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Widespread testing begins on malaria vaccine

Mothers wait for their children to be vaccinated against malaria at the start of a pilot program at Mitundu Community Hospital, in Lilongwe, Malawi, on April 23, 2019.

    With malaria deaths rebounding worldwide, a pilot program testing a new and fiercely debated malaria vaccine began on Tuesday in Malawi. Dr. Katherine O’Brien, the World Health Organization’s director of immunization, called the rollout “a historic moment in the fight against malaria,” and said the testing will soon expand to malarious regions of Ghana and Kenya. But the vaccine, known as RTS,S, or Mosquirix, has been in development for more than 30 years, and it has serious drawbacks that have led some experts to argue that it does not work well enough to spend millions of dollars pursuing.

    Malaria kills about 450,000 people a year, most of them young African children. Over the last 15 years, the death rate has been reduced by more than half through extensive, donor-funded efforts to hand out free mosquito nets, spray homes with insecticide and treat people with a new generation of medicines. Nevertheless, deaths have increased again as money has run short, populations have grown, resistance to some new drugs has emerged and mosquitoes have expanded their ranges. Finding new weapons is crucial, experts agree, but making a malaria vaccine has proved challenging in the extreme.

    The new vaccine has many weaknesses. It is inconvenient: a child must receive four injections before age 2, sometimes at intervals that do not match the routine vaccine schedules for most other diseases. And it is only partly effective. Testing in more than 10,000 African children from 2009 to 2014 showed that, even after four doses, the vaccine prevented only about 40 percent of detectable malaria infections. The vaccine reduced the occurrence of severe malaria by about 30 percent. It did not protect well against parasite strains that were poor genetic matches, raising a concern that, over time, parasites could evolve resistance to the vaccine as they have to drugs.

(Donald G. McNeil Jr. www.nytimes.com, 24.04.2019. Adaptado.)

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Reducing preventable harm in hospitals

Each year, in the United States, millions of patients are harmed while receiving care in hospitals.
They get infections, experience adverse reactions to drugs, develop dangerous bedsores or come
down with pneumonia from the very ventilators meant to help them breathe.
The estimates of the number of people who die each year as a result of hospital errors have ranged
[5] from as many as 98,000 in a landmark Institute of Medicine report from 1999 to as many as 440,000
in a 2013 study.
It’s believed that most of these deaths could be prevented if health care providers always adhered
to evidence-informed practices. In recent years, the Centers for Medicare and Medicaid Services,
have sought to drive improvements by linking payments to hospital performance, including patient
[10] safety.
Amid the complexity, the chaotic pace and the increasing need for coordination, how can hospitals
do better to improve patient safety? How can they ensure, for example, that every single time a
patient receives a medication, precautions are taken to reduce the risks of an adverse drug reaction?
The big challenge is not just designing systems with better defenses; it is gaining acceptance for
[15] them, and properly implementing them. Over the past decade, for example, many hospitals have
adopted a key feature of aviation safety − checklists − to improve safety in areas where standard
protocols can save many lives, such as inserting central line catheters, using ventilators and while
performing surgery and assisting childbirth.
When the checklists are well implemented, the results of their use have been stunning. However,
[20] as checklists have proliferated, the results have been inconsistent, often because front-line
practitioners rejected them or adopted them halfheartedly. The devotion to protocol that pilots
see as integral to their professionalism is derided by some doctors as “cookbook medicine”. Atul
Gawande, a surgeon and contributor to The New Yorker, has said that the high value that physicians
place on autonomy and independence makes them reluctant to submit to checklists.
[25] So the big question is: how can health systems be made safer when success means changing the
attitudes and habits of health care professionals at a time when many are overwhelmed and deeply
frustrated by all of the demands being made on them? What does it take to get them to embrace,
with urgency, new ways of working?

opinionator.blogs.nytimes.com

Instilling empathy among doctors pays off for patient care

Sandra G. Boodman

    The patient was dying and she knew it. In her mid-50s, she had been battling breast cancer for years, but it had spread to her bones, causing unrelenting pain that required hospitalization. Jeremy Force, a first-year oncology fellow at Duke University Medical Center who had never met the woman, was assigned to stop by her room last November to discuss her decision to enter hospice.

    Employing the skills he had just learned in a day-long course, Force sat at the end of her bed and listened intently. The woman wept, telling him she was exhausted and worried about the impact her death would have on her two daughters. “I acknowledged how hard what she was going through was,” Force said of their 15-minute conversation, “and told her I had two children, too” and that hospice was designed to provide her additional support. A few days later, he ran into the woman in the hall. “You’re the best physician I’ve ever worked with,” Force remembers her telling him. “I was blown away,” he says. “It was such an honor.”

    Force credits “Oncotalk,” a course required of Duke’s oncology fellows, for the unexpected accolade. Developed by medical faculty at Duke, the University of Pittsburgh and several other medical schools, “Oncotalk” is part of a burgeoning effort to teach doctors an essential but often overlooked skill: clinical empathy. Unlike sympathy, which is defined as feeling sorry for another person, clinical empathy is the ability to stand in a patient’s shoes and to convey an understanding of the patient’s situation as well as the desire to help.

    Clinical empathy was once dismissively known as “good bedside manner” and traditionally regarded as far less important than technical acumen. But a spate of studies in the past decade has found that it is no mere frill. Increasingly, empathy is considered essential to establishing trust, the foundation of a good doctor-patient relationship. Studies have linked empathy to greater patient satisfaction, better outcomes, decreased physician burnout and a lower risk of malpractice suits and errors.

    While some people are naturally better at being empathic, said Mohammadreza Hojat, a research professor of psychiatry at Jefferson Medical College in Philadelphia, empathy can be taught. “Empathy is a cognitive attribute, not a personality trait,” said Hojat, who developed the Jefferson Scale of Empathy, a tool used by researchers to measure it. Empathy courses are rarely required in medical training; however, interest in them is growing, experts say, and programs are underway at Jefferson Medical College and at Columbia University School of Medicine. Columbia has pioneered a program in narrative medicine, which emphasizes the importance of understanding patients’ life stories in providing compassionate care.

One doctor’s experience

    Andy Lipman has taken the Duke course twice: first as an oncology fellow in 2004 and last year as a practicing oncologist in Naples, Fla., when he felt in need of a “booster shot.” Oncology, he said, “is a full-contact” specialty with a high burnout rate. Among the most important lessons Lipman said he learned during both sessions was to let go of “my own medical agenda, the desire to fix something or make something happen in that visit.” He learned to pace himself, monitor his reactions and talk less. One technique Lipman routinely employs is taking 15 seconds before entering an exam room to ask himself, “What is needed here?”

    On the day he was interviewed, Lipman said, he used what he has learned with a patient with end-stage cancer. She was scheduled for a brief appointment but began weeping loudly as she told Lipman how alone she felt. “I engaged, I expected the emotional response and I hung in there,” he said of the meeting, which lasted 45 minutes. “It felt good to me,” Lipman said, and he hoped it gave his patient some comfort.

(http://us.cnn.com. Adaptado.)