than midwifery students: 46.9 vs. 44.6). Regarding legal dilemmas, most students (83.4%) agreed that adult JW patients should have access to medical care using non-blood management techniques (midwifery students were more likely to agree than nursing students: 88.5% vs. 77.9%). Respondents also felt that the guardianship court should authorise blood transfusions for JW children in cases where parental consent is withheld (62.6%, with 88.5% of midwifery students and 77.9% of nursing students agreeing). A clear majority (74.8%) of participants also agreed that an individual’s decision to refuse treatment should be subject to legal regulation, with midwifery students (78.3%) more likely to agree than nurses (71.0%).

Students’ dilemmas related to JW’s stance toward blood transfusions

Table  3 illustrates the variations in students’ views regarding bioethical and legal dilemmas across categories delineated by socio-demographic characteristics. Although there is no discernible trend in the influence of specific socio-demographics, some interesting differences were observed. The results demonstrate that the differences between survey participant groups are negligible in almost all cases, so we will briefly describe the differences between midwifery and nursing students. MSs agree more strongly than their nursing counterparts with JWs’ stance on treatment methods in which they refuse allogeneic blood transfusion in adults (32.5% vs. 26.2%). While a slightly higher proportion of MSs support the right of JWs to refuse blood transfusions in life-threatening circumstances, NSs display a marginally higher inclination toward disagreement (48.4% vs. 41.4%). A discrepancy exists in accepting legal regulations describing the way to express informed consent for medical treatment, with MSs registering a notably higher agreement percentage than their nursing counterparts (78.3% vs. 71.0%). The only significant discrepancy between students of nursing and midwifery surfaces in their acceptance of the right to medical care from doctors specialised in non-blood management techniques, with MSs registering a notably higher agreement percentage than their nursing counterparts (88.5% vs. 77.9%, p  = 0.040). The results also show that the distribution of opinions on whether JWs should have the right to refuse blood transfusions on religious grounds, even in life-and-death situations, is firmly based on the perceived role of religion in their lives ( p  = 0.020).

Among students for whom religion plays a very or fairly important role 34.3% agree that JWs should have this right. Conversely, among those who see religion as playing little or no role in their lives, 50.2% agree that JWs should have the right to refuse blood transfusions. Those who see religion as very important in their lives are therefore more likely to oppose the right to refuse transfusions, while those who see religion as less important are more likely to support this right.

Finally, Table  4 presents students’ educational needs regarding non-blood management techniques. The results indicate that many nurses and midwives have had no courses on non-blood management techniques (overall 61.3%, with significantly ( p  < 0.001) more midwifery students (75.2%) reporting having had no such courses during their studies, compared to nursing students (46.2%)). There was also a significant consensus in favour of the inclusion of mandatory courses on strategies to minimise blood loss in medical curricula (overall support above 80%, with midwifery students significantly more likely to agree (85.4%) than their nursing counterparts (75.2%), p  < 0.001. A relatively small percentage of participants (11.3%) felt adequately prepared to care for patients who require non-blood management techniques despite this inclination, but nursing students were significantly ( p  < 0.001) more likely to report being prepared than midwifery students (17.9% vs. 5.1%; p  < 0.01). The findings underscore the need for targeted educational interventions and training programmes to bridge gaps in healthcare professionals’ preparedness for non-blood management, especially given the apparent positive disposition toward such training courses. Note that the differences between the nursing and midwifery students are statistically significant, except for their willingness to expand their knowledge about non-blood management techniques. In both groups, the vast majority of students declared the intention to expand their knowledge. Note that the differences for other socio-demographic categories are insignificant.

Poland remains one of Europe’s most ethnically and culturally homogeneous and religious countries. It has an extremely low rate of people of non-Polish descent, and Polish society is predominantly Christian. Most Poles identify as Roman Catholics (71.3%) [ 14 ]. Over the past few decades, however, Polish society has become more diverse. Demographic changes in Europe require that all healthcare professionals, including nurses and midwives, develop the knowledge and skills needed to provide holistic, patient-centred, culturally sensitive care [ 5 , 6 ] and the growing body of literature in Poland stresses the importance of cultural competency in healthcare [ 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 ]. While many educational programmes that seek to develop nurses’ cultural competence have been implemented in Europe and elsewhere [ 58 , 59 , 60 , 61 , 62 , 63 , 64 ], this has only recently begun in Poland [ 65 , 66 ].

Earlier studies have shown that the Polish public is relatively poorly informed about other cultures and religions. On the other hand, although JWs are more familiar than other faith groups, such as Muslims, Jews, Hindus and Buddhists, and 60% of people claim to know a JW personally, many Poles are still critical of JWs [ 67 , 68 ]. More importantly, research has demonstrated that 61.3% of nurses in Poland have prior experiences with a patient with a distinct cultural background, less than half had heard the term cultural competences (47.2%), and 92.5% felt unprepared to care for patients from different cultures. 91.5% of nurses also declared that all nurses should know other cultures, including their impact on healthcare and disease (57.5%), be able to identify problems arising from cultural differences (59.4%) and have the skills required to overcome ethnocentrism, stereotypes and prejudices (59.4%) [ 54 ].

In another study 86.8% of nurses claimed to have had little or no contact with patients from a different culture or religion and 62.3% experienced difficulties interacting with such patients due to a lack of knowledge or communication skills. Finally, 74.3% of nurses admitted to having various stereotypes of Muslims, JWs, the Roma or Hindus and 55.7% had an unfavourable image of such patients [ 68 ]. A recent study by Zalewska-Puchała et al. showed that, since many Polish nurses revealed varying levels of social distance towards followers of various religions, there is a need to train nurses in transcultural nursing [ 69 ]. Walkowska et al., however, demonstrated that cross-cultural education increases future healthcare professionals’ levels of cultural competence and professional confidence [ 66 ].

This research therefore reports three significant findings. Firstly, it shows that future nurses and midwives have limited knowledge regarding JWs’ stance in refusing blood transfusions. Nursing students taking part in this study showed some general knowledge regarding JWs’ refusal of blood transfusion, but their awareness of blood products and medical procedures approved by JWs was relatively low. This result aligns with a previous study, indicating that while many nurses in Poland lack the cultural competences required to care for JW patients and, even though they tend to support adult JWs’ right to refuse a blood transfusion, they show little understanding of such a decision and expressed resentment towards JWs’ stance [ 42 ]. More than 83% of nurses in Lublin, Poland, claimed to have had contact with JW patients and more than half (50.02%) rejected JWs’ position concerning blood treatment, 44.23% admitting to having tried to persuade JW parents to change their minds and accept blood transfusions [ 70 ]. While 83% of anaesthesiologists, physicians and surgeons in France did not oppose the medical care of JWs, they remained committed to their primary focus: to save the patient, as long as it is not an end-of-life situation, and 67% admitted that in life and death situations, where there is a lack of alternative procedures, blood products should be administered [ 71 ]. Although German doctors stressed the importance of personal autonomy, they also referred to doctors’ consciences and their ethical professional obligations [ 25 ].

Secondly, this research also found that future nurses and midwives are aware of the bioethical and legal dilemmas healthcare professionals face when caring for JW patients. The majority, however, showed limited support for both JWs’ stance in their refusal of blood transfusions and their preferences for bloodless medicine. Less than half of respondents supported JWs’ right to refuse blood transfusions for religious reasons in life-threatening situations and the majority stressed JWs’ right to alternative, non-blood management techniques. Even fewer supported JW parents’ right to refuse blood transfusion for their children. Similar results were found in other studies, suggesting that in the case of infant or juvenile patients, blood transfusions should be performed even against parents’ will [ 69 , 70 ].

Thirdly, these findings underscore the educational needs regarding cultural competences in nursing, both in terms of general knowledge regarding JWs’ stance in refusing blood transfusions and non-blood management techniques. Since nursing and midwifery students felt unprepared to care for JW patients, this study shows an urgent need to include transcultural nursing and strategies to minimise blood loss modules in university curricula and postgraduate nursing training [ 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ].

Limitations

This study has some limitations that should be acknowledged. Firstly, although the response rate was high (86.5%), the sample size was still small. Secondly, since 47 students decided against participating, this survey study solely represents the opinions of students who completed the questionnaire. Thirdly, nursing and midwifery students from only one Polish medical university participated in this study. For all these reasons, our results cannot be extrapolated to include the entire population of nursing and midwifery students, either in Poznan or Poland and further in-depth studies are required. Fourthly, it would be desirable to compare our findings with students of other departments and those in contact with patients who refuse blood transfusion, i.e. medicine or medical rescue. The questionnaire used in this survey was also ad hoc and, though we consulted four specialists in nursing, sociology and the culture of Jehovah’s Witnesses, it was not validated. Finally, this study is based exclusively on the quantitative method. Further in-depth studies based on qualitative methods are recommended in order better to understand students’ attitudes towards and experiences in providing medical care for JW patients.

Despite these limitations, there are some advantages to this study. Most importantly, as there is a scarcity of previous work on the topic, this research helps bridge the gap in research on the knowledge of future healthcare professionals on JWs’ stance toward blood transfusion. This study compares the knowledge of nursing and midwifery students and may also stimulate further discussion on the need for better education and increasing cross-cultural competences among future nurses and midwives, whose roles in caring for JW patients is vital.

This study demonstrates that nursing and midwifery students possess inadequate knowledge regarding JWs’ stance on blood transfusions and their acceptance of specific blood products and medical procedures. It also shows that, despite being cognisant of the ethical and legal dilemmas of caring for JW patients, future nurses and midwives show limited support for patients’ autonomy to reject blood transfusions and their preferences for bloodless medicine. Finally, students articulated educational needs regarding cultural competencies on the JWs’ beliefs regarding blood transfusions and non-blood management techniques. Since culturally competent nurses and midwives must establish trust and approach all patients with respect for their cultural identity and values, this study reveals an urgent need to train future nurses and midwives in transcultural nursing and increase their cultural competencies. To achieve this goal, all medical curricula should include a transcultural nursing module akin to those in other European countries. Students should also be trained in the ways cultural norms and healthcare professionals’ personal beliefs may affect their decision-making, hinder patient communication and prevent individuals from receiving patient-centred and culturally sensitive care. Finally, future nurses and midwives must be taught and trained about the challenges of caring for JW patients, including ethical and legal dilemmas.

Data availability

Data generated as part of this study with replication codes for all analyses are available from the corresponding author upon reasonable request.

Abbreviations

Jehovah’s Witnesses

• Midwifery students

Nursing students

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Acknowledgements

We are grateful to all the students who completed the survey. We also thank the Jehovah’s Witness Hospital Liaison Committee for their support in designing the research questionnaire. We are also indebted to Mr Bob France for his assistance with the language editing of the manuscript.

The authors received no financial support for this research.

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Jan Domaradzki and Piotr Jabkowski contributed equally to this work.

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Department of Social Sciences and Humanities, Poznan University of Medical Sciences, Rokietnicka 7, Poznań, 60-806, Poland

Jan Domaradzki, Katarzyna Głodowska & Natalia Markwitz-Grzyb

Independent researcher, Binyamina, Israel

Einat Doron

Faculty of Sociology, Adam Mickiewicz University, Poznań, Poland

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JD and KG conceptualised the study, designed the questionnaire and collected data. JD administrated and supervised the study. PJ performed the statistical analyses and prepared the tables and figures. JD and PJ discussed the study results and assisted in interpreting the data. JD, ED, NMG, and PJ conducted the literature study and drafted the original manuscript. All authors contributed to the article and approved the submitted version.

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Domaradzki, J., Głodowska, K., Doron, E. et al. Cultural competences among future nurses and midwives: a case of attitudes toward Jehovah’s witnesses’ stance on blood transfusion. BMC Med Educ 24 , 663 (2024). https://doi.org/10.1186/s12909-024-05646-1

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The use of podcasts as patient preparation for hospital visits—an interview study exploring patients’ experiences.

1. Introduction

2. materials and methods, 2.1. study design, 2.2. participants.

• Referral to the hospital because of suspected lung cancer, COPD, or sleep apnea;
• ≥18 years old;
• Able to understand and speak Danish.

2.3. Podcasts

2.4. data collection, 2.5. data analysis, 2.6. ethics.

• Objective 1: Patients’ experiences of receiving information through podcasts. ○ Theme 1: Technical challenges in utilization of the podcasts for patient preparation. ○ Theme 2: Individual preferences for information prior to hospital visits. ○ Theme 3: Building trust and reducing anxiety through podcasts.
• Objective 2: Patients’ views on podcasts, including their usefulness, format, and comprehensibility. ○ Theme 4: Podcasts as an accessible and convenient source of information. ○ Theme 5: Enhanced engagement and empowerment through podcasts.

3.1. Theme 1: Technical Challenges in Utilization of the Podcasts for Patient Preparation

Podcasts are probably more suited to the younger generation. Personally, I feel I’m way too old to engage with such modern mediums (P9).

I find podcasts to be a valuable resource for information and entertainment. It’s not about age; it’s about personal choice (P21).

I faced difficulties accessing the podcast episodes, which was frustrating. Technical issues like these can significantly reduce the usefulness of such resources. Nevertheless, I would have listened if I had been able to access it (P6).

I simply received a hospital appointment, and everything went from there. I wasn’t aware there was a podcast (P14).

I tried accessing the podcasts on my iPad, computer, and phone. I even sought assistance from the hospital staff, because I really wanted to understand and be well-prepared (P1).

3.2. Theme 2: Individual Preferences for Information Prior to Hospital Visits

I don’t think a podcast like that would interest me at all. I haven’t really listened to it much or read about it extensively. I simply take it as it comes without expecting anything serious from it (P5).

I felt fully prepared for the hospital visit, knowing exactly what to expect. I must say, the visit unfolded exactly as described in the podcast (P7).

I felt completely informed, leaving me with no desire for further information, especially considering my depleted energy reserves (P18).

I was really confused and concerned because of the sudden rush in which I was referred for the examinations. The lack of information made it even more challenging. I felt a bit lost and overwhelmed by the situation (P13).

I became aware of why the assessment is so important. It was surprising that I still maintained my nonchalant attitude. It felt more like an informed calmness than uncertainty. This has truly taught me that even if you’re not worried, it doesn’t mean you shouldn’t be informed (P20).

3.3. Theme 3: Building Trust and Reducing Anxiety through Podcasts

I felt reassured listening to the podcasts. Hearing from healthcare professionals and other patients helped build trust in the information provided. It felt like a personalized conversation tailored to my needs (P2).

Listening to the podcasts helped alleviate some of my anxiety about the upcoming hospital visit. I felt more prepared and knew what to expect, which significantly reduced my stress levels (P3).

Feeling that one is in good hands not only alleviates anxiety but also fosters a sense of confidence and security (P15).

3.4. Theme 4: Podcasts as an Accessible and Convenient Source of Information

I like that I can listen to podcasts whenever I want, whether it’s during my commute, while I’m doing chores at home, or together with my wife (P8).

Podcasts present information in a way that’s easy to understand. It’s like having a conversation with someone who knows what they’re talking about (P7).

The voice of the podcast host is crucial; a pleasant and clear delivery enhances the overall experience, making it more engaging and enjoyable to listen to (P12).

3.5. Theme 5: Enhanced Engagement and Empowerment through Podcasts

The podcasts provided me with valuable insights into my condition and the upcoming procedure (P10).

The podcasts empowered me to be more proactive in my treatment decisions and to ask questions, as recommended (P22).

Listening to the podcasts made me feel more informed and involved. I felt better equipped to understand my condition and explore different treatment options (P2).

4. Discussion

4.1. technical challenges and individuals’ information preferences, 4.2. the podcasts’ format and accessibility, 4.3. strengths and limitations, 4.4. implications for practice, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Share and Cite

Frølund, J.C.; Løkke, A.; Jensen, H.I.; Farver-Vestergaard, I. The Use of Podcasts as Patient Preparation for Hospital Visits—An Interview Study Exploring Patients’ Experiences. Int. J. Environ. Res. Public Health 2024 , 21 , 746. https://doi.org/10.3390/ijerph21060746

Frølund JC, Løkke A, Jensen HI, Farver-Vestergaard I. The Use of Podcasts as Patient Preparation for Hospital Visits—An Interview Study Exploring Patients’ Experiences. International Journal of Environmental Research and Public Health . 2024; 21(6):746. https://doi.org/10.3390/ijerph21060746

Frølund, Jannie Christina, Anders Løkke, Hanne Irene Jensen, and Ingeborg Farver-Vestergaard. 2024. "The Use of Podcasts as Patient Preparation for Hospital Visits—An Interview Study Exploring Patients’ Experiences" International Journal of Environmental Research and Public Health 21, no. 6: 746. https://doi.org/10.3390/ijerph21060746

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