Genesis Health System

Necrotizing soft tissue infection (NSTI) is a rare but life-threatening disease characterized by rapid spread and necrosis of the skin, subcutaneous tissue, fascia, and muscle. We present a fatal case of atraumaticNSTI involving the left lower extremity in an 80-year-old female with advanced myelodysplastic syndrome. Blood cultures grew Clostridium septicum and Staphylococcus epidermidis, the latter thought to be a blood contaminant. The patient rapidly progressed to septic shock and died within 34 hours of presentation. Our case emphasizes the need for a high index of suspicion for NSTI in patients with advanced malignancies.

ObjectivesEvidence regarding interventions to engage men and boys to improve sexual and reproductive health and rights (SRHR) has grown rapidly across subtopics such as HIV, family planning and gender-based violence (GBV). We conducted a review of the effectiveness of interventions to engage men and boys across SRHR domains, lessons learnt about successful programming, and about harms/unintended consequences, in low- and middle-income countries (LMIC).DesignSystematic review of reviews following Cochrane guidelines.Data sourcesPubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane were searched (18 October–9 November 2022; 9 September 2024).Eligibility criteriaEligible reviews were published since 2015, covered WHO-defined SRHR domain(s) and focused mostly on LMIC.Data extraction and synthesisData extraction by multiple reviewers focused on intervention effectiveness, implementation best practices, unintended consequences, and quality/risk of bias.ResultsThirty-five systematic reviews were included, comprising ~960 primary studies. Reviews focused on HIV prevention/care, reproductive health, maternal and newborn health, and GBV. Reviews consistently concluded that men were successfully engaged, yielding benefits to both women and men’s SRHR outcomes; no adverse intervention impacts on prevalence of SRHR outcomes were reported. We summarised the interventions most consistently found to be effective across reviews, in a programmer-friendly visual mapped onto a framework of men as clients, partners and agents of change. Person-centred, gender-transformative, multilevel approaches were most effective. Remaining evidence gaps include engaging men as contraceptive users, sexually transmitted infections other than HIV, preventing unsafe abortion and SGBV as experienced by men and boys.ConclusionsThere is substantial evidence supporting a range of successful interventions to engage men and boys to improve SRHR, with markedly similar principles and approaches emerging across SRHR domains. It is time to scale up and integrate these strategies, monitoring for any potential harms and tailoring as needed to socio-cultural contexts and for specific vulnerable subpopulations.

The SARS-CoV-2 pandemic has compelled the western world to consider as uncertain many principles considered definitively acquired. Among them, the right of every human being to health and its protection has been put to the test more than others. The purpose of this article is to provide a post-pandemic re-reading of the fundamental principles of equality and equity that underlie the right to health protection and the safeguard of universalistic healthcare systems. Conceiving health as physical, mental and social well-being, not only as the absence of disease/disability, means promoting the human beings dignity understood as the freedom to make choices that pertain to the desired quality of life integrating biology and biography of everyone, according to a project of individual realization. This goal requires a new model of healthcare not only able to solve the clinical problems, but also to act on all the economic, social, cultural and environmental determinants of the diseases and health. This new vision is supported by the One health, the Planetary health and the Health in all policies approaches promoting a more equitable healthcare system aimed to recognize, intercept and satisfy the health and social needs of everyone. The protection of health requires all governments make concrete juridical and economic commitments to ensure universal accessibility to effective, equitably distributed healthcare and to promote, through adequate funds, the enhancement of the psycho-physical well-being of human beings. By contrast, implementing economic policies aimed to reduce funding for healthcare means not only questioning the concept of fair and egalitarian healthcare system, compromising the health and dignity of people, undermining the national and international rules of law protecting them. The sustainability of this new health understanding represents also a cultural challenge concerning physicians. They should reconsider their social role and function by reconciling the dichotomy between clinical medicine and public health, and reviewing the concept of medicine in light of the needs of health determinants above mentioned. Political, legal, economic and cultural actions have to be implemented so that the right to health is considered as a primary right incorporated in the legal systems of all states. In this sense the One health approach focused on healthy ecosystems, sustainable development, social justice, equity and the appropriate use of scientific innovation and human, technological and economic resources should represent the answer.

Simple SummaryCancer-of-unknown-primary-origin (CUP) is challenging to diagnose and treat, and little is known about its diagnostic work-up, treatment, and outcomes in routine healthcare. We examined data from elderly patients (at least 66 years old) diagnosed with CUP in real-world US clinical practice, using the Surveillance, Epidemiology, and End Results–Medicare-linked database. Only half of elderly patients with CUP received all three diagnostic work-up procedures (biopsy, immunohistochemistry, and imaging), as recommended by guidelines. Patients who received all three diagnostic work-up procedures were more likely to receive any type of anticancer treatment, and patients who did not receive full diagnostic work-up had shorter median overall survival, particularly with increasing age. Overall, these results suggest that further studies are needed to understand why many patients given a diagnosis of CUP do not receive complete diagnostic work-up or treatment. Further research into improving diagnostic work-up and treatment effectiveness in patients diagnosed with CUP is required.Knowledge of contemporary patterns of cancer-of-unknown-primary-origin (CUP) diagnostic work-up, treatment, and outcomes in routine healthcare is limited. Thus, we examined data from elderly patients diagnosed with CUP in real-world US clinical practice. From the Surveillance, Epidemiology, and End Results–Medicare-linked database, we included patients ≥ 66 years old with CUP diagnosed between 1 January 2013 and 31 December 2015. We analyzed baseline demographics, clinical characteristics, methods of diagnostic work-up (biopsy, immunohistochemistry, imaging), treatment-related factors, and survival. CUP diagnosis was histologically confirmed in 2813/4562 patients (61.7%). Overall, 621/4562 (13.6%) patients received anticancer pharmacotherapy; among these, 97.3% had a histologically confirmed tumor and 83.1% received all three procedures. Among those with a histologically confirmed tumor, increasing age, increasing comorbidity score, not receiving all three diagnostic measures, and having a not-further specified histologic finding of only ‘malignant neoplasm’ were all negatively associated with receipt of anticancer pharmacotherapy. Median overall survival was 1.2 months for all patients. Median time between CUP diagnosis and treatment initiation was 41 days. Limited diagnostic work-up was common and most patients did not receive anticancer pharmacotherapy. The poor outcomes highlight a substantial unmet need for further research into improving diagnostic work-up and treatment effectiveness in CUP.

1 Background: A post-hoc analysis of pooled data from two randomized, double-blind studies and their open-label extensions evaluated whether baseline characteristics and efficacy endpoints differ between cancer and noncancer adults with advanced illness and opioid-induced constipation treated with methylnaltrexone (MNTX) or placebo. Methods: Patients received SC MNTX 0.15 mg/kg or placebo (study 302) and SC MNTX 8 mg (38≤62 kg), 12 mg (≥62 kg), or placebo (study 4,000) every other day for two weeks and received the same doses of MNTX as needed during the first 2 weeks of the open-label extensions. Double-blind populations were stratified by those with/without cancer. Efficacy endpoints included rescue-free bowel movements (RFBMs) within 4 hours after each dose for ≥2 of the first 4 doses; time to rescue-free laxation; rescue laxatives use; and ≥3 RFBMs/week and ≥1 RFBM/week in ≥3 of 4 weeks. Results: Median baseline opioid use (mg/day) was greater in cancer (187.9 placebo [n=114]; 180.0 MNTX [n=116]) versus noncancer patients (80.0 placebo [n=71]; 120.0 MNTX [n=62]). MNTX significantly ( P<0.0001) improved the proportion of cancer (56.9%) and noncancer (58.1%) patients with an RFBM within 4 hours after each dose for ≥ two of the first four doses versus placebo (5.3% cancer; 11.3% noncancer). Median time to laxation was significantly ( P≤0.0002) shorter in cancer (0.96 hours) and noncancer (1.25 hours) patients 24 hours after the first dose of MNTX versus placebo (22.53 and >24 hours, respectively). Rescue laxatives were used by 39.7% of cancer and 30.6% of noncancer MNTX patients versus 51.8% of cancer and 39.4% of noncancer placebo patients. Of 108 open-label extension double-blind MNTX patients, 79 (73.1%) achieved ≥3 RFBMs/week with ≥1 RFBM/week increase in ≥ three of four weeks versus 48 (46.6%) of 103 double-blind placebo patients (data from double-blind and first two weeks of open-label). Conclusions: MNTX treatment improved the laxation response, with a faster onset of laxation in patients with and without cancer, and reduced the need for rescue laxatives vs placebo. Improvements over placebo continued into the first two weeks of the open-label extensions for MNTX-treated patients. Clinical trial information: NCT00672477, NCT00402038.

The objective of this study was to determine specific provider practices associated with high provider efficiency in community emergency departments (EDs). A mixed-methods study design was utilized to identify key behaviors associated with efficiency. Stage 1 was a convenience sample of 16 participants (ED medical directors, nurses, advanced practice providers, and physicians) identified provider efficiency behaviors during semistructured interviews. Ninety-nine behaviors were identified and distilled by a group of three ED clinicians into 18 themes. Stage 2 was an observational study of 35 providers was performed in four (30,000- to 55,000-visit) community EDs during two 4-hour periods and recorded in minute-by-minute observation logs. In Stage 3, each behavior or practice from Stage 1 was assigned a score within each observation period. Behaviors were tested for association with provider efficiency (relative value units/hour) using linear univariate generalized estimating equations with an identity link, clustered on ED site. Five ED provider practices were found to be positively associated with efficiency: average patient load, using name of team member, conversations with health care team, visits to patient rooms, and running the board. Two behaviors, "inefficiency practices," demonstrated significant negative correlations: non-work-related tasks and documentation on patients no longer in the ED. Average patient load, running the board, conversations with team member, and using names of team members are associated with enhanced provider productivity. Identification of behaviors associated with efficiency can be utilized by medical directors, clinicians, and trainees to improve personal efficiency or counsel team members.